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149 Cards in this Set
- Front
- Back
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4 steps involved in primary hemostasis...
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1. adhesion
2. activation 3. aggregation 4. production of fibrin |
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platelets have a life span of .....
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8-12 days
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nl platelet count is....
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150-400k
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approx _____% of platelet pool is sequestered in the speen
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33%
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what anchors the platelets to the wall of the damaged blood vessel?
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vWf
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vWF anchors platelets to the _____ layer of the _______.
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collagen
subendothelium |
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vWF is synthesized and released by ________
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endothelial cells
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vWF is factor...
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VIII (VIII:v or VII:R)
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______ is the most common inherited coagulation defect
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von Willebrand's
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______ should be suspected in any patient with an increased bleeding time despite a normal platelet count and normal clot retention
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von Willebrand's disease
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The more common form of von Willebrand's disease is characterized by insufficient production of vWF by_______
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endothelial cells
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______is a non-pressor analogue of arginine vasopresin
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DDAVP
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DDAVP causes.....
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release of endogenous vWF.
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a side effect of DDAVP administration is...
occurs in _______ |
hyponatremia
mostly children |
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DDAVP DOSE?
onset? duration of action.... |
0.3ug/kg IV for 15-20 minutes
30 minutes 4-6 hours |
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first line treatment for factor VIII deficiency?
2nd line tx? 3rd line tx? |
DDAVP.....vWF
cryoprecipitate factor VII concentrate |
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factor VIII concentrate used to treat...
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vWF
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vWF can be increased by giving....[2]
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DDAVP
cryoprecipitate |
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activation of platelets requires.....
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thrombin (IIa)
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_______ combines with the ______ receptor on the platelet surface to activate the platelet
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thrombin
thrombin receptor |
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activation of a platelet involves...
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a shape change in the platelet and the release of a variety of mediators involved in coagulation and bleeding
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mediators synthesized and released from activated platelets are..[2
these mediators _______ |
thromboxane A2
ADP promote platelet agregation |
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factor__ activates the platelet
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thrombin or factor IIa or
activated factor II |
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____ and _____ promote platelet agreagation by _______.
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thromboxane A2
ADP uncovering fibrinogen receptors |
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______ links platelets to each other.
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fibrinogen
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when the clot is only held together by fibrinogen, it is _____ soluble
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water
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factor 1 is _____
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fibrinogen
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the fibrinogen receptor is also known as.....
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GPIIB/IIIa
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pharmacological causes of aggregation disorders include...
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ASA cox inhibitor (no arachniddonic acid to thromboxane A2)
NSAIDS (torodol, ibuprofen) same as ASA, but temporary. ticlodipine (ticlid) ADP clopridogel (plavix) anti-ADP (lifetime of plts) dipyridamole (persantine) increases cAMP, prevents aggregation ANTI-FIBRINOGEN RECEPTOR eptifibatide (integraline) tirofiban (aggrastat) abciximab(reopro) |
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Anti-fibrinogen receptor drugs work by....
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preventing the linking of platelets
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the most common aquired clotting defect is from....
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inhibition of cox production by ASA or NSAIDS
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factor 1 is_____, made in the _______
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fibrinogen
liver |
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factor II is ______, made in... _____
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prothrombin
liver Vit K dependent |
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factor III is _____, made in...
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tissue factor or thromboplastin
vasular wall, released from truamatized cells |
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factor IV is ____, made in...
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calcium
diet |
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factor V is ______, made in...
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proaccelerin
liver |
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factor VII is _____, made in ....
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proconvertin
liver VIT K DEPENDENT |
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factor VIII:C is _____, made in.....
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anti-hemophiliac factor
liver |
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factor VIII:vWF is _____, made in.....
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VWF
vascular endothelial cells |
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factor IX is ______, made in...
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christmas factor
liver and other tissues VIT K denpendent |
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factor X is _____, made in.....
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stuart-power factor
liver VIT K denpendent |
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factor XI is _____, made in.....
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plasma-thromboplantin antecedent
liver |
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factor XII is _____, made in.....
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Hageman factor
liver |
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factor XIII is _____, made in.....
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fibrin stabilizing factor
liver |
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the Vitamin K dependent factors are...[6]
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II, VII, IX, X, protien S, protien C
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only factors not made in the liver [3]
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tissue thromboplastin
calcium vWF |
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________ regulates the production and release of factor VIII:C and serves as it's carrier in the blood
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VIII:vWF
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______ encases agregated platelets.
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fibrin
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_____ is insoluble in water.
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cross-linked fibrin
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cross-linking of fibrin requires factor _____.
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XIII aka fibrin stabilizing factor
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the final steps in fibrin production involve which pathways.
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extrinsic, intrinsic, common
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damage to the outside of (extrinsic) blood vessels triggers the release of _______
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thromboplastin (III)
*this is the first event in the extrinsic pathway |
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what is the first event in the extrinsic pathway.
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damage to the outside of (extrinsic) blood vessels triggers the release of thromboplastin (III)
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______ is the primary physiologic initiator of coagulation
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thromboplastin (III)
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thromboplastin (III)activates factor ___?
