Coagulation Disorders (Coagulopathy)
Introduction
Coagulation Disorders
Hemostasis
Management
Extrinsic Pathway
Intrinsic Pathway
Presented by:
Nardalyn Johnson, RN
MSN Student
Alverno College
Medications
Labs
April 22, 2010
Clinical Application
Summary
QUIZ
In collaboration with:
Jim Molnar, APRN – Preceptor
Jan Theis, APRN
MSN 621 Instructors:
Patricia Bowne
Luanne Wielichowski
Coagulation Disorders
Introduction
Coagulation Disorders
INTRODUCTION
Hemostasis
Management
Extrinsic Pathway
Intrinsic Pathway
Medications
Labs
Clinical Application
The Interventional Radiology (IR)
department multidisciplinary team works
with patients who have various types of
coagulation disorders.
Summary
QUIZ
Hemostasis management is complex due
to the wide array of patient co-morbidities
and demographics.
Malloy, P.C., Grassi, C. J., Kundy, S., Gervais, Miller, D. L., Osnis, R. B. et al. (2009). Consensus Guidelines for
Periprocedural Management of Coagulation Status and Hemostasis Risk in Percutaneous. Society of Interventional Radiology.
Coagulation Disorders
Introduction
Coagulation Disorders
Hemostasis
Management
Extrinsic Pathway
Intrinsic Pathway
Medications
Labs
Clinical Application
Summary
• Objectives
– Review importance of hemostasis management
in IR
– Review coagulation disorders
– Review the coagulation cascade (intrinsic and
extrinsic pathways)
– Identify common lab tests
– Identify common medications that can affect
hemostasis
– Focus on clinical application of hemostasis in IR
QUIZ
Special Note:
– Whenever you see an underlined word, move the
curser over the underlined word to view more
information
Coagulation Disorders
Introduction
Coagulation Disorders
Hemostasis
Management
Extrinsic Pathway
Intrinsic Pathway
Wellcome Images
Medications
Labs
Clinical Application
A group of conditions that cause an individual to
experience either:
Summary
QUIZ
Excessive
bleeding
Porth, C.M., 2005. Pathophysiology, 7th edition. Lippincott.
Excessive
Clotting
Case Study
Introduction
Coagulation Disorders
Hemostasis
Management
Extrinsic Pathway
Intrinsic Pathway
Medications
Labs
Clinical Application
Summary
A 49 yr old male
Presents to IR for placement of
a permCath to initiate dialysis.
He returns to IR the following
day due to excessive bleeding
during dialysis.
QUIZ
BP 159/75 HR 76 Temp 97.8
Lab: INR 1.8 (0.9 – 1.3)
Coagulation Disorders
Introduction
Coagulation Disorders
Hemostasis
Management
Extrinsic Pathway
Intrinsic Pathway
Medications
Click the diagram to reveal the answer
Why Does the IR
multidisciplinary team need
to be concerned about
patients with clotting or
bleeding disorders?
Labs
Clinical Application
Summary
QUIZ
Hemostasis
management
Hemostasis
Introduction
Definition: Hemostasis is the process of stopping blood loss.
Coagulation Disorders
Hemostasis
Management
This process occurs via the hemostatic mechanism known as blood
coagulation
Extrinsic Pathway
Intrinsic Pathway
It is regulated by “activators” and “inhibitors”.
Medications
Labs
Clinical Application
If Normal
Seals blood vessels and
prevents blood loss and
hemorrhage
Summary
QUIZ
If Abnormal
Nowak, T.J., Handford, G. A. (2004). Pathophysiology:
Concepts and Applications for Health Care Professionals. (3rd Ed). McGraw-Hill. NY
Causes inappropriate blood
clotting or excessive bleeding
Why is Hemostasis Management Important?
Introduction
Coagulation Disorders
Nursing Outcomes
Hemostasis
Management
•
Prevents cancellation of IR procedures due to appropriate
pre-op procedure not done
•
Prevents excessive bleeding pre, intra, or post procedure
Medications
•
Decreased risk for post-procedural thrombosis
Labs
•
Achieves hemostasis pre, intra, and prior to discharge
•
Helps with healing
Summary
•
Provide appropriate patient education
QUIZ
•
Identify new protocols for patients with coagulation
disorders
•
Early identification of at risk patients pre-procedure
Extrinsic Pathway
Intrinsic Pathway
Clinical Application
http://www.vascularsolutions.co
m/company-info/contact
Coagulation Disorders
Introduction
Coagulation Disorders
Hemostasis management for patients
undergoing percutaneous image-guided
procedures can be complex due to the
wide range of procedures and equally
wide range of patient demographics and
co-morbidities.
Hemostasis
Management
Extrinsic Pathway
Intrinsic Pathway
Medications
Labs
Microsoft clipart
Clinical Application
Summary
QUIZ
Microsoft clipart
Some patients are on special medications
that increase their risk for bleeding
or have internal stents or other devices
that predispose them to forming clots.
