A

28-year-old man is brought in at emergency room department because of bleeding from a

right forearm laceration. He has stable vital signs. Rest of physical examination is unremarkable.

1. What are the major physiologic responses in the hemostatic process?
2. Explain the role of platelets in hemostasis.
3. Explain the role of coagulation system in hemostasis.

TXA cause • Vascular spasm (Vasoconstriction)
vasoconstriction o blood vessels’ first response to injury
1. Vasoconstriction
2. Platelet aggregation o produced by vascular smooth muscle cells: controlled by vascular endothelium,
-subendothelial collagen is which releases intravascular signals to control the contracting properties.
exposed which causes o When a blood vessel is damaged, there is an immediate reflex, initiated by local
aggregation and vwb factor sympathetic pain receptors, which helps promote vasoconstriction.
cause it to stick to each
other o The damaged vessels will constrict (vasoconstrict) which reduces the amount of
PrimaRy hemostasis- blood flow through the area and limits the amount of blood loss.
unstable clot o Collagen is exposed at the site of injury, the collagen promotes platelets to adhere
3. Coagulation
4. Fibrinolysis/ clot lysis
to the injury site.

• Platelet plug formation
o Platelets adhere to damaged endothelium to form a platelet plug (primary
hemostasis) and then degranulate. This process is regulated through
thromboregulation. Plug formation is activated by a glycoprotein called Von
Willebrand factor (vWF), which is found in plasma.
o When platelets come across the injured endothelium cells, they change shape,
release granules and ultimately become ‘sticky’. Platelets express certain
receptors, some of which are used for the adhesion of platelets to collagen. When
platelets are activated, they express glycoprotein receptors that interact with
other platelets, producing aggregation and adhesion.
o Platelets release cytoplasmic granules such as adenosine diphosphate (ADP),
serotonin and thromboxane A2. Adenosine diphosphate (ADP) attracts more
platelets to the affected area, serotonin is a vasoconstrictor and thromboxane A2
assists in platelet aggregation, vasoconstriction and degranulation. As more
chemicals are released more platelets stick and release their chemicals; creating
a platelet plug and continuing the process in a positive feedback loop.
o Platelets alone are responsible for stopping the bleeding of unnoticed wear and
tear of our skin on a daily basis. This is referred to as primary hemostasis.
o There are a dozen proteins that travel along the blood plasma in an inactive state
and are known as clotting factors. Once the platelet plug has been formed by the
platelets, the clotting factors begin creating the clot. When this occurs the clotting
factors begin to form a collagen fiber called fibrin. Fibrin mesh is then produced
all around the platelet plug, which helps hold the plug in place. Once this begins,
red and white blood cells become caught up in the fibrin mesh which causes the
clot to become even stronger. This step of coagulation is referred to as secondary
hemostasis.

• Blood coagulation
o third and final step in this rapid response reinforces the platelet plug
o Coagulation or blood clotting uses fibrin threads that act as a glue for the sticky
platelets. As the fibrin mesh begins to form, the blood is also transformed from a
liquid to a gel like substance through involvement of clotting factors and pro-
coagulants.
o The coagulation process is useful in closing up and maintaining the platelet plug
on larger wounds. The release of prothrombin also plays an essential part in the
coagulation process because it allows for the formation of a thrombus, or clot, to
form. This final step forces blood cells and platelets to stay trapped in the
wounded area.

A 40-year-old man is scheduled for laparoscopic cholecystectomy. He is not hypertensive and no
history of cardiac disease. CBC with platelet count reveals normal result except that the
Hemoglobin level is 9 g/dL. His BP 110/70, PR 84/min, RR 20/min, pink palpebral conjunctiva. The
rest of the physical examination is normal.

1. How would you do your preoperative evaluation in patients with anemia?
• The evaluation of the anemic preoperative patient should always begin with a thorough
Anemia can be due history and physical examination.
to: o elicit symptoms of bleeding such as menstrual blood loss, hematochezia, melena,
1. Nutritional hematemesis, hemoptysis, or hematuria
2. Internal Bleeding o symptoms related to the anemia and the body’s compensatory mechanisms, that
-PUD is, anginal chest pain, dyspnea, fatigue and palpitations
3. Menstrual Bleeding o any history of or symptoms of underlying illnesses, such as constitutional
4. Congenital
symptoms, malignancy, renal failure, endocrinopathies (thyroid disorders, for
-thalassemia
example), infections, or liver disease
-congenital
spherocytosis o past history of anemia is also important, including previous hemoglobin values and
therapies, onset, need for previous blood transfusions, splenectomy, and blood
If blood is further lost donations
can cause hypoxia o patient’s family history may contain a history of anemia, bleeding and other
hematological disorders, splenectomy, and early onset cholelithiasis, which may
As long as patient is indicate congenital hemolytic disorders
asymptomatic at 9g/dl o the social history should take into account occupational hazards and exposures,
no need to transfuse dietary habits, alcohol and illicit drug use, and a detailed list of all prescription and
But below 9 need to non-prescription medications, including herbal and over-the-counter medications
transfuse • Initial laboratory testing should include
o complete blood count (CBC)
o peripheral blood smear
o reticulocyte count: indication of bone marrow production, but it usually needs to
be corrected for differences in hematocrit and the effect of erythropoietin on the
marrow. This is done by calculating a reticulocyte production index (RPI)
 o stool guaiac, radiological, and endoscopic testing may be required in an effort to
exclude blood loss

2. Will you give blood transfusion preoperatively?
Anemia is the most common hematological problem in the preoperative patient. Often, it is a
sign of an underlying disease or condition that could affect the surgical outcome. Consequently,
blood transfusions are commonly given perioperatively to anemic patients.

