CURRENT Essentials of Critical Care.pdf

40 Current Essentials of Critical Care■■■Coagulopathy, AcquiredEssentials of Diagnosis• Excessive or prolonged bleeding from punctures, incisions, GItract, mucosal membranes, joints, retroperitoneal space, othersites• Abnormal coagulation time (prothrombin time [PT] or activatedpartial thromboplastin time [aPTT]) in absence of inherited coagulopathy• Causes: warfarin, heparin administration; liver disease; vitaminK deficiency (malnutrition, antibiotics, poor intake); disseminatedintravascular coagulation (sepsis, hypotension, release ofbone marrow thromboplastins, liver injury, abruptio placenta,amniotic fluid embolism), trauma (fat embolism, brain injury);acquired circulating anticoagulant (antibody to coagulationfactor)Differential Diagnosis• Inherited coagulopathy• Thrombocytopenia or qualitative platelet disorder, vitamin C deficiency• Abnormal aPTT without increased risk of bleeding (lupus anticoagulant)Treatment• Establish etiology• Treat if active bleeding, high risk for bleeding, anticipated procedure(lumbar puncture, central venous catheter, surgery)• Vitamin K, 1–10 mg orally or subcutaneously, if vitamin K deficiencysuspected• Replace factors if moderate to severe bleeding; fresh frozenplasma (FFP) contains factors absent in liver disease, vitaminK deficiency, warfarin treatment, DIC; give FFP equal to 50%of plasma volume (20 mL/kg ideal body weight); one unit FFPapproximately 250–300 mL, so give 4–6 units FFP over 6–12hours■ PearlMany antibiotics destroy enteric bacteria, which produce vitamin K;give weekly vitamin K to ICU patients who are receiving antibiotics.ReferenceTeitel JM: Clinical approach to the patient with unexpected bleeding. Clin LabHaematol 2000;22 (1 Suppl):9. [PMID: 11251652]