Malloy, P.C., Grassi, C. J., Kundy, S., Gervais, Miller, D. L., Osnis, R. B. et al. (2009). Consensus Guidelines for
Periprocedural Management of Coagulation Status and Hemostasis Risk in Percutaneous. Society of Interventional Radiology.
A Closer Look at “Hemostasis process”
Introduction
Five Stages for Achieving Hemostasis
Coagulation Disorders
Click each box along the pathway to reveal the steps
Move the curser over the underlined word to view more information
Hemostasis
Management
Extrinsic Pathway
Vessel spasm
Intrinsic Pathway
Medications
Formation of platelet plug,
platelet adhesion, & aggregation
Labs
Clinical Application
Summary
Formation of fibrin clot and activation
of intrinsic or extrinsic coagulation cascade
QUIZ
Clot retraction
Clot dissolution
Nowak, T.J., Handford, G. A. (2004). Pathophysiology:
Concepts and Applications for Health Care Professionals. (3rd Ed). McGraw-Hill. NY
Coagulation Disorders
Introduction
Coagulation Disorders
Clot retraction: is when the blood clot becomes smaller, squeezing
serum from the clot and joining the edges of the broken vessel
Hemostasis
Management
Clot retraction normally
occurs within ____time
after a clot is formed
Extrinsic Pathway
Intrinsic Pathway
Medications
Labs
Clinical Application
Summary
Incorrect…
This is abnormal and
could be due to
low platelet
count
NO…….
This is not enough
time and you are
at risk for bleeding
5 to 10 minutes
8 to 10 hours
2 to 4 hours
20 – 60 minutes
QUIZ
TRY AGAIN…….
It begins shortly
after formation
CORRECT!
This is key
for
hemostasis
The Intrinsic and Extrinsic Coagulation Cascade
Introduction
Coagulation Disorders
Hemostasis
Management
Extrinsic Pathway
Intrinsic Pathway
The coagulation cascade is one component of the hemostasis process. For coagulation
to work successfully, we need both the “Intrinsic pathway” and the “extrinsic pathway.”
Both pathways are interrelated and link to form the common pathway.
Here is a list of Factors that help to build the coagulation cascade
Factor Name
Roman Numeral
Fibrinogen
I
Prothrombin
II
Tissue Factor
III
Calcium
IV
Clinical Application
Preaccelerin
V
Summary
Proconvertin
VII
Antihemophilic Factor
VIII
Christmas Factor
IX
Stuart-Prower Factor
X
Plasma thromboplastin antecedent
XI
Hageman Factor
XII
Fibrin-stabilizing Factor
XIII
Medications
Labs
QUIZ
Nowak, T.J., Handford, G. A. (2004). Pathophysiology:
Concepts and Applications for Health Care Professionals. (3rd Ed). McGraw-Hill. NY
Sometimes
you will see
them
referenced by
their original
name. Other
times you will
see only the
roman
numeral
references.
A Closer Look at “Normal Coagulation Cascade”
Introduction
Blood vessel damage
Damaged Tissue
Coagulation Disorders
Hemostasis
Management
The Intrinsic Pathway
The Extrinsic Pathway
Ca2+
Factor XII
Tissue Factor (III)
(from activePLT)
Cascade reaction
Extrinsic Pathway
Intrinsic Pathway
Medications
Labs
Clinical Application
Summary
Proconvertin(VII)
Factor V
Factor III
Ca 2+
PF3
Plasma thromboplastin antecedent (XI)
Factor X
RBC & PLT get
caught in mesh
Forming blood clot
Prothrombin
Activator
Prothrombin (II)
Thrombin
Cross-linked
Fibrin mesh
QUIZ
Fibrinogen (I)
Fibrin (monomer)
Fibrin (polymer)
Return to
Calcium (Ca 2+)
Factor XIII
See step-by-step explanation on next slide
Slide created by Nardayn Johnson
The Coagulation Cascade Explained
(See previous slide)
Introduction
 The extrinsic pathway gets initiated when there is damage to blood
vessels or surrounding tissue (usually a fast process).
Coagulation Disorders
Hemostasis
Management
 Factor III is released in response to damaged tissue which then
activates Factor VII with the help of calcium ions.
Extrinsic Pathway
Intrinsic Pathway
 The intrinsic pathway (a slower process) is then activated when
factor XI gets activated by Factor XII from active platelets.
Medications
Labs
 Activated factor XI and factor VII cause a cascade reaction which
leads to the activation of factor X.
Clinical Application
Summary
QUIZ
 Activated Factor X with the help of calcium ions, Factor III, Factor V,
and PF3 activates prothrombin activator which then converts
prothrombin to thrombin.
 Next, thrombin converts fibrinogen to fibrin which forms a loose
mesh.
 Fibrin along with factor III forms a denser network of mesh fibers
which can trap RBC & PLT forming a successful clot.
Nowak, T.J., Handford, G. A. (2004). Pathophysiology:
Concepts and Applications for Health Care Professionals. (3rd Ed). McGraw-Hill. NY
The Intrinsic and Extrinsic Coagulation Cascade
Introduction
Coagulation Disorders
Hemostasis
Management
Extrinsic Pathway
Microsoft clipart
Intrinsic Pathway
Medications
Labs
Clinical Application
 Blood coagulation requires systematic activation of
coagulation factors controlled by activators and
inhibitors.
