Coagulation Disorders Coagulopathy Introduction Coagulation Disorders Hemostasis Management

Coagulation Disorders (Coagulopathy) Introduction Coagulation Disorders Hemostasis Management Extrinsic Pathway Intrinsic Pathway Presented by: Nardalyn Johnson, RN MSN Student Alverno College Medications Labs April 22, 2010 Clinical Application Summary QUIZ In collaboration with: Jim Molnar, APRN – Preceptor Jan Theis, APRN MSN 621 Instructors: Patricia Bowne Luanne Wielichowski

Coagulation Disorders Introduction Coagulation Disorders Hemostasis Management Extrinsic Pathway Intrinsic Pathway Medications Labs Clinical Application INTRODUCTION The Interventional Radiology (IR) department multidisciplinary team works with patients who have various types of coagulation disorders. Summary QUIZ Hemostasis management is complex due to the wide array of patient co-morbidities and demographics. Malloy, P. C. , Grassi, C. J. , Kundy, S. , Gervais, Miller, D. L. , Osnis, R. B. et al. (2009). Consensus Guidelines for Periprocedural Management of Coagulation Status and Hemostasis Risk in Percutaneous. Society of Interventional Radiology.

Coagulation Disorders Introduction Coagulation Disorders Hemostasis Management Extrinsic Pathway Intrinsic Pathway Medications Labs Clinical Application Summary QUIZ • Objectives – Review importance of hemostasis management in IR – Review coagulation disorders – Review the coagulation cascade (intrinsic and extrinsic pathways) – Identify common lab tests – Identify common medications that can affect hemostasis – Focus on clinical application of hemostasis in IR Special Note: – Whenever you see an underlined word, move the curser over the underlined word to view more information

Coagulation Disorders Introduction Coagulation Disorders Hemostasis Management Extrinsic Pathway Intrinsic Pathway Wellcome Images Medications Labs Clinical Application A group of conditions that cause an individual to experience either: Summary QUIZ Excessive bleeding Porth, C. M. , 2005. Pathophysiology, 7 th edition. Lippincott. Excessive Clotting

Case Study Introduction Coagulation Disorders Hemostasis Management Extrinsic Pathway Intrinsic Pathway Medications Labs Clinical Application Summary A 49 yr old male Presents to IR for placement of a perm. Cath to initiate dialysis. He returns to IR the following day due to excessive bleeding during dialysis. QUIZ BP 159/75 HR 76 Temp 97. 8 Lab: INR 1. 8 (0. 9 – 1. 3)

Coagulation Disorders Introduction Coagulation Disorders Hemostasis Management Extrinsic Pathway Intrinsic Pathway Medications Click the diagram to reveal the answer Why Does the IR multidisciplinary team need to be concerned about patients with clotting or bleeding disorders? Labs Clinical Application Summary QUIZ Hemostasis management

Hemostasis Introduction Definition: Hemostasis is the process of stopping blood loss. Coagulation Disorders Hemostasis Management This process occurs via the hemostatic mechanism known as blood coagulation Extrinsic Pathway Intrinsic Pathway It is regulated by “activators” and “inhibitors”. Medications Labs Clinical Application If Normal Summary Seals blood vessels and prevents blood loss and hemorrhage QUIZ If Abnormal Nowak, T. J. , Handford, G. A. (2004). Pathophysiology: Concepts and Applications for Health Care Professionals. (3 rd Ed). Mc. Graw-Hill. NY Causes inappropriate blood clotting or excessive bleeding

Why is Hemostasis Management Important? Introduction Coagulation Disorders Nursing Outcomes Hemostasis Management • Prevents cancellation of IR procedures due to appropriate pre-op procedure not done • Prevents excessive bleeding pre, intra, or post procedure Medications • Decreased risk for post-procedural thrombosis Labs • Achieves hemostasis pre, intra, and prior to discharge • Helps with healing • Provide appropriate patient education • Identify new protocols for patients with coagulation disorders • Early identification of at risk patients pre-procedure Extrinsic Pathway Intrinsic Pathway Clinical Application Summary QUIZ http: //www. vascularsolutions. co m/company-info/contact

Coagulation Disorders Introduction Coagulation Disorders Hemostasis management for patients undergoing percutaneous image-guided procedures can be complex due to the wide range of procedures and equally wide range of patient demographics and co-morbidities. Hemostasis Management Extrinsic Pathway Intrinsic Pathway Medications Labs Microsoft clipart Clinical Application Summary QUIZ Microsoft clipart Some patients are on special medications that increase their risk for bleeding or have internal stents or other devices that predispose them to forming clots. Malloy, P. C. , Grassi, C. J. , Kundy, S. , Gervais, Miller, D. L. , Osnis, R. B. et al. (2009). Consensus Guidelines for Periprocedural Management of Coagulation Status and Hemostasis Risk in Percutaneous. Society of Interventional Radiology.

