Académique Documents
Professionnel Documents
Culture Documents
6/17/2009
CLOTTING TESTS
VII TF PL
Fibrin
MKSAP-Q1
80 yr man 3 week h/o massive bruising on no meds; FH negative Labs: platelets 350,000 PT 12 sec; aPTT 78 sec; Bleeding time: 6 min fibrinogen 390 g/dL; D-dimer: 1000 ng/mL aPTT 1:1 mix: 71 sec LFTs normal acquired F VIII inhibitor DIC LA Factor XII deficiency chronic liver disease
Q: Dx?
Q: Dx?
A: chronic liver disease (vitamin K deficiency; DIC; acquired f V inhibitor)
MKSA-Q3
46 yr man post CABG On heparin DVT prophylaxis 5000 U q 12 Day 4 post-op right calf swelling and pain Doppler-US: DVT plts 75,000 What do you do? Begin full-dose heparin Change to LMWH D/c heparin and observe D/c heparin and start warfarin D/c heparin, start danaproid or lepirudin
HIT
XII VII
thrombin
[ASH 2001, Ortel]
Arixtra = Fondaparinux
clot
Bleeding MKSAP-Q4
55 yr woman
Planned cholecystectomy
Hx: easy bruising, frequent prolonged nosebleeds Bleeding after nasal surgery
Factor concentrates
PCCs: II, VII, IX, X Bebulin, FEIBA, Autoplex, Cryo: fibrinogen, von Willebrand factor (factor VIII) FFP: all other factors (little fibrinogen and von Willebrand factor) half-life of factor VII: 4 h Humate P: von Willebrand factor, factor VIII
Bleeding MKSAP-Q5
30 yr man Lifelong epistaxis + easy bruising Tooth extraction bleeding for several days Adopted Hbg 13.0; MCV 78; plts. 250,000 BT 13.5 min; PT 12 sec; aPTT 40 sec; TCT normal Platelet aggregation study normal
Rx:
Cryo
MKSAP-Q6
A 86
B 87
C 89
D 90
E 88
MKSAP-Q7
27 yr woman SLE 2 DVTs, now 3rd PT 13.6 sec; aPTT 43 sec; LA Standard heparin 5000 U bolus, then 1200 U/h. F/u aPTT 120 sec Q: How to best give and monitor heparin rx? heparin Use anti-Xa level, not aPTT LMWH and follow aPTT IVC filter
Antiphospholipid antibodies
I) antibody test (ELISA)
APL A
L A ACA
anticardiolipin anti-2-glycoprotein I
2-GP I
Lupus anticoagulant
1) Screening test (aPTT, dRVVT, KCT, Silica clot time) prolonged 2) Normal plasma mixing study does not correct 3) Confirm (mix with excess of phospholipids) corrects - hexagonal phospholipid test - platelet neutralization procedure (PNP)
aPTT
XII
VII TF
PL PT
PL
X
DRVVT PL
Fibrinogen
Fibrin
MKSAP-Q8
20 yr woman, bleeds after dental extraction SLE steroids. No h/o bleeding; plts 160,000;
DIC
Congenital XII deficiency F VIII inhibitor
LA-hypoprothrombinemia syndrome
Vitamin K deficiency
APLA syndrome
1) thrombosis or 2) recurrent abortions 3) pos. APLA test (repeat) (+ thrombopenia, derm. or neurol. symptoms)
MKSAP-Q9
33 yr man with CP
MKSAP-Q10
21 yr woman from Nigeria SOB, CP post airline flight
On OCPs
Mother: thrombophlebitis x 2 postpartum. Sister: sudden death pstpartum
VQ: PE
Q: Which diagnostic study should be done next? Factor V Leiden and factor II 20210 gene studies Protein C, protein S, and antithrombin tests Screening tests for cancer, incl. Chest and abdo CT A lupus anticoagulant panel
Thrombophilia
venous Protein S deficiency protein C def. AT III def. factor V Leiden prothrombin 20210 homocysteinemia MTHFR polymorphism antiphospholipid antibodies yes yes yes yes yes yes no yes arterial yes yes yes no no yes no yes
Factor V Leiden
prevalence : 2 - 15 % (western world) RR for 1st DVT/PE: heterozygotes: 3 - 8 homozygotes: 80 heterozygotes + pill: 30-50 Diagnosis: coagulation test (APC resistance) or genetic test Not associated with arterial clots (except for selected patients)
www.fvleiden.org
MKSAP-Q11
47 year-old man DVT after 1 h airplane flight FH: uncle with DVT after hip arthroplasty, grandfather stroke age 68 Thrombophilia w/u negative
at least 3 months
at least 3 months ??? indefinite indefinite indefinite
- APLA syndrome:
- Tumor 3. Recurrent DVT/PE
indefinite
indefinite (LMWH) indefinite
MKSAP-Q12
56 yr healthy man DVT calf and popliteal vein Adamantly refuses hospitalization
Q: Rx options?
A: LMWH s.c. in therapeutic doses + warfarin 5-10 mg qd (ASA, prophylactic LMWH, daily LMWH monitoring, 15 mg warfarin)
MKSAP-Q13
75 yr man Calf and popliteal DVT after 10 h car ride Smoking. Otherwise healthy Phys. exam nl. CBC, PT, PTT, routine serum chemistry nl
MKSAP-Q14
28 yr woman
ACA
three 1st trimester pregnancy losses Now 6 weeks pregnant
MKSAP-Q14
28 yr woman
ACA
three 1st trimester pregnancy losses Now 6 weeks pregnant
MKSAP-Q15
35 yr woman
epistaxis and bruising Plt: 5,000
ITP
1:20,000 Antibodies against platelets, often against GPIIb/IIIa Dx: negative history, r/o all other causes:
- iron studies (deficiency?)
- vitamin B12, folate - blood smear (clumping?) - TSH (hypo?) - HIV (- ANA) - PT, PTT - bone marrow aspirate and biopsy: controversial
ITP - Therapy
Guided by patients bleeding symptoms
Iv Ig 1 g/kg q d x 2 d
Anti-D antibody (WinRho) single dose. Response in 2-3 d. Duration of response: 1 month Relapse: splenectomy. Good response in 60-70%. Rituximab. If splenectomy fails: cyclophosphamide, azathioprine, danazol, multiagent chemotherapy
Questions?
Comments?