Differential bleeding management. János Fazakas MD, PhD, Associate Professor - PDF

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Differential bleeding management János Fazakas MD, PhD, Associate Professor GLOBÁLIS HEMOSZTÁZIS? COAGULATION FIBRINOLYSIS Kallikrein, Bradikinin 5 % 95 % Initiation Amplification Propagation XIIa Plasminogen

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Differential bleeding management János Fazakas MD, PhD, Associate Professor GLOBÁLIS HEMOSZTÁZIS? COAGULATION FIBRINOLYSIS Kallikrein, Bradikinin 5 % 95 % Initiation Amplification Propagation XIIa Plasminogen HEMOSTASIS = every time we deal with 4 Processes!!! Endothel tpa PROCESS DIRECTION = Activator/Inhibitor rapports T + TM XIIIa PROCESS RESERVE = Substrate quantitate Influenced by = Factors Half life and Production (minutes hours) Influenced APC by= (fast) Consumption, Loss, Dilution, Homeostasis Exstrinsic kinase AT-III (slow) ANTICOAGULATION ANTIFIBRINOLYSIS Plasmin SZERVSPECIFIKUS? PLT PLT monocyte 25% plasma volume static 75% plasma volume dynamic P-selectin+++ TF + TR ++ PAI tpa +++ TFPI +++ Heparan + TM +++ PCR +++ vwf absent TF + TR ++ PAI-1 + tpa + TFPI ++ Heparan +++ TM +++ Vascular bed-specific hemostasis balances BMC Systems Biology 2010,4:7-12 Int Care Med : Vascular bed-specific hemostasis control 1. The blood flow is natural anticoagulant Hypotension, hypoperfusion (IRI) is procoagulant 2. The hemostasis is regulated by anticoagulation and fibrinolysis i. AT III / Heparan ii. TM / protein C and S iii. TFPI iv. Plasmin / PA / PAI-1 Synthesis ; Consumption ; Degradation, Downregulation ICU pts: OP pts : downregulation of anticoagulant and fibrinolysis pathways loss of factors, dilution, vascular bed-specific consumption Semin Immunopathol (2012) 34: Circ Res. 2012;111: Differential bleeding management Systemic versus organ hemostasis PROCOAGULANTS vwf ++++ TF + TR ++ PAI EC ANTICOAGULANTS tpa + TFPI +++ Heparan +++ TM ++ Different endothelial cells Different expression of hemostatic factors Every organ define its hemostasis according to its function Crit Care Med 2001; 29 [Suppl.]:S28 S35 Differential bleeding management Vascular bed specific organ hemostasis vwf ++++ TF + TR + PAI tpa + TFPI + Heparan + TM absent high flow = anticoagulation Brain: TM absent, vwf, ICAM-VCAM, PAI-1 Semin Immunopathol (2012) 34: Circ Res. 2012;111: Differential bleeding management Vascular bed specific organ hemostasis vwf +++ TF + TR ++ PAI-1 ++ tpa + TFPI + PC + TM + high flow = anticoagulation Low flow = IRI = TF = procoagulation= microthrombosis Kidney medulla: vwf, TFPI, PC, TM Semin Immunopathol (2012) 34: Circ Res. 2012;111: Differential bleeding management Vascular bed specific organ hemostasis vwf ++/++ TF + TR ++ PAI-1 + tpa + TFPI ++ Heparan + TM ++ high flow = anticoagulation intermittent Heart: vwf, TFPI, TM, ICAM-VCAMM Semin Immunopathol (2012) 34: Circ Res. 2012;111: Differential bleeding management Vascular bed specific organ hemostasis vwf ++ TF + TR + PAI-1 + tpa ++++ TFPI +++ Heparan +++ TM ++++ low or medium flow Lung and intestins: TFPI, t PA, TM Semin Immunopathol (2012) 34: Circ Res. 2012;111: Differential bleeding management Vascular bed specific organ hemostasis vwf absent TF + TR ++ PAI-1 + tpa + TFPI +++ Heparan +++ TM ++++ low flow = 4-8 mmhg Liver: vwf absent, TFPI, Heparan, TM Semin Immunopathol (2012) 34: Circ Res. 2012;111: Differential bleeding management don t bleed don t coagulate Crit Care Med 2012; 40: ) Semin Immunopathol (2012) 34: ENDOTÉL TERÜLETEK? GLIKOKÁLIX? Normal microcirculation Degradation of glycocalyx after injury Degradation of glycocalyx after injury HOL ÉS HOGYAN VISELKEDIK A VÉR? ATC DIC Normal Properities of blood inside and outside the vessels Circulation Inside Outside Hemostasis No coagulation Coagulation Blood Hypercoagulable Hypocoagulable Hypocoagulable Thrombosis Bleeding Bleeding Gando, S. et al. J Thrombosis and Hemostasis. 