A Closer Look at “Hemostasis process” Introduction Five Stages for Achieving Hemostasis Coagulation Disorders Click each box along the pathway to reveal the steps Move the curser over the underlined word to view more information Hemostasis Management Extrinsic Pathway Vessel spasm Intrinsic Pathway Medications Labs Clinical Application Summary Formation of platelet plug, platelet adhesion, & aggregation Formation of fibrin clot and activation of intrinsic or extrinsic coagulation cascade QUIZ Clot retraction Clot dissolution Nowak, T. J. , Handford, G. A. (2004). Pathophysiology: Concepts and Applications for Health Care Professionals. (3 rd Ed). Mc. Graw-Hill. NY

Coagulation Disorders Introduction Coagulation Disorders Clot retraction: is when the blood clot becomes smaller, squeezing serum from the clot and joining the edges of the broken vessel Hemostasis Management Clot retraction normally occurs within ____time after a clot is formed Extrinsic Pathway Intrinsic Pathway Medications Labs Clinical Application Summary Incorrect… This is abnormal and could be due to low platelet count NO……. This is not enough time and you are at risk for bleeding 5 to 10 minutes 8 to 10 hours 2 to 4 hours 20 – 60 minutes QUIZ TRY AGAIN……. It begins shortly after formation CORRECT! This is key for hemostasis

The Intrinsic and Extrinsic Coagulation Cascade Introduction Coagulation Disorders Hemostasis Management Extrinsic Pathway Intrinsic Pathway The coagulation cascade is one component of the hemostasis process. For coagulation to work successfully, we need both the “Intrinsic pathway” and the “extrinsic pathway. ” Both pathways are interrelated and link to form the common pathway. Here is a list of Factors that help to build the coagulation cascade Factor Name Roman Numeral Fibrinogen I Prothrombin II Tissue Factor III Calcium IV Clinical Application Preaccelerin V Summary Proconvertin VII Antihemophilic Factor VIII Christmas Factor IX Stuart-Prower Factor X Plasma thromboplastin antecedent XI Hageman Factor XII Fibrin-stabilizing Factor XIII Medications Labs QUIZ Nowak, T. J. , Handford, G. A. (2004). Pathophysiology: Concepts and Applications for Health Care Professionals. (3 rd Ed). Mc. Graw-Hill. NY Sometimes you will see them referenced by their original name. Other times you will see only the roman numeral references.

A Closer Look at “Normal Coagulation Cascade” Introduction Blood vessel damage Damaged Tissue Coagulation Disorders Hemostasis Management The Intrinsic Pathway The Extrinsic Pathway Ca 2+ Tissue Factor (III) Factor XII (from active. PLT) Cascade reaction Extrinsic Pathway Intrinsic Pathway Medications Labs Clinical Application Summary Proconvertin(VII) Factor V Factor III Ca 2+ PF 3 Plasma thromboplastin antecedent (XI) Factor X RBC & PLT get caught in mesh Forming blood clot Prothrombin Activator Prothrombin (II) Thrombin Cross-linked Fibrin mesh QUIZ Fibrinogen (I) Fibrin (monomer) Fibrin (polymer) Return to Calcium (Ca 2+) Factor XIII See step-by-step explanation on next slide Slide created by Nardayn Johnson

The Coagulation Cascade Explained (See previous slide) Introduction Coagulation Disorders Hemostasis Management q The extrinsic pathway gets initiated when there is damage to blood vessels or surrounding tissue (usually a fast process). q Factor III is released in response to damaged tissue which then activates Factor VII with the help of calcium ions. Extrinsic Pathway Intrinsic Pathway q The intrinsic pathway (a slower process) is then activated when factor XI gets activated by Factor XII from active platelets. Medications Labs q Activated factor XI and factor VII cause a cascade reaction which leads to the activation of factor X. Clinical Application Summary QUIZ q Activated Factor X with the help of calcium ions, Factor III, Factor V, and PF 3 activates prothrombin activator which then converts prothrombin to thrombin. q Next, thrombin converts fibrinogen to fibrin which forms a loose mesh. q Fibrin along with factor III forms a denser network of mesh fibers which can trap RBC & PLT forming a successful clot. Nowak, T. J. , Handford, G. A. (2004). Pathophysiology: Concepts and Applications for Health Care Professionals. (3 rd Ed). Mc. Graw-Hill. NY

The Intrinsic and Extrinsic Coagulation Cascade Introduction Coagulation Disorders Hemostasis Management Extrinsic Pathway Microsoft clipart Intrinsic Pathway Medications Labs Clinical Application Summary QUIZ ü Blood coagulation requires systematic activation of coagulation factors controlled by activators and inhibitors. ü It is vital to promoting healing after a patient undergoes any percutaneous imaging procedure. Porth, C. M. , 2005. Pathophysiology, 7 th edition. Lippincott.