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VII (proconvertin)
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activated VII (proconvertin), when complexed on the surface of the platelet with ______ and ______ activates factor _____
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calcium (IV) and thromboplastin (IIIa)
Xa (stuart-prower factor) |
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trauma to the blood itself or exposure to collagen in a traumatized blood vessel wall activates factor_____.
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XIIa (Hageman)
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XIIa (hageman) activates _____.
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XIa (plasma thrombin antecendent)
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XIa (plasma thrombin antecedent) activates ______
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IXa (Christmas)
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IXa (Christmas), when complexed on the platelet surface with activated VIII:C and Ca++, activates ________
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Xa (stuart-prower factor)
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activated Xa (stuart-prower), when complexed on the platelet surface with activated ______ and _______ converts ______ to _____>
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Va (proaccelerin) and Ca++
II (prothrombin) to IIa (thrombin) |
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IIa (thrombin) converts _______ to _____ and in the presence of ______, cross-linking occurs
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fibrinogen (I) to fibrin
XIII (fibrin stabilizing) |
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______ helps position clotting factors on the surface of the platelet so biochemical reactions can occur.
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Calcium (IV)
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coumadin acts on the ______ pathways
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extrinsic and final common
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heparin acts on the _____ pathways
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intrinsic and final common
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the ACT assess what drug?
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heparin
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what activates complement..
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kallikrien from XIIa
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The factors of the extrinsic pathway are....
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3 and 7
thirty seven cents, outside the vessel |
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The factors of the intrinsic pathway are....
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12,11,9,8
fi you cannot buy the intrinsic pathway for $12, you can get it for 11.98. inside the vessel |
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The factors of the final common pathway are....
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10,5,2,1,13
the final common pathway can be purchased at the five and dime for 1 or 2 dollars on the 13th of the month |
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fibrin cross-linking occurs in the presence of factor______
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13
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coumadin interferes with the ____ pathway.
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extrinsic
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heparin interferes with the ___ pathway.
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intrinsic
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Hemophilia A is a deficiency of ____
treatment? |
factor VIII:C
FFP, CRYO (VIII) best is factor VIII concentrate |
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sex linked recessive genetic disorder that is carried by the female member of a kindred and affects males almost exclusively
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hemophilia A
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What is the 2nd most common inherited coagulation disorder?
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hemophilia A
1:10000 MALE BIRTHS |
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Christmas disease is....
treatment... |
hemophilia B, factor 9 deficiency
factor 9 concentrate |
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hemophilia B is.....
treatment... |
def of factor 9, Christmas disease
factor 9 concentrate |
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The most important clue to clinically significant bleeding disorder in an otherwise healthy patient is.....
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the history
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One of the most important questions to ask preoperatively deals with the ______ to prior operations.
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homestatic responses
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The most common reason fo coagulopathy in patients receiving massive blood transfusions is the lack of ______
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functioning platelets
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Platelets in stored blood are non functional after ____ days
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1-2 days
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Abnormalities of coagulation owing to dilutino of factors ___ and ___ can occur with massive transfusions, especially if packed cells are infused with a minimal volume of plasma
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5 and 8
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What is the only clinical indication for transfusion of packed RBC's?
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to increase the oxygen carrying capacity of the blood
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ALL coagulalants except _____ are present in FFP.
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platelets
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Cryo contains _______? [3]
other cryo facts? |
VIII C and vWF
I (fibrinogen) XIII harvested from thawing FFP enriched (concentrated) |
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One unit of RBCs will increase the HCT how much?
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3-4% or 1 gm/dl
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1cc/kg of RBC's will increase the HCT how much?
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1%
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one unit of platelets will increase plts count by...
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50000-10,000/mm3
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massive transfusion is defined as?
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1 complete blood volume transfused w/i 24 hours
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activated antithrombin III binds ___ and ___ greatly and ___, ___ and ____ to a lesser degree.
by attaching to these clotting factors, antithrombin (III) effectively removes them from circulation, thereby anticoagulating the blood what agent works by increasing the effectiveness of III 1,000 fold? |
2 (thrombin) and 10 greatly
9,11,12 heparin |
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How does Heparin work?
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by increasing the effectiveness of III 1,000 fold.
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Antithrombin III is made where?
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liver
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Antithrombin III neutralizes what?
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final common pathway factors thrombin(2) and Xa
and by forming complexes with intrinsic factors 9,11,12 |
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what is a required cofactor for heparin?
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antithrombin (III)
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heparin binds to what factor?
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III-antithrombin
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aquired antithrombin (III) deficiency states are found in patients with...
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liver cirrhosis and nephrotic syndrome
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What is the most common reason a patient is unresponsive to heparin?
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antithrombin (III) deficiency
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appropriate heparinization is indicated by an ACT of?
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>400 seconds
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if a patient is unresponsive top heaparin, what is the treatment?
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give FFP...replaces (III) antithrombin
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what factors does heparin inhibit?
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2 (thrombin) and
9,11,12 to a lesser degree |
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heparin blocks which pathway(s)
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intrinsic and common
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protamine has what charge?
how does it inhibit heparin what is this reaction called? |
positive
electrostatically binds with it, heparin is negatively charged a neutralization reaction |
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protamine reverses the action of heparin by....