3. What are the indications for transfusion in patients with low hemoglobin level?
Recently updated guidelines from the American Society of Anesthesiology recommend
transfusion if hemoglobin level is less than 6 g/dL and that transfusion is rarely necessary when
the level is more than 10 g/dL.1 When hemoglobin concentrations fall between 6 and 10 g/dL,
the guidelines state that transfusion decisions should be based on indication of organ ischemia,
risk of or ongoing bleeding, intravascular volume status, and susceptibility to complications of
inadequate oxygenation.

4. What are the factors to consider in deciding when to transfuse?
• hemoglobin concentration
• red cell volume
• circulatory status
• oxygen requirement

You are doing a preoperative evaluation in a 60-year-old man scheduled for colon surgery. He
has been taking clopidogrel for 8 months. On further examination, you noticed bruises and
ecchymosis on his right arm and left cervical area. No other significant findings.

1. How would you differentiate based on clinical characteristics between a platelet
disorder and coagulation disorder?
Abnormalities of platelet function are characterized by clinical bleeding of varying severity. In
most cases, patients present with mucocutaneous bleeding or excessive hemorrhage following
surgery or trauma (Order platelet count and bleeding time test). Evaluation of the coagulation
pathways relies on four relative simple tests: the activated partial thromboplastin time (APTT),
prothrombin time (PT), thrombin time (TT), and fibrinogen assays.

2. How will clopidogrel affect the outcome of surgery?
Clopidogrel is an inhibitor of platelet activation and aggregation through the irreversible binding
of its active metabolite to the P2Y12 class of ADP receptors on platelets. All antiplatelet drugs
used in the secondary prevention of thromboembolic diseases can cause intraoperative and
postoperative hemorrhagic complications. However, stopping these drugs before a procedure
exposes the patient to vascular problems with the potential for significant morbidity.

3. When do you stop clopidogrel prior to an elective surgery?
Stop platelet and wait for 7-10 days
before operation then check again for
the levels

Transfuse platelet during OR

Patients who are receiving clopidogrel and require elective non-cardiac surgery should
discontinue clopidogrel 7-10 days prior to surgery if the risk for cardiovascular events is low but
continue therapy if cardiovascular risk is high (Class IIa, Level B) to reduce risk of bleeding.

A 50-year-old man scheduled for Whipple’s surgery for an adenocarcinoma of the head of the
pancreas. He has been on warfarin treatment for valvular heart disease. His vital signs are normal.
He has icteric sclerae. There are bruises in the abdominal area and the rest of the physical
examination is normal. Temporarily stop warfarin
Have vitamin K ready and fresh frozen plasma
1. What laboratory exam will you request? Stop warfarin 4-5 days before surgery
Prothrombin time: to ensure you are taking your medications safely and not at increased risk for
bleeding. Usually when taking a "blood thinner," such as warfarin (Coumadin), the desired PT is
about one and a half times the normal PT.

2. What is the effect of warfarin in the coagulation system?
Warfarin inhibits vitamin K reductase, resulting in depletion of the reduced form of vitamin K.
Vitamin K is a cofactor needed for the activation of vitamin K-dependent coagulant proteins. The
synthesis of vitamin K-dependent coagulation factors II, VII, IX, and X and anticoagulant proteins
C and S is inhibited. This results in decreased prothrombin levels and a decrease in the amount
of thrombin generated and bound to fibrin. This reduces the thrombogenicity of clots.

3. When do you recommend to discontinue warfarin before an elective surgery?
The American College of Chest Physicians proposed guidelines for antithrombotic prophylaxis in
patients with different risk factors, and it recommends that if the annual risk for
thromboembolism is low, warfarin therapy can be withheld for 4-5 days before the procedure
without bridging.

4. If this was an emergency procedure, how would you reverse the effect of warfarin?
• Withdrawal of oral anticoagulants.
• Vitamin K.
• Fresh frozen plasma.
• Prothrombin complex concentrates.

A 21-year-old man is complaining of severe right knee pain. He has history of hemophilia A since
2 years old. On physical examination, there is hemarthrosis on the right knee.

1. What are the different congenital coagulation factor deficiencies?

2. What are the blood products used for the treatment of each type?

Affected is facto 8
3. How would you manage the patient? Sex linked
Give the missing factor or if none
Give cryoprecipitate more concentrated in clotting factors
***Read book abt Congenital factor deficiencies
And DIC, SEPSIS