Summary
QUIZ
 It is vital to promoting healing after a patient
undergoes any percutaneous imaging procedure.
Porth, C.M., 2005. Pathophysiology, 7th edition. Lippincott.
The Intrinsic vs. Extrinsic Coagulation Cascade
Introduction
Coagulation Disorders
Hemostasis
Management
Extrinsic Pathway
The activation of one procoagulation factor/enzyme leads to the
activation of the next factor, similar to a domino effect.
“Most of the inactive procoagulation factors are present in the blood all
the time.” (Porth, 2005)
Intrinsic Pathway
Medications
The Intrinsic pathway
The Extrinsic pathway
A slow Process
Begins in the blood itself
A faster Process
Begins with damage to blood vessel
or surrounding tissue
Labs
Clinical Application
Summary
QUIZ
Need both for Hemostasis
Extrinsic pathway
Gets activated
Small amount of
Thrombin formed
Stimulus to Intrinsic
pathway
Formation of more
Thrombin
Produce large
Amount of Fibrin
Return to
Protein C
Damage to
tissue
Porth, C.M., 2005. Pathophysiology, 7th edition. Lippincott.
+
Coagulation
Successful
The Intrinsic vs. Extrinsic Coagulation Cascade
Introduction
CASE STUDY:
Coagulation Disorders
Hemostasis
Management
Extrinsic Pathway
Intrinsic Pathway
Medications
Recall the 49 yr old male who presented to IR
for placement of a permCath to initiate dialysis.
He returned to IR the following day
due to excessive bleeding problems during dialysis.
A defect in which pathway would cause bleeding
problems?
Labs
Clinical Application
Summary
QUIZ
Extrinsic Pathway
Intrinsic Pathway
Try Again
Try Again.
There’s a better answer
Think about the procedure performed
This is not be most correct response
Both
Correct!
The Intrinsic vs. Extrinsic Coagulation Cascade
Introduction
Coagulation Disorders
Hemostasis
Management
Extrinsic Pathway
Intrinsic Pathway
Medications
Labs
Clinical Application
Summary
QUIZ
Jim Molnar, 2010 – (Preceptor)
Molnar. J. (2010). Thrombolytics. Froedtert hospital Radiology Department.
The Intrinsic vs. Extrinsic Coagulation Cascade
Introduction
Coagulation Disorders
Hemostasis
Management
Extrinsic Pathway
Intrinsic Pathway
Medications
Labs
Abnormality in the clotting process can result
if there is a problem with one or more factors
(Porth, 2005).
Clinical Application
Summary
QUIZ
This can lead to inappropriate activation at any
point along the pathway depending on the factor(s)
causing the problem (Nowak, 2004).
Porth, C.M., 2005. Pathophysiology, 7th edition. Lippincott.
Nowak, T.J., Handford, G. A. (2004). Pathophysiology: Concepts and Applications for Health Care
Professionals. (3rd Ed). McGraw-Hill. NY
Why are Ca 2+, Vitamin K, Protein C, and Platelets Important?
Introduction
Coagulation Disorders
Hemostasis
Management
Ca2+
View
coagulation pathway
Calcium (ionized)
Extrinsic Pathway
Intrinsic Pathway
Medications
Labs
Clinical Application
Summary
• Calcium plays a key role in the coagulation cascade.
It is “required in all but the first two steps of the clotting process.”
(Porth, 2005)
• 3 types of calcium (calcium salts, protein bound, and ionized calcium)
• **ionized calcium** aid in coagulation cascade
• Calcium = Factor IV
QUIZ
• Only need a small amount so patients with calcium deficiency will not
necessarily exhibit any significant effect on coagulation cascade.
• If calcium gets inactivated when it is removed from the body, then blood
will not clot.
Think about the EDTA tubes that you use to collect blood. They contain chelating agent that
inactivates Ca++ that prevents the blood from clotting.
Nowak, T.J., Handford, G. A. (2004). Pathophysiology: Concepts and Applications for Health Care
Professionals. (3rd Ed). McGraw-Hill. NY
Why are Ca 2+, Vitamin K, Protein C, and Platelets Important?
Introduction
Coagulation Disorders
VITAMIN K
Hemostasis
Management
Is a fat soluble vitamin and
without it your blood will not clot
Extrinsic Pathway
Intrinsic Pathway
Medications
Labs
Clinical Application
FUNCTION OF VITAMIN K:
 Needed by liver to produce clotting factors
 Needed to produce clotting Factors such as VII, IX, X and to synthesize
Protein C
 Helps to regulate calcium…keeping it in your bones and out of your blood
Summary
QUIZ
 Watch patients who are taking warfarin as it can decrease clotting by
interfering with vitamin K and increase risk for excesses bleeding after
a procedure
 You do not need much—just enough to prevent you from bleeding to death
 Older patients will need more vitamin K
http://www.hemophilia.org/NHFWeb/MainPgs/MainNHF.aspx?menuid=176&contentid=378&rptname=bleeding
Why are Ca 2+, Vitamin K, Protein C, and Platelets Important?
