SURG - Bleeding Disorders in a Surgical Patient

Hemorrhagic diathesis

What term refers to any abnormal tendency to bleed?

Technical failure

What is the most common cause of postoperative bleeding?

Hemostatic disorders

What general category includes inherited and acquired bleeding disorders?

Hemostasis

What physiologic process stops bleeding after vascular injury?

Primary and secondary hemostasis

What are the two stages of normal hemostasis? →

Platelet plug formation

What occurs during primary hemostasis?

Fibrin clot formation

What occurs during secondary hemostasis?

Primary hemostatic disorder

What disorder is due to platelet or vessel wall defects?

Secondary hemostatic disorder

What disorder results from coagulation factor deficiency?

von Willebrand disease

What is the most common inherited bleeding disorder overall?

Congenital and acquired

What are the two main classifications of bleeding disorders?

Congenital

What type of bleeding disorder presents in childhood or early life? →

Acquired

What type of bleeding disorder develops secondary to other diseases or drugs?

Hemophilia A

What is the most common congenital coagulation defect?

Anticoagulant use

What is the main acquired cause of bleeding in surgical patients?

von Willebrand disease

What congenital defect affects platelet adhesion?

Glanzmann thrombasthenia

What congenital defect affects platelet aggregation?

Hereditary hemorrhagic telangiectasia

What congenital vascular defect causes telangiectasias and bleeding?

Factor VIII

What coagulation factor is deficient in Hemophilia A?

Factor IX

What coagulation factor is deficient in Hemophilia B?

Platelets

What blood component is defective in primary hemostasis disorders?

Quantitative and qualitative

What are the two major categories of platelet disorders?

Thrombocytopenia

What condition refers to a low platelet count?

Thrombocytopathy

What condition refers to abnormal platelet function?

150,000-450,000/uL

What is the normal platelet count range?

<20,000/uL

What platelet count range usually produces spontaneous bleeding?

Aspirin

What common drug causes acquired thrombocytopathy?

Immune thrombocytopenic purpura (ITP)

What immune-mediated cause of thrombocytopenia destroys platelets?

Thrombocytopenia

What condition presents with petechiae, purpura, and mucosal bleeding?

Prolonged

What is the characteristic bleeding time result in thrombocytopenia?

Normal

What are the PT and PTT results in isolated platelet disorders?

Corticosteroids

What treatment increases platelet count in ITP?

Splenectomy

What is the definitive therapy for refractory ITP?

Glanzmann thrombasthenia

What platelet function defect results in failure of aggregation?

Bernard-Soulier syndrome

What platelet function defect results in failure of adhesion?

GpIb

What receptor is defective in Bernard–Soulier syndrome?

GpIIb/IIIa

What receptor is defective in Glanzmann thrombasthenia?

Mucocutaneous bleeding

What is the bleeding pattern in primary hemostatic disorders?

Epistaxis or gingival bleeding

Give an example of mucocutaneous bleeding.

CBC (plate count)

What is the initial lab test for platelet number?

Clotting factors

What component is defective in secondary hemostasis disorders?

Deep tissue or joint bleeding

What type of bleeding is typical in secondary hemostasis disorders?

Hemophilia A

What is the most common inherited secondary hemostatic defect?

X-linked recessive

What is the inheritance pattern of hemophilia?

Hemarthrosis

What is the hallmark clinical sign of hemophilia?

Factor IX

What factor deficiency defines Hemophilia B?

Factor VIII

What factor deficiency defines Hemophilia A?

aPTT

What laboratory test is prolonged in hemophilia?

Bleeding time and PT

What laboratory tests are normal in hemophilia?

Factor VIII concentrate

What treatment is given for Hemophilia A?

Factor IX concentrate

What treatment is given for Hemophilia B?

Desmopressin (DDVAp)

What drug promotes release of vWF and Factor VIII?

von Willebrand disease

What condition causes deficiency of both vWF and Factor VIII?

Autosomal dominant

What is the inheritance pattern of von Willebrand disease?

Mucosal bleeding

What type of bleeding occurs in von Willebrand disease?

Prolonged bleeding time and aPTT

What lab findings are seen in von Willebrand disease?

Factor VII deficiency

What factor deficiency causes prolonged PT but normal aPTT?

Factor X or V deficiency

What factor deficiency causes prolonged PT and aPTT?

Vitamin K deficiency

What vitamin deficiency leads to decreased Factors II, VII, IX, X?

Liver disease

What is the most common acquired cause of Factor deficiency?

Warfarin

What drug therapy causes an acquired coagulopathy with prolonged PT?

Heparin

What drug therapy causes prolonged aPTT?

Vitamin K

What reversal agent is used for warfarin toxicity?

Protamine sulfate

What reversal agent is used for heparin toxicity?

Disseminated intravascular coagulation (DIC)

What systemic condition consumes platelets and coagulation factors?

Prolonged PT, PTT, low platelets, low fibrinogen

What are the typical lab findings in DIC?

D-dimer

What test detects fibrin degradation products in DIC?

Sepsis, trauma, malignancy

What are the common causes of DIC in surgical patients?

Bleeding and thrombosis

What is the hallmark clinical feature of DIC?

Treat underlying cause

What is the cornerstone of DIC management?

Fresh frozen plasma (FFP)

What blood product is used to replace coagulation factors in DIC?

Cryoprecipitate

What component replaces fibrinogen in DIC?

Platelet transfusion

What component corrects thrombocytopenia in DIC?

Liver disease

What condition presents with prolonged PT and aPTT but normal platelets?

Prothrombin complex concentrate

What synthetic factor complex is sometimes used in severe coagulopathy?

Bleeding history and labs

What should be done preoperatively to detect bleeding tendencies?

Bleeding time

What is the most sensitive test for platelet function defect?

Prothrombin time (PT)

What test assesses extrinsic coagulation pathway?

Activated partial thromboplastin time (aPTT)

What test assesses intrinsic coagulation pathway?

Thrombin time (TT)

What test assesses common coagulation pathway?

Extrinsic

What pathway does PT primarily assess?

Intrinsic

What pathway does aPTT primarily assess?

aPTT

What factor is monitored when using heparin?

PT/INR

What factor is monitored when using warfarin?

2.0-3.0

What is the target INR for most anticoagulated surgical patients?

Hemoglobin and hematocrit

What should be checked before surgery in anemic patients?

Identify and control source

What is the first step in managing intraoperative bleeding?

Vitamin K + FFP

What product is used for rapid reversal of warfarin before surgery?

Aspirin

What drug should be avoided preoperatively due to platelet inhibition?

7-10 days

How long before surgery should aspirin be stopped?

5 days

How long before surgery should warfarin be stopped?

Heparin

What can be used as bridging therapy when stopping warfarin?

Platelet concentrate

What transfusion raises platelet count by ~10,000/µL per unit?

Fresh frozen plasma

What transfusion replaces all coagulation factors?

Cryoprecipitate

What transfusion replaces fibrinogen and Factor VIII?

>50,000/uL

What is the goal platelet count for major surgery?

>30,000/uL

What is the goal platelet count for minor surgery?

>100,000/uL

What is the goal platelet count for neurosurgery?

Reassess for surgical cause

What should be done if bleeding persists after adequate transfusion?

Vascular control or Pringle maneuver

What intraoperative technique reduces bleeding in liver surgery?