Athale – Bleeding and Clotting Disorders in the ICU
Jul 14, 2023
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Janhavi Athale, an assistant professor in critical care medicine and hematology at Mayo Clinic, dives into the complexities of bleeding and clotting disorders in the ICU. She discusses crucial conditions like thrombocytopenia and TTP, emphasizing effective management strategies. The conversation also uncovers the impact of shear stress on platelet function, particularly for patients on devices like ECMO and LVADs. Athale shares real clinical cases, making the intricate world of critical care both enlightening and engaging.
Thrombocytopenia in ICU patients necessitates identifying the underlying cause, as treatment varies significantly depending on conditions like TTP or HIT.
Emerging novel anticoagulants complicate management strategies in urgent procedures, highlighting the importance of timely interventions and specific lab monitoring.
Deep dives
Understanding Thrombocytopenia in ICU Patients
Thrombocytopenia, a condition characterized by low platelet counts, is commonly encountered in ICU patients and can result from various factors, including production issues, sequestration, and consumption of platelets. A clinical case of a 32-year-old man with multiple comorbidities highlights the importance of identifying the underlying etiology, such as TTP or HIT, especially when fever and altered mental status are present. Diagnosis often involves examining laboratory results, including the immature platelet fraction and a peripheral blood smear, which can reveal signs of microangiopathic hemolytic anemia and guide treatment decisions. Immediate interventions may include administering fresh frozen plasma instead of platelets in cases of TTP, as platelet transfusions can worsen the condition.
Management of Thrombocytosis
Thrombocytosis, or elevated platelet counts, can pose distinct risks, particularly when platelet levels exceed 1 million, which may lead to bleeding rather than clotting due to the consumption of von Willebrand factor. In a presented case, a patient with polycythemia vera exhibits extreme thrombocytosis that raises concerns over potential arterial clot formation. However, the recommendation against the immediate use of drugs like aspirin and heparin emphasizes the need to assess bleeding risks associated with such high platelet counts. Treatment becomes crucial only when specific symptoms arise, especially in cases with significant elevations beyond 1 million platelets, where more invasive strategies like plateletpheresis may be necessary.
Navigating New Anticoagulants and Their Reversal Strategies
The emergence of novel anticoagulants (NOACs) has introduced complexities in both management and reversal strategies in patients with conditions such as atrial fibrillation undergoing urgent procedures. For instance, the direct thrombin inhibitor dabigatran is typically reversed using idarucizumab, a specific monoclonal antibody, which underscores the importance of timely intervention when anticoagulated patients require surgical evaluation. Additionally, monitoring the anticoagulant effects through specific lab tests, like thrombin time or anti-factor Xa levels, can inform decisions before surgical interventions. Understanding the half-lives and potential antidotes for other NOACs, like rivaroxaban and apixaban, also aids in ensuring patient safety during emergency procedures.
DIC and Its Distinction from Liver Disease Coagulopathy
Disseminated intravascular coagulation (DIC) presents unique challenges in differentiating it from coagulopathies associated with liver disease, especially in critically ill patients. Understanding the pathological progression of DIC, often triggered by sepsis or trauma, involves recognizing its effects on clotting factor consumption and subsequent bleeding risks. Clinical scoring systems, like the ISTH DIC score, can assist in diagnosing DIC by evaluating the patient's coagulation parameters against expected norms in liver disease. Managing these patients involves careful monitoring of fibrinogen levels and administering cryoprecipitate or vitamin K when appropriate, to counterbalance the complex interplay of clotting and bleeding tendencies common in liver pathology.
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Understanding Bleeding and Clotting Disorders in Critical Care
Janhavi Athale, MD is an assistant professor in the critical care medicine department as well as the hematology and oncology department at Mayo Clinic in Phoenix, Arizona. Her lecture focuses […]
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