Introduction
View
Positive feedback
Coagulation Disorders
Hemostasis
Management
Extrinsic Pathway
Intrinsic Pathway
Medications
Protein C
A special anticoagulant protein. Activated Protein C functions
as an anticoagulant, limiting clot formation (down regulates the
coagulation cascade). Resistance to activated Protein C
prevents Protein C from cleaving to Factor V and/or VIII.
Labs
You need the help of vitamin K to help build Protein C.
Clinical Application
Summary
Do not confuse this with “C-reactive protein.” This is produced in the liver and is a
bi-product of inflammation.
QUIZ
Nowak, T.J., Handford, G. A. (2004). Pathophysiology: Concepts and Applications for Health Care
Professionals. (3rd Ed). McGraw-Hill. NY
Why are Ca 2+, Vitamin K, Protein C, and Platelets Important?
Introduction
Coagulation Disorders
Hemostasis
Management
Extrinsic Pathway
Intrinsic Pathway
Medications
Labs
Clinical Application
Summary
QUIZ
You found out during testing that
JT has a Protein C deficiency.
Click here
This deficiency predisposes him to __________?
Venous Thrombosis
Why are Platelets important for Hemostasis?
Introduction
Coagulation Disorders
Hemostasis
Management
Extrinsic Pathway
Wellcome Images
Intrinsic Pathway
Medications
Labs
Clinical Application
Summary
Platelets are very important in hemostasis management
You need enough to prevent excessive bleeding, but too
many can be problematic because they cause
hypercoagulation
QUIZ
Some patients may have internal stents or other devices
that predispose them to forming clots
Cancer patients who have decreased platelet count are at
increased risk for bleeding
King, K. W. (2010). Platelet Activation and von Willebrand Factor (vWF). IU School of Medicine.
Why are Platelets important for Hemostasis?
Introduction
Coagulation Disorders
Hemostasis
Management
Microsoft clipart
CASE STUDY
Extrinsic Pathway
Intrinsic Pathway
Medications
Labs
Clinical Application
Summary
QUIZ
KLS presents to IR for permCath evaluation due to poor blood flow.
This is his third visit to IR in one mouth.
KLS requests a new catheter because he believes
something is wrong with the current catheter.
Lab tests prior to procedure reveal:
INR=1.0 (0.9-1.3), Plt = 654 (150-350), PTT 24 (25-33)
You change the catheter, but two weeks later he is back again.
It makes no sense to keep changing the catheter. It appears his body
is forming thrombi around the catheter causing decreased blood flow.
Medical Decision: In addition to performing a catheter stripping procedure,
he is started on Aspirin 325 mg by mouth MWF to help decrease platelet
aggregation. Aspirin would help to decrease platelet aggregation.
Medications that Affect Coagulation Cascade
Introduction
Some patients are on special
medications that increases
their risk for bleeding
Coagulation Disorders
Hemostasis
Management
Extrinsic Pathway
Intrinsic Pathway
Medications
Microsoft clipart
Labs
Clinical Application
Summary
Anticoagulants
(heparin, warfarin)
QUIZ
Thombolytics (tPA)
Anti-platelet agents
(ASA, Plavix, ticlid)
These medications can
complicate a procedure if not
managed appropriately.
Medications that Affect Coagulation Cascade
Introduction
Coagulation Disorders
Anticoagulants
Hemostasis
Management
Warfarin: is “prescribed to ~2 million new
patients per Year in US” (USA Today, 2010).
Therefore, your chance of having a patient
on this medication is high.
Extrinsic Pathway
Two commonly used drugs in the US are:
Intrinsic Pathway
Medications
Warfarin (Coumadin)
Heparin
Labs
Clinical Application
Vitamin K antagonist
Activate
anti-thrombin III
E.g. prescribed to patients with history of
DVT, PE, prosthetic heart valve etc.
Anticoagulants help with hemostasis
by preventing inappropriate blood clotting
in vessels.
They chip away at clot making it smaller
Summary
Prevents thrombosis in veins
QUIZ
Decrease production of
Factors II, VII, IX, X
Blocks thrombin
Prevent
thrombosis
Close hemostasis management is
important pre, intra, and post
procedure to prevent excessive
bleeding complications.
Remember labs: INR, PT
Heparin - released from tissue basophils and
inactivates thrombin.
Sternberg, S. (2010). Gene test cuts complications from blood thinner warfarin. USA Today.
