a case, and something about it. r1, su hung chang a patient with antithrombin iii deficiency...
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A Case, and Something About It.
R1, SU HUNG CHANGR1, SU HUNG CHANG
• A patient with antithrombin III deficiency
• Preoperative evaluation of coagulation disorder
• 66 year-old female• antithrombin III deficiency with DVT
history• HTN, DM, CRF• Family History : DVT• Long-term oral anticoagulation
• 66 year-old female• antithrombin III deficiency with DVT
history• HTN, DM, CRF• Family History : DVT• Long-term oral anticoagulation
The CaseThe Case
• General weakness, malaise, soreness since late June
• Multiple migratory aching
• Fever
• General weakness, malaise, soreness since late June
• Multiple migratory aching
• Fever
Treating CourseTreating Course
• 6/25 : admitted to 淡水馬偕• Blood Culture : MRSA (+)• Image : abscess over R’t psoas
muscle; ostemyelitis was noted.• Conservative treatment
• 6/25 : admitted to 淡水馬偕• Blood Culture : MRSA (+)• Image : abscess over R’t psoas
muscle; ostemyelitis was noted.• Conservative treatment
• 7/15 : transferred to NTUH
• 7/29 : Tarry stool (+) : coumadin suspended
• PES : duodenal ulcer• No improvement;
surgical management is indicated
• 7/15 : transferred to NTUH
• 7/29 : Tarry stool (+) : coumadin suspended
• PES : duodenal ulcer• No improvement;
surgical management is indicated
手術過程很順利 , 對於病人有
antithrombin III deficiency 這個因素 , 並沒有發現在術中有特別的影響。 • 當初進行手術的
indication, 在術後皆達到解決 , 目前病人的復原情形大致良好。
某不具名的骨科住院醫師某不具名的骨科住院醫師 負責其 primary care的住院醫師負責其 primary care的住院醫師
Why this case ?Why this case ?
• Role of coagulation• Between anesthesia and
coagulation
• What can we do ?
Preoperative Assessment of Coagulation Disorder
• Miguel Cobas, MD• Int Anesthesiol Clin (39-1), 2001: p.1-
15
Thrombin : the most important coagulation
modulator
Thrombin : the most important coagulation
modulator
Antithrombin III : the major physiological inhibitor of coagulation
Antithrombin III : the major physiological inhibitor of coagulation
Bleeding or not bleeding, that is the question.Bleeding or not bleeding, that is the question.
Personal HistoryFamily HistoryMedicationPhysical
Examination
Personal HistoryFamily HistoryMedicationPhysical
Examination
The Evidence Speaking...The Evidence Speaking...
• The platelet count was abnormally low in less than 1.5% of patients, and further work-up rarely revealed any significant hematological abnormality.
• The PT and PTT were abnormal in 4.8% and 15.6% of patients, respectively.
• The PTT had no ability to predict the occurrence or absence of hemorrhage in a low-risk group, but it was a predictor of modest strength in the high-risk group.
• The platelet count was abnormally low in less than 1.5% of patients, and further work-up rarely revealed any significant hematological abnormality.
• The PT and PTT were abnormal in 4.8% and 15.6% of patients, respectively.
• The PTT had no ability to predict the occurrence or absence of hemorrhage in a low-risk group, but it was a predictor of modest strength in the high-risk group.
Munro et al. : Health Technol Assess 1997
Miguel Cobas said that...Miguel Cobas said that...
• Routine screening in an asymptomatic population yields no benefit or significantly changes the anesthetic plan or outcome.
• “...all patients receive a platelet count, PT, and PTT preoperatively if for no other purpose than to delineate baseline values.”
• Routine screening in an asymptomatic population yields no benefit or significantly changes the anesthetic plan or outcome.
• “...all patients receive a platelet count, PT, and PTT preoperatively if for no other purpose than to delineate baseline values.”
