ANEMIA. Oral iron. IV iron gluconate (order set #233)

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1 PREVENTION

2 ANEMIA Oral iron IV iron gluconate (order set #233)

3 TRANSEXAMIC ACID Efficacy of IV TXA in Reducing Blood Loss After Elective C-section: Prospective, Randomized, Double-blind, Placebo Controlled Study 660 women 330 in each arm 1 g TXA IV over 5 minutes at least 10 minutes prior to skin incision Oxytocin given after delivery

4 TXA Mean blood loss less in TXA group TXA group has less patients with >1000 ml bleeds No increase in thrombotic events

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17 DIC AND TRANSFUSION

18 DIC DIAGNOSIS Depends on the appropriate test results in the proper clinical setting

19 DIC ETIOLOGIES Sepsis (up to 50%) Obstetrical complications Malignancy (up to 20%) Trauma (especially brain and crush) Severe toxins (snakes) Immunologic reaction (incompatible blood) Organ destruction (acute pancreatitis) Vascular abnormalities

20 OB DIC Acute Hemorrhagic DIC Placental abruption (50%) Eclampsia (up to 7%) Amniotic fluid embolus (50%) HELLP (20 to 84%) Eclampsia Acute fatty liver of pregnancy Massive Hemorrhage Septic abortion

21 DIC Activation of BOTH procoagulant and fibrinolytic pathways leading to thrombosis and bleeding Diverse etiologies

22 DIC Two PARADOXICAL clinical problems Tissue injury caused by disseminated microvascular thrombosis (macro too) Hemorrhage caused by consumption of coagulation factors and accelerated fibrinolysis Thrombosis AND Hemorrhage

23 DIC Clinical features ACUTE CHRONIC

24 DIC ACUTE Usually hemorrhage and thrombosis Diffuse bleeding Multi-organ failure Skin necrosis

25 DIC Major bleeding occurs in a minority (5-12%) of patients More common is organ failure secondary to intravascular thrombi

26 Placental abruption DIC The degree of placental separation tends to correlate with the severity of DIC The leakage of thromboplastin-like material (tissue factor) from the placenta may initiate the DIC Amniotic fluid embolism Amniotic fluid also can initiate the DIC

27 DIC DIAGNOSIS Diagnosis of DIC must encompass both clinical and laboratory information that is being continually monitored by repeating both lab tests and the clinical evaluation

28 DIC LABS DIC Profile (Wesley Lab) CBC (WBC, HBG, PLATELET COUNT) PTT PT/INR FIBRINOGEN D-DIMER FSP ORDER TESTS EVERY 30 MINUTES

29 DIC LAB RESULTS WITH ACUTE DIC Decreased platelet count Decreasing fibrinogen (look at trends) Increased PT/INR Increased PTT Increased D-DIMER Increased FSP

30 DIC LAB RESULTS WITH CHRONIC DIC Variable platelet count Normal PT/INR Normal PTT Normal or increased fibrinogen Increased D-DIMER Increased FSP

31 DIC FSP Detects BOTH Fibrinolysis Fibrinogenolysis D-DIMER Detects Fibrinolysis Plasmin degradation crosslinked fibrin

32 DIC FSP and D-DIMER They do NOT differentiate between SYSTEMIC fibrinolysis of DIC and the LOCALIZED fibrinolysis seen with surgery and trauma

33 TREATMENT DIC MOST IMPORTANT Control/correct the underlying triggering pathologic disease

34 TREATMENT DIC SUPPORTIVE CARE VOLUME EXPANSION TO CORRECT HYPOTENSION BLOOD PRODUCTS ONLY IF BLEEDING OR HIGH RISK FOR BLEEDING MBT

35 TREATMENT DIC BLOOD PRODUCTS ONLY IF BLEEDING OR HIGH RISK FOR BLEEDING (e.g. going to surgery) ONLY IF COAGULATION LABS ABNORMAL REPEAT COAG TESTS EVERY 30 MINUTES

36 TREATMENT DIC IF BLEEDING YELLOW blood can be life saving with severe hemorrhage If platelets less than 50,000, then transfuse platelets One plateletpheresis pack = therapeutic dose Transfuse as quickly as possible Keep at room temperature (do NOT put on ice)

37 TREATMENT DIC IF BLEEDING YELLOW blood can be life saving with severe hemorrhage If INR greater than or equal to 2, then transfuse Fresh Frozen Plasma (FFP) Therapeutic dose = 15 to 30 ml per kg (3-6 units) FFP must be thawed first (30 minutes) Transfuse as quickly as possible Blood warmer can be used Can be stored on ice in cooler

38 TREATMENT DIC IF BLEEDING YELLOW blood can be life saving with severe hemorrhage If fibrinogen less than 200, then transfuse cryo Therapeutic dose = units cryoprecipitate Cryoprecipitate must be thawed first Individual units that need to be pooled (30 minute) Prepooled 5 unit packs (15 minutes) Transfuse as quickly as possible Do not put cryoprecipitate on ice or in refrigerator

39 TREATMENT DIC IF BLEEDING -- RED blood can be life saving with severe hemorrhage -- RED blood used to keep hemoglobin greater than at least 7 (some say 8 to 10) -- Transfuse as quickly as possible (after first 15 minutes) -- Blood warmer can be used -- Blood can be stored on ice in cooler

40 TREATMENT DIC BLOOD PRODUCT USAGE IF BLEEDING YELLOW blood can be life saving with severe hemorrhage If fibrinogen less than 200 transfuse cryo If platelets less than 50,000 transfuse platelets If INR greater than or equal to 2...transfuse FFP RED blood used to keep hemoglobin greater than 7 at least (some say 8 to 10)

41 TREATMENT DIC REMEMBER IF BLEEDING IS ONLY MILD, THEN DO NOT TRANSFUSE JUST BECAUSE THE LABS ARE ABNORMAL BLOOD PRODUCTS JUST BUY YOU TIME TO TREAT THE UNDERLYING PROBLEM ONLY TRANSFUSE IF SIGNIFICANT BLEEDING OR INVASIVE PROCEDURE WITH RISK OF SIGNIFICANT BLEEDING

42 DIC Important to stress that DIC is NOT a disease in itself DIC is ALWAYS secondary to an underlying disorder that activates the coagulation and fibrinolytic systems TREAT THE UNDERLYING PROCESS FIRST

43 TREATMENT DIC If bleeding is uncontrollable Then order MASSIVE BLOOD TRANSFUSION (MBT) PROTOCOL