Medications that Affect Coagulation Cascade
Introduction
Coagulation Disorders
Hemostasis
Management
Microsoft clipart
Microsoft clipart
Extrinsic Pathway
Intrinsic Pathway
Medications
Labs
Clinical Application
Warfarin (Coumadin)
Heparin
Deceases prothrombin & other
procoagulation factors
Found naturally in body
Vitamin K antagonist
Increase availability of
antithrombin III which decrease
formation of fibrin
Summary
QUIZ
36-72 hr to take effect
Oral prescription available
Huber, C. (2007). Anticoagulant Therapy Management. Cedar Rapids Healthcare Alliance.
http://en.wikipedia.org/wiki/Anticoagulant
IV/SC preparation only
Medications that Affect Coagulation Cascade
Introduction
Coagulation Disorders
Hemostasis
Management
Extrinsic Pathway
Why Give Heparin by IV or SC preparation
Versus taking it by mouth?
Intrinsic Pathway
Medications
Labs
Clinical Application
Summary
QUIZ
Answer
It is unable to cross membrane of GI Tract
Medications that Affect Coagulation Cascade
Introduction
Coagulation Disorders
Hemostasis
Management
A patient scheduled for central line placement in IR
with a recent history of Pulmonary Emboli (PE)
Anticoagulant medication: Warfarin 4 mg by mouth daily
Recent lab: INR 2.1 (0.9-1.3)
Extrinsic Pathway
Which of the following instructions should be given to the patient?
Intrinsic Pathway
Medications
Click on the correct response:
Labs
Clinical Application
Summary
a) Hold Warfarin 3 days before procedure
Initiate Lovenox therapy
Hold AM dose of Lovenox prior to procedure
Recheck INR prior to procedure
Correct
Due to different
half live of
preformed
clotting factors
QUIZ
b) Hold Warfarin 7 days before procedure
Initiate Lovenox therapy
Hold AM and PM dose of Lovenox prior to procedure
Recheck INR prior to procedure
c) Hold Warfarin 5 days prior to procedure
X No
Only need 3 days
X Try Again
Medications that Affect Coagulation Cascade
Introduction
Article Published by USA Today 3/16/2010
Coagulation Disorders
Title: Gene Test Cuts Complication from Blood Thinner
Warfarin
Hemostasis
Management
Extrinsic Pathway
Intrinsic Pathway
Medications
Labs
Clinical Application
Summary
QUIZ
Points from article:
It takes time for a doctor to settle on a safe and effective dose when
prescribing warfarin.
“Roughly 1 in 5 patients are hospitalized for bleeding within six months of
starting the drug. Others develop a life-threatening blood clot.”
“Warfarin is the second-greatest cause of hospitalization due to drug
complication.”
“Warfarin is prescribed to 2 million new patients in the USA each year.”
Genetic tests can be used to personalize warfarin treatment and
decrease the rate of hospitalization.
See full article at: http://www.usatoday.com/news/health/2010-03-16-warfarin-gene_N.htm
Sternberg, S. (2010). Gene test cuts complications from blood thinner warfarin. USA Today.
Medications that Affect Coagulation Cascade
Introduction
TB reported to IR for tunneled catheter evaluation with a
report from the dialysis center of poor blood flow.
Coagulation Disorders
Hemostasis
Management
Medical decision: tPA catheter
Post evaluation: Catheter flush & aspirate w/o difficulty
Extrinsic Pathway
FMLH Radiology
Intrinsic Pathway
Thombolytics (tPA)
Medications
Labs
A protein that breaks down blood clot
Clinical Application
A clot-busting medication
Summary
QUIZ
tPA
Catalyses
Plasminogen
Important for cell migration and tissue
healing
Increase activity = increase bleeding
Plasmin
Fibrin
Degradation
Thrombolytic drug. Retrieved March 19, 2010 from http://en.wikipedia.org/wiki/Thrombolytic_drug
Decreased activity = thrombosis
Medications that Affect Coagulation Cascade
Introduction
Coagulation Disorders
Hemostasis
Management
Anti-platelet agents
Extrinsic Pathway
Intrinsic Pathway
Two commonly used drugs in the US are:
Medications
Aspirin (ASA)
Ticlid
Labs
Suppress platelet aggregation
Clinical Application
Summary
Inhibit
COX enzyme
Blocks ADP
receptor on platelet
surface
Prevent thrombosis in arteries while
anticoagulants (Warfarin & heparin,
Prevent thrombosis in veins
QUIZ
Decrease Platelet
Synthesis of TXA2
Decrease Pathway
in platelet activation
Prevent Thrombus
formation
Antiplatelet. Retrieved March 19, 2010 from http://en.wikipedia.org/wiki/Antiplatelet_drug
King, K. W. (2010). Platelet Activation and von Willebrand Factor (vWF). IU School of Medicine.
Some Important Labs You Need to Know About
Introduction
If the procedure is invasive, hemostasis status should
be assessed and closely monitored. Tests needed will
be based on the procedure you will perform.
Coagulation Disorders
Hemostasis
Management
Extrinsic Pathway
Intrinsic Pathway
FMLH Radiology
Medications
Tests for Hemostasis--Needed Pre-Invasive Procedures
Labs
INR (.09-1.3)
Assess problems with extrinsic or common pathway
Clotting factors I, II, V, VII, X
Be aware of patients on anticoagulant therapy and patients with liver
disease
PT (10-13)
Same as INR
aPTT (25-33)
Assess problems with intrinsic pathway
Deficiency in Factor VIII, IX, XI.