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neutralization
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coumadin binds to ________ in the liver and competively inhibits ______.
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Vit K
Vit K |
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what are the 4 Vit K dependent clotting factor?
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2,7,9,10
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how does coumadin work?
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binds to viK, thereby depressing the productino of Vit K dependent clotting factors
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coumadin blocks which pathway(s)?
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extrinsic (7) and common (2/10)
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direct thrombin inhibitors (3)
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hirudin, Ximelagatran, Argatroban
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____ and _____ are acceptable alternatives to heparin for CPB.
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hirudin and aragatroban
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normal bleeding time?
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3-10 min
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normal platelet count?
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150-400K
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normal PT?
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12-14 sec
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PT assesses which pathways?
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extrinsic and common
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PTT assesses which pathways?
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intrinsic and common
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normal PTT?
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23-35 sec (40-100 barash)
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normal Thrombin Time
assesses which pathway? |
<30 sec
final common |
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normal ACT?
assess what? |
80-150 sec
adequacy of heparinization 400-450 (>480, barash) |
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normal fibrinogen?
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>150
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what is the inactive form of plasmin?
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plasminogen
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Plasminogen is made in the ______, circulates in the blood, and is incorporated into a clot as the clot is formed.
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liver
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what converts plasminogen to plasmin?
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uPA, tPA
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plasmin does what?
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BREAKS DOWN FIBRIN to fibrin split (degradation) products
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components of fibrinolytic system? [3]
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plasminoge
plasmin |
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plasminogen activators [3]
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tPA
uPA streptokinase |
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only plasminogen activator with affinity for fibrin
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tPA
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most widely used thronbolytic agent for intra-arterial infusion into peripheral systems and grafts
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urokinase
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streptokinase made by...
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beta-hemolytic streptococci
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tPA made by...
release stimulated by... works by... |
endothelial cells and released into the circulation
thrombin and venous stasis by avidly binding to fibrin, converts plasminogen to plasmin |
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aprotinin (trasylol) works by....
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inhibiting plasmin, which slows fibrin breakdown (anti-fibrinolytic)
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aprotinin (traysolol) indication?
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reduces intraoperative blood loss during cardiac surgery
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Amicar (EACA) and transexamic acid work by...
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preventing the breakdown of fibrin by displacing the plasim from the fibrin.
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Amicar indication?
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control of hemorrhage associated with primary fibinolysis caused by increased plasminogen activation
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Aprotinin and Amicar work by....
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inhibiting plasmin...when plasmin in inhibited, fibrin that is formed breaks down slowly so, bleeding is decreaed
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what is the most important action of aprotinin (traysolol)?
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potent inhibition of plasmin
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risks of Aprotinin (traysolol)?
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primary allergic reaction after first dose
severe anaphylaxis after second dose exacerbation of renal function increased risk for MI widespread thrombotic vascular occlusion after profound hypothermic perfusion |
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benefits of aprotinin
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reduces intra/postop bleeding
decrease need for donor blood can chorten operation reduce risk where bleding is big cause of mortality |
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commonly encountered problems associated with abnormal hemostasis are...[4]
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DIC
liver dz uremia multiple transfusion |
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DIC is a manifestation of .....
such as.... |
an underlying disease process
sepsis hemolysis (massive transfusion) ischemia trauma OB emergencies (abrupto, amniotic embolus) localized DIC (aneuysms, hemangioma, allograft rejections, glomerolonephritis) |
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what are the most common precipitating factors for DIC in surgical patients? [3]
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shock, ischemia, infection
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In DIC, lab abnormalities reflect....[2]
examples? |
consumption of clotting factors and enhanced fibrinolysis
decreased -plts -fibrinogen -prothrombin -V,VIII, XIII increased -fibrin split products |
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What is the most common cause of an isolated high PT?
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liver disease
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Liver disease coagulation defects causes....
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formation of plt plugs
-thrombocytopenia from hypersplenism -plts dysfunction from eleveated fibrin split products formation of fibrin clot on the surface of the plt -synthesis of all coagulation factors except VIII is decreased -elevated split products interferes with fibrin polymerization fibrinolysis -increased lytic activity d/t poor clearance of TPA |
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Liver disease coagulation defects treatment....
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replace clotting factors
FFP, cryo, Vit K |
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coagulation abnormalities associated with renal failure?
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uremia related problems
-plt dysfunction -fibrinolytic system is impaired |
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in ESRF, uremia realted problems with plt function stem from....
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poor adherence to subendothelial collagen
inhibition of thromboxane A lower ADP concentrations plt transfusions ineffective decreased fibrinogen and other factors |
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Treatment for coagulation abnormalities associated with renal failure? [3]
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dialysis, elevate Hct
Cryo DDAVP |
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with massive transfusion, which factors are deficient?
diffuse bleeding caused by... treatment? |
5 and 13
thrombocytopenia (low plts) plts, FFP, cryo |
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cryo has what factors?
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1 (fibrinogen),8,13
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