The Intrinsic vs. Extrinsic Coagulation Cascade Introduction Coagulation Disorders Hemostasis Management Extrinsic Pathway The activation of one procoagulation factor/enzyme leads to the activation of the next factor, similar to a domino effect. “Most of the inactive procoagulation factors are present in the blood all the time. ” (Porth, 2005) Intrinsic Pathway Medications The Intrinsic pathway The Extrinsic pathway A slow Process Begins in the blood itself A faster Process Begins with damage to blood vessel or surrounding tissue Labs Clinical Application Summary QUIZ Need both for Hemostasis Extrinsic pathway Gets activated Small amount of Thrombin formed Stimulus to Intrinsic pathway Formation of more Thrombin Produce large Amount of Fibrin Return to Protein C Damage to tissue Porth, C. M. , 2005. Pathophysiology, 7 th edition. Lippincott. + Coagulation Successful

The Intrinsic vs. Extrinsic Coagulation Cascade Introduction CASE STUDY: Coagulation Disorders Hemostasis Management Extrinsic Pathway Intrinsic Pathway Medications Recall the 49 yr old male who presented to IR for placement of a perm. Cath to initiate dialysis. He returned to IR the following day due to excessive bleeding problems during dialysis. A defect in which pathway would cause bleeding problems? Labs Clinical Application Summary QUIZ Extrinsic Pathway Intrinsic Pathway Try Again. There’s a better answer Think about the procedure performed This is not be most correct response Both Correct!

The Intrinsic vs. Extrinsic Coagulation Cascade Introduction Coagulation Disorders Hemostasis Management Extrinsic Pathway Intrinsic Pathway Medications Labs Clinical Application Summary QUIZ Jim Molnar, 2010 – (Preceptor) Molnar. J. (2010). Thrombolytics. Froedtert hospital Radiology Department.

The Intrinsic vs. Extrinsic Coagulation Cascade Introduction Coagulation Disorders Hemostasis Management Extrinsic Pathway Intrinsic Pathway Medications Labs Abnormality in the clotting process can result if there is a problem with one or more factors (Porth, 2005). Clinical Application Summary QUIZ This can lead to inappropriate activation at any point along the pathway depending on the factor(s) causing the problem (Nowak, 2004). Porth, C. M. , 2005. Pathophysiology, 7 th edition. Lippincott. Nowak, T. J. , Handford, G. A. (2004). Pathophysiology: Concepts and Applications for Health Care Professionals. (3 rd Ed). Mc. Graw-Hill. NY

Why are Ca 2+, Vitamin K, Protein C, and Platelets Important? Introduction Ca 2+ Coagulation Disorders Hemostasis Management View coagulation pathway Calcium (ionized) Extrinsic Pathway Intrinsic Pathway Medications Labs Clinical Application Summary QUIZ • Calcium plays a key role in the coagulation cascade. It is “required in all but the first two steps of the clotting process. ” (Porth, 2005) • 3 types of calcium (calcium salts, protein bound, and ionized calcium) • **ionized calcium** aid in coagulation cascade • Calcium = Factor IV • Only need a small amount so patients with calcium deficiency will not necessarily exhibit any significant effect on coagulation cascade. • If calcium gets inactivated when it is removed from the body, then blood will not clot. Think about the EDTA tubes that you use to collect blood. They contain chelating agent that inactivates Ca++ that prevents the blood from clotting. Nowak, T. J. , Handford, G. A. (2004). Pathophysiology: Concepts and Applications for Health Care Professionals. (3 rd Ed). Mc. Graw-Hill. NY

Why are Ca 2+, Vitamin K, Protein C, and Platelets Important? Introduction Coagulation Disorders VITAMIN K Hemostasis Management Is a fat soluble vitamin and without it your blood will not clot Extrinsic Pathway Intrinsic Pathway Medications Labs Clinical Application Summary QUIZ FUNCTION OF VITAMIN K: Ø Needed by liver to produce clotting factors Ø Needed to produce clotting Factors such as VII, IX, X and to synthesize Protein C Ø Helps to regulate calcium…keeping it in your bones and out of your blood Ø Watch patients who are taking warfarin as it can decrease clotting by interfering with vitamin K and increase risk for excesses bleeding after a procedure Ø You do not need much—just enough to prevent you from bleeding to death Ø Older patients will need more vitamin K http: //www. hemophilia. org/NHFWeb/Main. Pgs/Main. NHF. aspx? menuid=176&contentid=378&rptname=bleeding