Assess patients on heparin therapy or have history of von Willebrand
disease
Platelet count
(150-250)
Used to diagnose bleeding disorder e.g. DIC, thrombocytopenia
Abnormally low platelet count increase risk for excessive bleeding
Clinical Application
Summary
QUIZ
Malloy, P.C., Grassi, C. J., Kundy, S., Gervais, Miller, D. L., Osnis, R. B. et al. (2009). Consensus Guidelines for Periprocedural Management
of Coagulation Status and Hemostasis Risk in Percutaneous. Society of Interventional Radiology.
Functions of the Liver
Introduction
Most clotting Factors are produced in the
liver
Coagulation Disorders
Hemostasis
Management
Microsoft clipart
Extrinsic Pathway
Factor Name
Roman Numeral
Source
Fibrinogen
I
Liver
Medications
Prothrombin
II
Liver *
Labs
Tissue Factor
III
Damages cells
Calcium
IV
Gut and bone
Preaccelerin
V
Liver and platelet
Proconvertin
VII
Liver * *
Antihemophilic Factor
VIII
Platelets and endothelium
Christmas Factor
IX
Liver * *
Stuart-Prower Factor
X
Liver * *
Plasma thromboplastin antecedent
XI
Liver
Hageman Factor
XII
Liver
Fibrin-stabilizing Factor
XIII
Liver
Intrinsic Pathway
Clinical Application
Summary
QUIZ
* * Dependent on vitamin K for synthesis in liver
Nowak, T.J., Handford, G. A. (2004). Pathophysiology:
*
What Happens if the Liver is Damaged?
Introduction
Coagulation Disorders
Liver Damage
Tissue Damage
Hemostasis
Management
Decrease
Clotting Factor
Synthesis
Compromise
Bile synthesis
Extrinsic Pathway
Shortage of
Vitamin K
Intrinsic Pathway
Depletion of
Clotting Factors
Medications
Labs
Wellcome Images
Decrease clotting
Factor synthesis
Clinical Application
Hypocoagulation
Summary
QUIZ
 Liver disease (e.g. liver cancer, cirrhosis, fibrosis, hepatitis) will
decrease the synthesis of all liver dependent clotting factor
 Your body will take longer to clot, thereby increasing the risk for
bleeding
 INR lab - Will be elevated with severe liver damage
Porth, C.M., 2005. Pathophysiology, 7th edition. Lippincott.
What happens if the Liver is Damaged?
Introduction
Case Study
Coagulation Disorders
Hemostasis
Management
Patient with increased liver function test present to IR for
liver biopsy
Extrinsic Pathway
Intrinsic Pathway
Medications
Labs
Clinical Application
Summary
QUIZ
History of ESRD, kidney transplant, on immunosuppression,
basal cell carcinoma, fatty liver
Lab: Liver fn panel, Plt 99 (150-350) Hgb 7.2
Stat type & cross
IR medical team decision:
2 units packed RBC ordered, 1 unit infused prior to
procedure
Role of Inflammation & Effects on Coagulation
Introduction
•
Coagulation Disorders
Hemostasis
Management
•
Inflammation is a biochemical and cellular process that occurs in
vascularized tissues
Inflammation in the liver will affect coagulation
Extrinsic Pathway
Inflammation
Intrinsic Pathway
Medications
Liver Damage
Labs
Clinical Application
Summary
Decrease
Clotting Factor
Synthesis
Tissue
Damage
QUIZ
Wellcome Images
Depletion of
Clotting Factor
Hypocoagulation
Porth, C.M., 2005. Pathophysiology, 7th edition. Lippincott.
Role of Inflammation & Effects on Coagulation
Introduction
Coagulation Disorders
Hemostasis
Management
Extrinsic Pathway
Intrinsic Pathway
Medications
Labs
chronic inflammatory process (outside the liver) can
trigger the clotting cascade.
Clotting causes damage through lack of perfusion
(ischemia) to vital organs, such as the liver, kidneys,
heart which would then activates the clotting cascade
which increase clotting.
Chronic Inflammation
Clinical Application
Summary
QUIZ
Decrease activity of natural
anticoagulant mechanism
Impairs Fibrinolytic system
Hypercoagulation
Esmon, C. T. (2005). The interactions between inflammation and coagulation . British Journal of Haematology.
131(14) 417-430.
What happens if the Liver is Damaged?
Introduction
Coagulation Disorders
Hemostasis
Management
Extrinsic Pathway
Which of these Factors is not synthesized in the liver?
Click on the correct response:
Intrinsic Pathway
Medications
a) Prothrombin (Factor II)
Labs
b) Antihemophilic Factor (Factor VIII)
Clinical Application
Summary
X Incorrect
Correct
Source: Platelets and endothelium
c) Hageman Factor (Factor XII)
X No
d) Stuart-Prower Factor (Factor X)
X Try Again
QUIZ
Stress Adaptation Response & Effects on Coagulation
Introduction
Coagulation Disorders
Hemostasis
Management
Microsoft clipart
•The stress response protects the individual from
threats to homeostasis.