2013; 11: A BETEGSÉG VAGY A MŰTÉT. Map of hemostasis during liver transplantation 6 10 AT III 4 2 Fibrinolysis Endogeneous heparinoids 0 Anesthesia Prepare for anhepatic phase Optimize all function hepatectomy hepatectomy anhepatic PV reperfusion Art reperfusion End of surgery POP 1 hour 0 A RÉGI EGYENSÚLY? Surgical hemostasis physiological hemostasis Case 1 Medical History: 15 years, ALF Solitary kidney!!! Progressive jaundice - 1 week ALF Department of Transplantation ICU OLT Split liver - cross clamp technique (VCI) The weakest organ: The liver: cause of transplant The most at risk organ: The solitary kidney The solution: to deal with all 4 processes of hemostasis Factors FDP Endogen heparinoids 75% PLT 25% fibrin tpa XIII XII Hemoglobin 98 g/l Hematocrit 29% Prothrombin 41% AT-III 25.8% INR 1.77 V. factor 27% VII. factor 22% X. factor 129% apti no coagulation Platelet 81 G/L Fibrinogen 0.6 g/l Trombocita szám és az aggregációs endothéliumok Koronária, KIR, vese Cadaver Donor 8 gr Fibrinogen IU Beriplex received on ICU in 12 hours OP Factors FDP Heparinoids 75% PLT 25% fibrin OLTx incision of the abdominal wall tpa XIII XII Hemoglobin 75 g/l Hematocrit 22 % Platelets 36 G/L Prothrombin 32% AT-III 61.5% INR 2.20 V. factor 31% VII. factor 9 % X. factor 110% apti no coag. Fibrinogen no coag. After 2000 IU Octaplex INR: activators / inhibitors = test = patient blood + healthy blood factors 75%PLT tpa Patient blood ACT 178s INR bedside 1,3 Patient Sick blood 1 ml + anesthesiologist Healthy blood 1ml mixture coagulation test improvement absence of activators mixture coagulation test no improvement presence of inhibitors 75% PLT 25% fibrin tpa? Factors Endogen heparinoids ACT 125 s 173 s INR bedside 5 gr Fibrinogen + 12 U Platelets + 5 U FFP IU AT III OLTx hepatectomy Factors FDP Endogen heparinoids 75% PLT 25% fibrin tpa XIII XII Hemoglobin 90 g/l Hematocrit 28% Prothrombin 57% AT-III 62 % INR 1.39 V. factor 52% VII. factor 44% X. factor 118% apti s Platelet 82 G/L Fibrinogen 1.90 g/l AMIKOR A REGIONÁLIS JOBB? Graftectomy failed local hemostasis (antiplatelet th.) Reintervention: bleeding hematoma Topical application of fibrinogen powder Surgical hemostasis physiological hemostasis Case 2 Medical History: L. R., 52 years male, ESRD HD AMI PCI = 2 coronary LAD BMS Clopidogrel + Aspirin 2012 KTX The weakest organ: The kidney: uremic patient Most at risk organ: The heart The renal graft: back table : lesions The solution: to deal with topical administration of fibrinogen and Tachosil Topical application of fibrinogen powder and Tachosil HCC HCC drain Chemo embolization attempt Topical application: 2 gr Hemocompletan, 1000 UI, 1000 UI Fibrogammin No Bleeding, Drain Removed Surgical hemostasis physiological hemostasis Case 4 Medical History: 35 years, 37 week gestation Emergency cesarean section Traumatic liver injury OP Transfer ICU systemic hemostasis OP local hemostasis: topical factors Weakest organ: The liver: injuried Most at risk organ: The others T 1/2 AT III (pregnancy) The solution: to deal with all 4 processes of hemostasis on the ICU + topical administration of fibrinogen and PCC Blood flow? Weakest organ? Most at risk organ? OP: loss, consumption, dilution ICU: Downregulation of anticoagulation and fibrinolysis MIKOR MÉRÜNK? Hb 96 gr/l Htc 0,28 Thrombocyta 352 G/L 52,2 % gátlás Prothrombin 63 % INR 1,29 Fibrinogén 5,5 g/l Bagi Lajosné Bagi Lajosné Bagi Lajosné MÉRÜNK ÉS A LIMFA? Differential bleeding management Vascular specific hemostasis: the lymphatics factors I -30%, II -60%, V -20%, VII -50% VIII - 30%, IX -25%, X -70%, XIII -30% ATIII -60% TEG and PTT, thrombin time various coagulation properties could be detected in blood and lymph.
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