Why are Ca 2+, Vitamin K, Protein C, and Platelets Important? Introduction View Positive feedback Coagulation Disorders Hemostasis Management Extrinsic Pathway Intrinsic Pathway Medications Protein C A special anticoagulant protein. Activated Protein C functions as an anticoagulant, limiting clot formation (down regulates the coagulation cascade). Resistance to activated Protein C prevents Protein C from cleaving to Factor V and/or VIII. Labs Clinical Application Summary You need the help of vitamin K to help build Protein C. Do not confuse this with “C-reactive protein. ” This is produced in the liver and is a bi -product of inflammation. QUIZ Nowak, T. J. , Handford, G. A. (2004). Pathophysiology: Concepts and Applications for Health Care Professionals. (3 rd Ed). Mc. Graw-Hill. NY

Why are Ca 2+, Vitamin K, Protein C, and Platelets Important? Introduction Coagulation Disorders Hemostasis Management Extrinsic Pathway Intrinsic Pathway Medications Labs Clinical Application Summary QUIZ You found out during testing that JT has a Protein C deficiency. Click here This deficiency predisposes him to _____? Venous Thrombosis

Why are Platelets important for Hemostasis? Introduction Coagulation Disorders Hemostasis Management Extrinsic Pathway Wellcome Images Intrinsic Pathway Medications Labs Clinical Application Summary Ø Platelets are very important in hemostasis management Ø You need enough to prevent excessive bleeding, but too many can be problematic because they cause hypercoagulation QUIZ Ø Some patients may have internal stents or other devices that predispose them to forming clots Ø Cancer patients who have decreased platelet count are at increased risk for bleeding King, K. W. (2010). Platelet Activation and von Willebrand Factor (v. WF). IU School of Medicine.

Why are Platelets important for Hemostasis? Introduction Coagulation Disorders Hemostasis Management Microsoft clipart CASE STUDY Extrinsic Pathway Intrinsic Pathway Medications Labs Clinical Application Summary QUIZ KLS presents to IR for perm. Cath evaluation due to poor blood flow. This is his third visit to IR in one mouth. KLS requests a new catheter because he believes something is wrong with the current catheter. Lab tests prior to procedure reveal: INR=1. 0 (0. 9 -1. 3), Plt = 654 (150 -350), PTT 24 (25 -33) You change the catheter, but two weeks later he is back again. It makes no sense to keep changing the catheter. It appears his body is forming thrombi around the catheter causing decreased blood flow. Medical Decision: In addition to performing a catheter stripping procedure, he is started on Aspirin 325 mg by mouth MWF to help decrease platelet aggregation. Aspirin would help to decrease platelet aggregation.

Medications that Affect Coagulation Cascade Introduction Some patients are on special medications that increases their risk for bleeding Coagulation Disorders Hemostasis Management Extrinsic Pathway Intrinsic Pathway Medications Microsoft clipart Labs Clinical Application Summary Anticoagulants (heparin, warfarin) QUIZ Thombolytics (t. PA) Anti-platelet agents (ASA, Plavix, ticlid) These medications can complicate a procedure if not managed appropriately.

Medications that Affect Coagulation Cascade Introduction Coagulation Disorders Anticoagulants Hemostasis Management Extrinsic Pathway Two commonly used drugs in the US are: Intrinsic Pathway Medications Warfarin (Coumadin) Heparin Labs Clinical Application Vitamin K antagonist Summary QUIZ Activate anti-thrombin III Warfarin: is “prescribed to ~2 million new patients per Year in US” (USA Today, 2010). Therefore, your chance of having a patient on this medication is high. E. g. prescribed to patients with history of DVT, PE, prosthetic heart valve etc. Anticoagulants help with hemostasis by preventing inappropriate blood clotting in vessels. They chip away at clot making it smaller Prevents thrombosis in veins Decrease production of Factors II, VII, IX, X Blocks thrombin Prevent thrombosis Close hemostasis management is important pre, intra, and post procedure to prevent excessive bleeding complications. Remember labs: INR, PT Heparin - released from tissue basophils and inactivates thrombin. Sternberg, S. (2010). Gene test cuts complications from blood thinner warfarin. USA Today.