• Trauma as a result of percutaneous image-guided
procedures can induce the stress response
Extrinsic Pathway
Case Study
Intrinsic Pathway
Medications
Labs
Clinical Application
Summary
QUIZ
50 yr old Male presents to IR for treatment with drug eluting bead
chemoembolization
Diagnosed with neuroendocrine cancer w/liver metastasis
Had multiple hypertensive crises recently
BP 133/65 R=18 HR 72 wt=245#
The patient is at risk of a hypertensive crisis
Med requested = Alpha blockade
Medication ordered = phentolamine (REGITINE) 5 mg
Reason: Phentolamine prevent stress response (hypertensive crisis) which
may occur due to stress or due to a surgical procedure.
Hypertension damages the blood vessels thereby affecting the coagulation
cascade
Hehne, R. A. (2004). Pharmacology for Nursing Care. (5th Ed). Saunders. Missouri
Role of Aging & Effects on Coagulation
Introduction
Aging
Aging
Vitamin K
Deficiency **
**Defective Vessel
Support Due to
Weakness in
Connective Tissue
Coagulation Disorders
Hemostasis
Management
Extrinsic Pathway
Intrinsic Pathway
Medications
Labs
Decreased
Clotting Factor
Synthesis by Liver
Microsoft clipart
Clinical Application
Increased
Vessel Fragility
Summary
QUIZ
Hypocoagulation
Increase
Bleeding Risk
** Older patients will need more vitamin K
** With aging, the skin becomes thinner so tissues supporting underlying
blood vessels are more fragile
Toloza, E, (2005). Bruises. Department of Emergency Medicine, University of Texas at Houston School of Medicine.
Role of Genetics & Effects on Coagulation
Introduction
Coagulation Disorders
Hemostasis
Management
Extrinsic Pathway
Microsoft clipart
Intrinsic Pathway
Deficiencies in clotting factors may be due to genetics
Medications
Labs
Clinical Application
Factor VIII/IX Deficiency
Hemophilia
Summary
QUIZ
Factor V Deficiency
Owren’s Disease
Factor X Deficiency
Stuart-Prower Factor
Deficiency
Porth, C.M., 2005. Pathophysiology, 7th edition. Lippincott.
For all Bleeding and Clotting Disorders. Retrieved March 8, 2010 from
http://www.hemophilia.org/NHFWeb/MainPgs/MainNHF.aspx?menuid=176&contentid=378&rptname=bleeding
Taylor, A.K. (1997). Venous Thrombosis and the Factor V (Leiden) Mutation. The Mountain States Genetics Foundation (14).
Video Links
Introduction
Coagulation Disorders
Hemostasis
Management
A review of the coagulation cascade can be found at the following link
1. http://www.hopkinsmedicine.org/hematology/Coagulation.swf
Extrinsic Pathway
Intrinsic Pathway
Medications
Labs
Clinical Application
Summary
QUIZ
Microsoft clipart
A Closer Look at the “Hemostasis Process”
Introduction
Coagulation Disorders
Hemostasis
Management
Extrinsic Pathway
List The Five Stages for Achieving Hemostasis
Click each box to reveal the correct response
Vessel spasm
Intrinsic Pathway
Medications
Formation of platelet plug,
platelet adhesion, & aggregation
Labs
Clinical Application
Summary
Formation of fibrin clot
Activate intrinsic or extrinsic coagulation cascade
QUIZ
Clot retraction
Clot dissolution
Nowak, T.J., Handford, G. A. (2004). Pathophysiology:
Concepts and Applications for Health Care Professionals. (3rd Ed). McGraw-Hill. NY
Summary
Introduction
Coagulation Disorders
Hemostasis
Management
Extrinsic Pathway
Intrinsic Pathway
Medications
Labs
Clinical Application
Summary
The Interventional Radiology (IR) department multidisciplinary team work with
patients who have various types of coagulation disorders. Hemostasis
management is complex due to the wide array of patient co-morbidities of
patients undergoing percutaneous image-guided procedures in IR. This
complexity is further complicated by the wide range of procedures and patient
demographics.
Some patients are on special medications that increases their risk for bleeding
or have internal stents or other devices that predispose them to forming clots.
The use of Thombolytics (tPA), anti-coagulants (heparin, warfarin), or
anti-platelet agents (ASA, Plavix, ticlid) can complicate a procedure if not
managed appropriately.
QUIZ
Medical interdisciplinary team understanding of the various coagulation
disorders will assist in medical care to patients. This would include pre-op
measures to prevent lengthy delays or costly cancellation of procedures.
