Hemostasis, Surgical bleeding

and transfusion

Kriengchai Prasongsukarn
Prasongsukarn,, MD, MSc
Assoc. Prof. of surgery,
Division of Cardiothoracic Surgery
Pramongkutklao Hospital and College of Medicine
 Case II

A 70
70--year old woman came to a hospital due
to RUQ abdominal pain with fever for 1 day.
She was diagnosed as gallstone with acute
cholecystitis. She underwent mitral valve
replacement 8 years ago and had been taken
oral warfarin (5
(5mg) once daily since then

She also revealed a history of recent admission
to another hospital due to acute myocardial
infarction 6 weeks ago. Her cardiologist
carried out a percutaneous coronary artery
balloon dilation and prescribed once-
once-a-day
dose of ASA 81 mg and plavix 75 mg.

How should we manage this patient?
Management

Bleeding problem?
Emergency surgery Vs
nonemergency surgery
 Need emergency surgery?

Emergency  go ahead for surgery : OK?
case 60 years old male, S/P MVR with mechanical valve, on
coumadin. He had MCA 2 hours ago, came to the hospital
V/S: BP80
BP80//60 PR 110/min.
110/min. PE.Guarding, abdominal
distension INR 6.0
Wait for INR < 1.5 before going to emergency Sx?
Vitamin K injection, prepare FFP, Cryo, PRC,
Plt and emergency Sx !!
 Non emergency case

Preoperative evaluation of coagulation and
hemostasis in surgical patient

Management of patient with anticoagulants
and antiplatelet drugs

Management of patient with CAD, Valvular
heart disease
 Preoperative evaluation of coagulation and
hemostasis in surgical patient

I: Clinical history
Abnormal bleeding
Bruising
Hospital admission in 5 year
Drug use
Anemia
Family Hx:
Hx: abnormal bleeding

II: Basic lab testing
Platelet count: Major operation >100
>100,,000
Minor operation >50
>50,,000
PT or INR : <1
<1.5
PTT
Bleeding time <=7
<=7 min
TEG study
 PT / INR

Factor I, II, V, VII, X

Extrinsic factor, common pathway

Factor VII :vitamin K dependent, Coumadin
Therapy

INR 1.3-1.5
 PTT

Factor I, II, V common pathway

VIII, IX, X, XII intrinsic pathway

Heparin therapy :keep 1.5-2.5 times
 Bleeding time

Ivy method

Less than 7 minutes

Abnormal: platelet dysfunction(intrinsic, drug
induced; ASA, Clopidogel,
Clopidogel, SK, tPA)
tPA)
VWD
Vascular defect
 TEG

Ability of clot formation

Quantitative factor to form clot

III: Underlying disease; Liver, kidney disease

IV: Other factors: prosthesis implantation,
Stent graft
 Management in patient with
anticoagulant/ antiplatelet going
surgery

ASA

Clopidogel

Ticlopidine

Warfarin
 ASA

Inhibit enzyme cyclooxygenase which prevent
synthesis of Thromboxane A2 (normally for
platelet aggregation)

Acute event 300 mg/day then long term with
75--150 mg/day
75

Decrease vascular event 25%
25%

Need dual therapy
 Clopidogrel / Ticlopidine

Inhibit ADP - induced platelet aggregation
(stop activating IIb/
IIb/IIIa complex)

Combine with ASA : decrease the incidence of
stent thrombosis

Clopidogel :onset action in 5 hours Vs
ticlopidine 7 days

Clopidogel : less side effect (GI and
Neutropenia))
Neutropenia

Ticlopidine need monitoring neutropenia q2wk
for 4 months at least
 Warfarin

block the production of Factors VII, IX, X, and
II by the liver

Normally controlled by vitamin K

Effect by some medications

INR monitor
 Recommendation

ASA should stop 5 days before elective Sx

Clopidogel should stop 7 days before elective
Sx

Warfarin should stop 3 days before elective
surgery

Heparin should stop 4 hours before surgery

IIb/
IIb/IIIa receptor antagonist should stop 4-12
hours before surgery (depend on short/ long
acting)
 Lab

Antiplatelet: bleeding time
Antiplatelet:

Warfarin:: INR
Warfarin

Heparin: PTT

IIb/
IIb/IIIa receptor antagonist: bleeding time
 Management of patient with CAD, Valvular
heart disease going surgery

Type of stent
POBA
Bare metal stent
DES

Type of valve
Mechanical valve
Tissue valve

POBA/ Bare metal stent :recommended dual
therapy for at least 4 weeks, then continue
ASA for one year

DES :recommended dual therapy for at least
3/6 months, then continue ASA for one year

CABG pt. can stop ASA/clopidogel
ASA/clopidogel in
necessity situation

Tissue valve :recommended warfarin for three
months in MV (INR 2.5-3) and ASA or
warfarin for three months in AV

Mechanical valve :recommended warfarin for
life, keep INR 3-3.5 for MV and 2.5-3 for AV

Atrial fibrillation :recommended warfarin,
keep INR 2-3 esp. in old patient (in high risk
patient INR 2.5-3.5 plus ASA)
 case management

Surgery :nonemergency

Preop evaluation (Hx
(Hx,, Lab: CBC, INR,
bleeding time)

Stop coumadin,
coumadin, ASA, clopidogel

Start Heparin, keep PTT 1.5

Before going to the OR, stop heparin 4 hours
on call to OR and start antiplatelet,
antiplatelet, coumadin
coumadin,,
heparin once finish from the OR

After the INR got to the level, stop heparin