Medications that Affect Coagulation Cascade Introduction Coagulation Disorders Hemostasis Management Microsoft clipart Extrinsic Pathway Intrinsic Pathway Medications Labs Clinical Application Warfarin (Coumadin) Heparin Deceases prothrombin & other procoagulation factors Found naturally in body Vitamin K antagonist Increase availability of antithrombin III which decrease formation of fibrin Summary QUIZ 36 -72 hr to take effect Oral prescription available Huber, C. (2007). Anticoagulant Therapy Management. Cedar Rapids Healthcare Alliance. http: //en. wikipedia. org/wiki/Anticoagulant IV/SC preparation only

Medications that Affect Coagulation Cascade Introduction Coagulation Disorders Hemostasis Management Extrinsic Pathway Why Give Heparin by IV or SC preparation Versus taking it by mouth? Intrinsic Pathway Medications Labs Clinical Application Summary QUIZ Answer It is unable to cross membrane of GI Tract

Medications that Affect Coagulation Cascade Introduction Coagulation Disorders Hemostasis Management Extrinsic Pathway A patient scheduled for central line placement in IR with a recent history of Pulmonary Emboli (PE) Anticoagulant medication: Warfarin 4 mg by mouth daily Recent lab: INR 2. 1 (0. 9 -1. 3) Which of the following instructions should be given to the patient? Intrinsic Pathway Medications Labs Clinical Application Summary Click on the correct response: a) Hold Warfarin 3 days before procedure Initiate Lovenox therapy Hold AM dose of Lovenox prior to procedure Recheck INR prior to procedure üCorrect Due to different half live of preformed clotting factors QUIZ b) Hold Warfarin 7 days before procedure Initiate Lovenox therapy Hold AM and PM dose of Lovenox prior to procedure Recheck INR prior to procedure c) Hold Warfarin 5 days prior to procedure X No Only need 3 days X Try Again

Medications that Affect Coagulation Cascade Introduction Coagulation Disorders Hemostasis Management Extrinsic Pathway Intrinsic Pathway Medications Labs Clinical Application Summary QUIZ Article Published by USA Today 3/16/2010 Title: Gene Test Cuts Complication from Blood Thinner Warfarin Points from article: It takes time for a doctor to settle on a safe and effective dose when prescribing warfarin. “Roughly 1 in 5 patients are hospitalized for bleeding within six months of starting the drug. Others develop a life-threatening blood clot. ” “Warfarin is the second-greatest cause of hospitalization due to drug complication. ” “Warfarin is prescribed to 2 million new patients in the USA each year. ” Genetic tests can be used to personalize warfarin treatment and decrease the rate of hospitalization. See full article at: http: //www. usatoday. com/news/health/2010 -03 -16 -warfarin-gene_N. htm Sternberg, S. (2010). Gene test cuts complications from blood thinner warfarin. USA Today.

Medications that Affect Coagulation Cascade Introduction TB reported to IR for tunneled catheter evaluation with a report from the dialysis center of poor blood flow. Coagulation Disorders Hemostasis Management Medical decision: t. PA catheter Post evaluation: Catheter flush & aspirate w/o difficulty Extrinsic Pathway FMLH Radiology Intrinsic Pathway Thombolytics (t. PA) Medications Labs Clinical Application A protein that breaks down blood clot A clot-busting medication Summary QUIZ t. PA Catalyses Plasminogen Important for cell migration and tissue healing Increase activity = increase bleeding Plasmin Fibrin Degradation Thrombolytic drug. Retrieved March 19, 2010 from http: //en. wikipedia. org/wiki/Thrombolytic_drug Decreased activity = thrombosis

Medications that Affect Coagulation Cascade Introduction Coagulation Disorders Hemostasis Management Anti-platelet agents Extrinsic Pathway Intrinsic Pathway Two commonly used drugs in the US are: Medications Labs Clinical Application Summary Aspirin (ASA) Ticlid Suppress platelet aggregation Inhibit COX enzyme Blocks ADP receptor on platelet surface Prevent thrombosis in arteries while anticoagulants (Warfarin & heparin, Prevent thrombosis in veins QUIZ Decrease Platelet Synthesis of TXA 2 Decrease Pathway in platelet activation Prevent Thrombus formation Antiplatelet. Retrieved March 19, 2010 from http: //en. wikipedia. org/wiki/Antiplatelet_drug King, K. W. (2010). Platelet Activation and von Willebrand Factor (v. WF). IU School of Medicine.

Some Important Labs You Need to Know About Introduction If the procedure is invasive, hemostasis status should be assessed and closely monitored. Tests needed will be based on the procedure you will perform. Coagulation Disorders Hemostasis Management Extrinsic Pathway Intrinsic Pathway FMLH Radiology Medications Tests for Hemostasis--Needed Pre-Invasive Procedures Labs INR (. 09 -1. 3) Assess problems with extrinsic or common pathway Clotting factors I, II, V, VII, X Be aware of patients on anticoagulant therapy and patients with liver disease PT (10 -13) Same as INR a. PTT (25 -33) Assess problems with intrinsic pathway Deficiency in Factor VIII, IX, XI. Assess patients on heparin therapy or have history of von Willebrand disease Platelet count (150 -250) Used to diagnose bleeding disorder e. g. DIC, thrombocytopenia Abnormally low platelet count increase risk for excessive bleeding Clinical Application Summary QUIZ Malloy, P. C. , Grassi, C. J. , Kundy, S. , Gervais, Miller, D. L. , Osnis, R. B. et al. (2009). Consensus Guidelines for Periprocedural Management of Coagulation Status and Hemostasis Risk in Percutaneous. Society of Interventional Radiology.