QUIZ
Introduction
Coagulation Disorders
Hemostasis
Management
Extrinsic Pathway
Intrinsic Pathway
Medications
Labs
Clinical Application
Summary
QUIZ
Answers
1. C
2. B
3. C
4. A
5. LIVER
1. The process of stopping blood loss is known as?
a)
Coagulation cascade
b)
Clot retraction
c)
Hemostasis
d)
Clot dissolution
2. For coagulation to work successfully we need these two pathways. Both pathways are
interrelated and link to form the common pathway.
a)
IR pathway AND clot retraction pathway
b)
Intrinsic pathway AND Extrinsic pathway
c)
Internal pathway AND External pathway
d)
None of the above
3. Calcium (Factor V) plays a key role in the coagulation cascade. It is “required in all but the first
two steps of the clotting process. The type of calcium needed in the coagulation cascade is?
a)
Calcium salts
b)
Protein bound calcium
c)
Ionized calcium
d)
Unbound calcium
4. Identify two commonly used anticoagulant medication used in the US. They can affect
hemostasis for patients undergoing percutaneous image-guided procedures in IR.
a)
Warfarin AND Heparin
b)
Aspirin AND Ticlid
c)
Tissue plasminogen activator (tPA) AND Streptokinase (SK)
d)
Prednisone AND Dexamethasone
5. Identify the organ where most of the clotting factors are synthesized: ____________________
Click here to reveal the answers
References
Introduction
Coagulation Disorders
Hemostasis
Management
Extrinsic Pathway
Intrinsic Pathway
Medications
Labs
Clinical Application
Summary
QUIZ
Porth, C.M., 2005. Pathophysiology, 7th edition. Lippincott.
Nowak, T.J., Handford, G. A. (2004). Pathophysiology: Concepts and Applications for Health Care Professionals. (3 rd Ed).
McGraw-Hill. NY
Hehne, R. A. (2004). Pharmacology for Nursing Care. (5th Ed). Saunders. Missouri
Rayfield, S., Manning, L. (1998). Nursing made Insanely Easy. (2nd Ed). ICAN Louisiana
Sternberg, S. (2010). Gene test cuts complications from blood thinner warfarin. USA Today.
Huber, C. (2007). Anticoagulant Therapy Management. Cedar Rapids Healthcare Alliance.
Guyton, A.C., Hall, J.E. 2000. Medical Physiology. 10th edition. Saunders.
Malloy, P.C., Grassi, C. J., Kundy, S., Gervais, Miller, D. L., Osnis, R. B. et al. (2009). Consensus Guidelines for
Periprocedural Management of Coagulation Status and Hemostasis Risk in Percutaneous. Society of Interventional
Radiology.
Hemostasis. Retrieved March 24, 2010 from
http://www.mhhe.com/biosci/esp/2002_general/Esp/folder_structure/tr/m1/s7/trm1s7_3.htm
Tissue Plasminogen Activator (tPA). Retrieved March 24, 2010 from
http://www.americanheart.org/presenter.jhtml?identifier=4751
Symptoms of Coagulation Disorders. Retrieved March 24, 2010 from http://www.signsofbleeding.com/index.php?page=4
Tissue plasminogen activator. Retrieved March 19, 2010 from http://en.wikipedia.org/wiki/Tissue_plasminogen_activator
Coagulation Cascade. Retrieved March 12, 2010 from http://www.hopkinsmedicine.org/hematology/Coagulation.swf
Thrombophilia or Hypercoagulable States. Retrieved March 12, 2010 from
http://www.peds.ufl.edu/residency/resources/hematology/th_states.pdf
Radiological Society of North America (2010). Radiology Info: the Radiology information for patients. Radiological Society
of North America, Inc.
For all Bleeding and Clotting Disorders. Retrieved March 8, 2010 from
http://www.hemophilia.org/NHFWeb/MainPgs/MainNHF.aspx?menuid=176&contentid=378&rptname=bleeding
Thrombolytic drug. Retrieved March 19, 2010 from http://en.wikipedia.org/wiki/Thrombolytic_drug
King, K. W. (2010). Platelet Activation and von Willebrand Factor (vWF). IU School of Medicine.
Molnar. J. (2010). Thrombolytics. Froedtert hospital Radiology Department.
Anticoagulants. Retrieved March 19, 2010 from http://en.wikipedia.org/wiki/Anticoagulant
Antiplatelet. Retrieved March 19, 2010 from http://en.wikipedia.org/wiki/Antiplatelet_drug
Ganda. K. (2005). The Clotting Pathway. TUFTSOPENCOURSEWARE ,Tufts University.
Toloza, E, (2005). Bruises. Department of Emergency Medicine, University of Texas at Houston School of Medicine.
References
Introduction
Coagulation Disorders
Hemostasis
Management
Taylor, A.K. (1997). Venous Thrombosis and the Factor V (Leiden) Mutation. The Mountain States Genetics Foundation
(14).
mcGilvray,I. , Rotstein, O.D.(2001). Assessment of Coagulation in Surgical Critical Care Patients. Department of surgery,
University of Toronto and Toronto General Hospital, Canada.
Esmon, C. T. (2005). The interactions between inflammation and coagulation . British Journal of Haematology. 131(14)
417-430.
Extrinsic Pathway
Intrinsic Pathway
Medications
Labs
Clinical Application
Summary
QUIZ
Contact Information
Nardalyn Johnson, RN
narjohnson@gmail.com