CURRENT Essentials of Critical Care.pdf

Chapter 4 Bleeding & Transfusions 39■■■Bleeding in the Critically Ill PatientEssentials of Diagnosis• Spontaneous bleeding or bleeding from invasive procedures dueto one or more defects in hemostasis• Normal hemostasis needs intact vascular endothelium, coagulationfactors, adequate platelet number and function• Thrombocytopenia or platelet dysfunction: ecchymoses and mucosalbleeding, posttraumatic or surgical bleeding• Acquired or inherited coagulopathies: spontaneous hemarthrosesor soft tissue hematomas• Severe coagulopathy, thrombocytopenia, or disseminated intravascularcoagulation (DIC): generalized bleeding, especiallynew acute onset• Excessive warfarin: soft tissue hematomaDifferential Diagnosis• Abnormal prothrombin time (PT) only: vitamin K deficiency,liver disease, warfarin, specific inhibitor• Abnormal activated partial thromboplastin time (aPTT) only: inheritedcoagulopathy, heparin, lupus anticoagulant, specific inhibitor• Both aPTT and PT abnormal: vitamin K deficiency, DIC, liverdisease, heparin or warfarin• Abnormal aPTT, PTT, platelet count: DIC (microangiopathichemolytic anemia, low fibrinogen, elevated fibrin degradationproducts, elevated D-dimer)• Screening tests normal: platelet dysfunction, endothelial damage,factor XIII deficiencyTreatment• Assess severity and acuity of bleeding; estimate rapidity ofblood loss; treat if active or anticipated bleeding, invasive proceduresnecessary• Management depends on etiology; vitamin K, fresh frozenplasma, cryoprecipitate, platelet transfusions, stopping anticoagulants■ PearlConsider acute acquired dysfunction of platelets if unexplained bleedingwith no previous history; may be due to renal failure, drugs suchas aspirin, NSAIDs, or platelet inhibitors.ReferenceDeSancho MT et al: Bleeding and thrombotic complications in critically ill patientswith cancer. Crit Care Clin 2001;17:599. [PMID: 11525050]