Functions of the Liver Introduction Most clotting Factors are produced in the liver Coagulation Disorders Hemostasis Management Microsoft clipart Extrinsic Pathway Intrinsic Pathway Medications Labs Clinical Application Summary QUIZ Factor Name Roman Numeral Source Fibrinogen I Liver Prothrombin II Liver * Tissue Factor III Damages cells Calcium IV Gut and bone Preaccelerin V Liver and platelet Proconvertin VII Liver * * Antihemophilic Factor VIII Platelets and endothelium Christmas Factor IX Liver * * Stuart-Prower Factor X Liver * * Plasma thromboplastin antecedent XI Liver Hageman Factor XII Liver Fibrin-stabilizing Factor XIII Liver * * Dependent on vitamin K for synthesis in liver Nowak, T. J. , Handford, G. A. (2004). Pathophysiology: *

What Happens if the Liver is Damaged? Introduction Coagulation Disorders Liver Damage Tissue Damage Hemostasis Management Decrease Clotting Factor Synthesis Compromise Bile synthesis Extrinsic Pathway Shortage of Vitamin K Intrinsic Pathway Medications Labs Wellcome Images Depletion of Clotting Factors Decrease clotting Factor synthesis Clinical Application Hypocoagulation Summary QUIZ Ø Liver disease (e. g. liver cancer, cirrhosis, fibrosis, hepatitis) will decrease the synthesis of all liver dependent clotting factor Ø Your body will take longer to clot, thereby increasing the risk for bleeding Ø INR lab - Will be elevated with severe liver damage Porth, C. M. , 2005. Pathophysiology, 7 th edition. Lippincott.

What happens if the Liver is Damaged? Introduction Coagulation Disorders Hemostasis Management Extrinsic Pathway Intrinsic Pathway Medications Labs Clinical Application Summary QUIZ Case Study Patient with increased liver function test present to IR for liver biopsy History of ESRD, kidney transplant, on immunosuppression, basal cell carcinoma, fatty liver Lab: Liver fn panel, Plt 99 (150 -350) Hgb 7. 2 Stat type & cross IR medical team decision: 2 units packed RBC ordered, 1 unit infused prior to procedure

Role of Inflammation & Effects on Coagulation Introduction • Coagulation Disorders Hemostasis Management • Inflammation is a biochemical and cellular process that occurs in vascularized tissues Inflammation in the liver will affect coagulation Extrinsic Pathway Inflammation Intrinsic Pathway Medications Liver Damage Labs Clinical Application Summary Decrease Clotting Factor Synthesis Tissue Damage QUIZ Wellcome Images Depletion of Clotting Factor Hypocoagulation Porth, C. M. , 2005. Pathophysiology, 7 th edition. Lippincott.

Role of Inflammation & Effects on Coagulation Introduction Coagulation Disorders Hemostasis Management Extrinsic Pathway Intrinsic Pathway Medications Labs chronic inflammatory process (outside the liver) can trigger the clotting cascade. Clotting causes damage through lack of perfusion (ischemia) to vital organs, such as the liver, kidneys, heart which would then activates the clotting cascade which increase clotting. Chronic Inflammation Clinical Application Summary QUIZ Decrease activity of natural anticoagulant mechanism Impairs Fibrinolytic system Hypercoagulation Esmon, C. T. (2005). The interactions between inflammation and coagulation. British Journal of Haematology. 131(14) 417 -430.

What happens if the Liver is Damaged? Introduction Coagulation Disorders Hemostasis Management Extrinsic Pathway Which of these Factors is not synthesized in the liver? Click on the correct response: Intrinsic Pathway Medications a) Prothrombin (Factor II) Labs Clinical Application Summary b) Antihemophilic Factor (Factor VIII) X Incorrect Correct Source: Platelets and endothelium c) Hageman Factor (Factor XII) X No d) Stuart-Prower Factor (Factor X) X Try Again QUIZ