MGH : algorithm for preoperative coagulation testing
MGH : algorithm for preoperative coagulation testing
• Quantitative rather than qualitative• <20,000/mm3 : spontaneous bleeding• 20,000-100,000/mm3 : bleeding associated
with surgery/ trauma• >100,000/mm3 : adequate for any challenge
of hemostasis, assuming that function is normal.
• Qualitative test : PACT; PFA100
• Quantitative rather than qualitative• <20,000/mm3 : spontaneous bleeding• 20,000-100,000/mm3 : bleeding associated
with surgery/ trauma• >100,000/mm3 : adequate for any challenge
of hemostasis, assuming that function is normal.
• Qualitative test : PACT; PFA100
Platelet CountPlatelet Count
• Not an effective predictor of bleeding during surgery, particularly in patients with a negative bleeding history.
• Too many factors interfering with BT.• No role in preoperative evaluation of a
patient with negative history, even in those patients taking aspirin.
• Not an effective predictor of bleeding during surgery, particularly in patients with a negative bleeding history.
• Too many factors interfering with BT.• No role in preoperative evaluation of a
patient with negative history, even in those patients taking aspirin.
Bleeding TimeBleeding Time
Ferraris et al. : Surg Gynecol Obster, 1983
Prothrombin TimeProthrombin Time
An unspecific indicator of an extrinsic or common pathway
defect
An unspecific indicator of an extrinsic or common pathway
defect
• The integrity of the entire intrinsic pathway
• Sensitive to all of the factors other than VII and XIII
• To monitor heparin therapy
• The integrity of the entire intrinsic pathway
• Sensitive to all of the factors other than VII and XIII
• To monitor heparin therapy
Activated Partial Thromboplastin Time
Activated Partial Thromboplastin Time
When do we need it?When do we need it?
To monitor high-dose heparin anticoagulation, ex. cardiopulmonary bypass surgery
When an immediate measure of heparin anticoagulation is needed at bedside, ex. ECMO, vascular surgery, hemodialysis, cardiac catheterization...
Etomidate and thiopental inhibit platelet function in patients undergoing infrainguinal vascular surgery Etomidate and thiopental inhibit platelet function in patients undergoing infrainguinal vascular surgery
A. GRIES et al.Acta Anaesthesiol Scand 2001; 45: 449–457
A. GRIES et al.Acta Anaesthesiol Scand 2001; 45: 449–457
Etomidate & thiopental offered significant platelet inhibitory properties.Higher transfusion rates & prolonged operation times may be possible
Course of Molecular Hemostatic Markers During and After Different Surgical Procedures
Course of Molecular Hemostatic Markers During and After Different Surgical Procedures
The THR and hemicolectomy : strong activation of the procoagulatory and fibrinolytic systems. Much less pronounced : endoscopic
cholecystectomy, subtotal thyroid resection. Maximum activation : 1 to 2 hours
postoperatively.Hans-Joachim G. Siemens et al.Journal of Clinical Anesthesia 11:622–629, 1999
Hans-Joachim G. Siemens et al.Journal of Clinical Anesthesia 11:622–629, 1999
A Prospective, Randomized Comparison of Thromboelastographic Coagulation Profile in Patients Receiving Lactated Ringer’s Solution, 6% Hetastarch in
a Balanced-Saline Vehicle, or 6% Hetastarch in Saline During Major Surgery
A Prospective, Randomized Comparison of Thromboelastographic Coagulation Profile in Patients Receiving Lactated Ringer’s Solution, 6% Hetastarch in
a Balanced-Saline Vehicle, or 6% Hetastarch in Saline During Major Surgery
LR Group : a hypercoagulative profile persisting into the postoperative period.HS-BS Group : a lesser change in the coagulation
profile HS-NS Group : associated with a hypocoagulative
state.G. Martin, et al. : J Cardiothorac Vasc Anesth, Vol 16, No 4 (August), 2002: pp 441-446
G. Martin, et al. : J Cardiothorac Vasc Anesth, Vol 16, No 4 (August), 2002: pp 441-446
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