Blood

Coagulation Disorders

There is prolongation of coagulation parameters

1. prolonged prothrombin time: in liver failure, Vitamin K deficiency, oral anticoagulants, disseminated intravascular coagulation,
2. prolonged thrombin time, heparin use, DIC.

Treatment

Treat the underlying cause. If cause is not clear, give Vitamin K and fresh frozen plasma (FFP) depending on investigation.
For overdose of oral anticoagulants or Vitamin K deficiency,
Inj. Vitamin K intravenous (use IV preparation) 10 mg IV once daily for 3 days or till response.
For infusion of plasma components refer to a specialist.
Fresh Frozen Plasma (FFP) contains all clotting factors present in blood.
One bag/kg (average 4 to 6 FFP units in an adult) infuse rapidly and repeat every 12 hourly or as clinically indicated.
Cryoprecipitate contains factor VIII and Fibrinogen and may be used in Haemophilia and in DIC as replacement therapy. Factor VIII concentrates are needed for Haemophilia A (consult specialist).

References

1. Bleeding and Thrombosis. In: Harrison’s Principles of Internal Medicine. Braunwald E, Fauci AS, Kasper DL et al (eds), 15th Edition, 2001, McGraw Hill Company Inc., New York, pp 354-360.

Platelet Function Defects

If clinical presentation suggests platelet defect but platelet counts are normal, suspect platelet dysfunction. Bleeding time is prolonged in most cases. Platelet function tests will confirm the defect but facilities are not routinely available. Commonly caused by aspirin and NSAID use.

Treatment

To stop NSAID use.

If active bleeding occurs, transfuse platelets.

Platelet Disorders (Thrombocytopenia)

Low platelet counts suggest either reduced production or increased destruction of platelets. In reduced platelet production, bone marrow examination shows reduced megakaryocytes and common causes are: megaloblastic anaemia, aplastic anaemia, marrow infiltration by malignancy. If bone marrow shows increased or normal megakaryocytes, it implies increased destruction as in idiopathic thrombocytopenic purpura (ITP), hypersplenism, disseminated intravascular coagulation (DIC).

Treatment

The primary cause to be treated.

Platelet transfusion is indicated mainly when platelets are not adequately produced and aim is to keep platelet count above 20,000/cu mm. If there is no fever and no clinical bleeding, even counts of 10,000/cu mm are acceptable. Transfusing platelets in ITP is not useful as these are rapidly destroyed, but platelet concentrates may be transfused in life threatening bleeding before specific therapy takes effect.

Platelets are never kept in refrigerator. They can be stored at room temperature (22oC) on an agitator for upto 3-5 days. Once issued they should be transfused rapidly.

Dose: one single donor platelet collected by a pheresis raises platelet counts by 30,000 to 50,000 in an adult. One random donor platelet collected from a single unit of donated blood raises platelet counts by 5000-10000/cu mm in an adult. The rise is less in DIC, ITP, febrile patients and during active bleeding.

Idiopathic thrombocytopenic purpura (ITP)

Treatment

Tab. Prednisolone 2 mg/kg/day till response or 4-6 weeks and taper off slowly.
Or
Inj. Immunoglobulin 400 mg/kg/day for 5 days is as effective as steroids, response may be faster, but is much more expensive.
Failure with one therapy may still be followed by response to other therapy. If there is poor response to the above, case must be referred to specialist centre for consideration of splenectomy.

Bleeding Disorders

The management of bleeding disorders is based on a precise diagnosis.

If bleeding is life threatening, replacement of blood and fluids for haemodynamic stability takes priority.

Treatment

General measures

No intramuscular injections. No aspirin or nonsteroidal antiinflammatory drugs (NSAIDs). Apply local pressure to stop bleeding.