Stress Adaptation Response & Effects on Coagulation Introduction Coagulation Disorders Hemostasis Management Microsoft clipart • The stress response protects the individual from threats to homeostasis. • Trauma as a result of percutaneous image-guided procedures can induce the stress response Extrinsic Pathway Intrinsic Pathway Medications Labs Clinical Application Summary QUIZ Case Study 50 yr old Male presents to IR for treatment with drug eluting bead chemoembolization Diagnosed with neuroendocrine cancer w/liver metastasis Had multiple hypertensive crises recently BP 133/65 R=18 HR 72 wt=245# The patient is at risk of a hypertensive crisis Med requested = Alpha blockade Medication ordered = phentolamine (REGITINE) 5 mg Reason: Phentolamine prevent stress response (hypertensive crisis) which may occur due to stress or due to a surgical procedure. Hypertension damages the blood vessels thereby affecting the coagulation cascade Hehne, R. A. (2004). Pharmacology for Nursing Care. (5 th Ed). Saunders. Missouri

Role of Aging & Effects on Coagulation Introduction Coagulation Disorders Hemostasis Management Extrinsic Pathway Aging Vitamin K Deficiency ** **Defective Vessel Support Due to Weakness in Connective Tissue Intrinsic Pathway Medications Labs Decreased Clotting Factor Synthesis by Liver Microsoft clipart Clinical Application Increased Vessel Fragility Summary QUIZ Hypocoagulation Increase Bleeding Risk ** Older patients will need more vitamin K ** With aging, the skin becomes thinner so tissues supporting underlying blood vessels are more fragile Toloza, E, (2005). Bruises. Department of Emergency Medicine , University of Texas at Houston School of Medicine.

Role of Genetics & Effects on Coagulation Introduction Coagulation Disorders Hemostasis Management Extrinsic Pathway Microsoft clipart Intrinsic Pathway Deficiencies in clotting factors may be due to genetics Medications Labs Clinical Application Factor VIII/IX Deficiency Hemophilia Summary QUIZ Factor V Deficiency Owren’s Disease Factor X Deficiency Stuart-Prower Factor Deficiency Porth, C. M. , 2005. Pathophysiology, 7 th edition. Lippincott. For all Bleeding and Clotting Disorders. Retrieved March 8, 2010 from http: //www. hemophilia. org/NHFWeb/Main. Pgs/Main. NHF. aspx? menuid=176&contentid=378&rptname=bleeding Taylor, A. K. (1997). Venous Thrombosis and the Factor V (Leiden) Mutation. The Mountain States Genetics Foundation (14).

Video Links Introduction Coagulation Disorders Hemostasis Management A review of the coagulation cascade can be found at the following link 1. http: //www. hopkinsmedicine. org/hematology/Coagulation. swf Extrinsic Pathway Intrinsic Pathway Medications Labs Clinical Application Summary QUIZ Microsoft clipart

A Closer Look at the “Hemostasis Process” Introduction Coagulation Disorders Hemostasis Management Extrinsic Pathway List The Five Stages for Achieving Hemostasis Click each box to reveal the correct response Vessel spasm Intrinsic Pathway Medications Labs Clinical Application Summary Formation of platelet plug, platelet adhesion, & aggregation Formation of fibrin clot Activate intrinsic or extrinsic coagulation cascade QUIZ Clot retraction Clot dissolution Nowak, T. J. , Handford, G. A. (2004). Pathophysiology: Concepts and Applications for Health Care Professionals. (3 rd Ed). Mc. Graw-Hill. NY

Summary Introduction Coagulation Disorders Hemostasis Management Extrinsic Pathway Intrinsic Pathway Medications Labs Clinical Application Summary The Interventional Radiology (IR) department multidisciplinary team work with patients who have various types of coagulation disorders. Hemostasis management is complex due to the wide array of patient co-morbidities of patients undergoing percutaneous image-guided procedures in IR. This complexity is further complicated by the wide range of procedures and patient demographics. Some patients are on special medications that increases their risk for bleeding or have internal stents or other devices that predispose them to forming clots. The use of Thombolytics (t. PA), anti-coagulants (heparin, warfarin), or anti-platelet agents (ASA, Plavix, ticlid) can complicate a procedure if not managed appropriately. QUIZ Medical interdisciplinary team understanding of the various coagulation disorders will assist in medical care to patients. This would include pre-op measures to prevent lengthy delays or costly cancellation of procedures.

QUIZ Introduction Coagulation Disorders Hemostasis Management Extrinsic Pathway Intrinsic Pathway Medications Labs Clinical Application Summary QUIZ Answers 1. C 2. B 3. C 4. A 5. LIVER 1. The process of stopping blood loss is known as? a) Coagulation cascade b) Clot retraction c) Hemostasis d) Clot dissolution 2. For coagulation to work successfully we need these two pathways. Both pathways are interrelated and link to form the common pathway. a) IR pathway AND clot retraction pathway b) Intrinsic pathway AND Extrinsic pathway c) Internal pathway AND External pathway d) None of the above 3. Calcium (Factor V) plays a key role in the coagulation cascade. It is “required in all but the first two steps of the clotting process. The type of calcium needed in the coagulation cascade is? a) Calcium salts b) Protein bound calcium c) Ionized calcium d) Unbound calcium 4. Identify two commonly used anticoagulant medication used in the US. They can affect hemostasis for patients undergoing percutaneous image-guided procedures in IR. a) Warfarin AND Heparin b) Aspirin AND Ticlid c) Tissue plasminogen activator (t. PA) AND Streptokinase (SK) d) Prednisone AND Dexamethasone 5. Identify the organ where most of the clotting factors are synthesized: __________ Click here to reveal the answers

References Introduction Coagulation Disorders Hemostasis Management Extrinsic Pathway Intrinsic Pathway Medications Labs Clinical Application Summary QUIZ Porth, C. M. , 2005. Pathophysiology, 7 th edition. Lippincott. Nowak, T. J. , Handford, G. A. (2004). Pathophysiology: Concepts and Applications for Health Care Professionals. (3 rd Ed). Mc. Graw-Hill. NY Hehne, R. A. (2004). Pharmacology for Nursing Care. (5 th Ed). Saunders. Missouri Rayfield, S. , Manning, L. (1998). Nursing made Insanely Easy. (2 nd Ed). ICAN Louisiana Sternberg, S. (2010). Gene test cuts complications from blood thinner warfarin. USA Today. Huber, C. (2007). Anticoagulant Therapy Management. Cedar Rapids Healthcare Alliance. Guyton, A. C. , Hall, J. E. 2000. Medical Physiology. 10 th edition. Saunders. Malloy, P. C. , Grassi, C. J. , Kundy, S. , Gervais, Miller, D. L. , Osnis, R. B. et al. (2009). Consensus Guidelines for Periprocedural Management of Coagulation Status and Hemostasis Risk in Percutaneous. Society of Interventional Radiology. Hemostasis. Retrieved March 24, 2010 from http: //www. mhhe. com/biosci/esp/2002_general/Esp/folder_structure/tr/m 1/s 7/trm 1 s 7_3. htm Tissue Plasminogen Activator (t. PA). Retrieved March 24, 2010 from http: //www. americanheart. org/presenter. jhtml? identifier=4751 Symptoms of Coagulation Disorders. Retrieved March 24, 2010 from http: //www. signsofbleeding. com/index. php? page=4 Tissue plasminogen activator. Retrieved March 19, 2010 from http: //en. wikipedia. org/wiki/Tissue_plasminogen_activator Coagulation Cascade. Retrieved March 12, 2010 from http: //www. hopkinsmedicine. org/hematology/Coagulation. swf Thrombophilia or Hypercoagulable States. Retrieved March 12, 2010 from http: //www. peds. ufl. edu/residency/resources/hematology/th_states. pdf Radiological Society of North America (2010). Radiology Info: the Radiology information for patients. Radiological Society of North America, Inc. For all Bleeding and Clotting Disorders. Retrieved March 8, 2010 from http: //www. hemophilia. org/NHFWeb/Main. Pgs/Main. NHF. aspx? menuid=176&contentid=378&rptname=bleeding Thrombolytic drug. Retrieved March 19, 2010 from http: //en. wikipedia. org/wiki/Thrombolytic_drug King, K. W. (2010). Platelet Activation and von Willebrand Factor (v. WF). IU School of Medicine. Molnar. J. (2010). Thrombolytics. Froedtert hospital Radiology Department. Anticoagulants. Retrieved March 19, 2010 from http: //en. wikipedia. org/wiki/Anticoagulant Antiplatelet. Retrieved March 19, 2010 from http: //en. wikipedia. org/wiki/Antiplatelet_drug Ganda. K. (2005). The Clotting Pathway. TUFTSOPENCOURSEWARE , Tufts University. Toloza, E, (2005). Bruises. Department of Emergency Medicine, University of Texas at Houston School of Medicine.

References Introduction Coagulation Disorders Hemostasis Management Taylor, A. K. (1997). Venous Thrombosis and the Factor V (Leiden) Mutation. The Mountain States Genetics Foundation (14). mc. Gilvray, I. , Rotstein, O. D. (2001). Assessment of Coagulation in Surgical Critical Care Patients. Department of surgery, University of Toronto and Toronto General Hospital, Canada. Esmon, C. T. (2005). The interactions between inflammation and coagulation. British Journal of Haematology. 131(14) 417430. Extrinsic Pathway Intrinsic Pathway Medications Labs Clinical Application Summary QUIZ Contact Information Nardalyn Johnson, RN narjohnson@gmail. com