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Pysiology of

Coagulation
Presentation

Dr Jitender Kenth
CT2 Anaesthetics
Overview:

Coagulation pathways
Cell based model
Tests for Coagulation
TEG
Mechanism of Coagulation:

Ye olde axiom!
Clotting or thrombosis
Rudolph Virchow
Haemostasis

Blood must be fluid


Must coagulate (clot) at
appropriate time
Rapid
Localized
Reversible
Thrombosis?inappropriate
coagulation
Components of haemostasis

COAGULATION
PROTEINS

Endothelium Platelets
Haemostasis
Primary
Vasoconstriction
Platelet plug formation
Secondary
Coagulation
Organisation of clot
Hemostasis
Vasoconstriction
Platelet plug formation
Activation
Adherence
Aggregation
Stabilization of platelet plug
Coagulation cascade
Fibrin
Pro-coagulant role of the
damaged endothelium
Synthesises tissue factor when damaged
Acquires the tissue factor from macrophages
Tissue factor, when bound to VIIa is the major
activator of the extrinsic pathway
Major site for the synthesis and storage of
vWF
Increased Platelet adhesion
Carrier protein for Factor VIII
Inhibition of Fibrinolysis
Thrombin activated fibrinolytic inhibitor
Plasminogen activator inhibitor
Platelets
Anucleate sub-cellular fragments
Arise from megakaryocytes in the
marrow
Normal count: 200-400 thousand/l
Several surface receptors
Activated by contact with extra-
cellular matrix
Aggregation to form a platelet plug
Stabilisation by the formation of a
Platelets-2
Contact with collagen
Swelling and pseudopod formation
Contractile proteins contract
forcefully
Release of platelet granules
Increased adhesion
Adhere to collagen and vWF
ADP and Thromboxane production
Cascade of events lead to a platelet
plug
Anti-platelet agents
Inhibition of COX mediated
Thromboxane synthesis: Aspirin
ADP receptor inhibition: Clopidogrel
Platelet phosphodiesterase inhibition:
Dipyridamole
Fibrinogen Fibrin
Thrombin
Fibrinogen Fibrin
Factor 2
Produced in the Liver
Vit K dependant Post translational
modification
Prothrombin (II)

Xa
Va

Thrombin (IIa)
Fibrinogen Fibrin
Extrinsic Pathway

TF
Prothrombin
VIIa
Xa
Va

Thrombin
Fibrinogen Fibrin
Intrinsic pathway

XIIa

Extrinsic Pathway
XIa
TF
Prothrombin
IXa VIIa
VIIIa Xa
Va

Thrombin
Fibrinogen Fibrin
Intrinsic pathway

XIIa

Extrinsic Pathway
XIa
TF
Prothrombin
IXa VIIa
VIIIa Xa
Va

Thrombin Unstable clot


Fibrinogen Fibrin
XIIIa Stable clot
Fibrin
APTT/ACT
Intrinsic pathway
Prothrombin time
XIIa

Extrinsic Pathway
XIa
TF
Prothrombin
IXa VIIa
VIIIa Xa
Va
+
+
Soft clot
Thrombin
Fibrinogen Fibrin
XIIIa Hard clot
Fibrin
PROCOAGULANT ANTICOAGULANT

Plasminogen activator inhibitors Plasminogen activators

Fibrinolytic inhibitors
Protein C Activated Protein C

Thrombin/Thrombomodulin Thrombin/Thrombomodulin

Tissue Factor Prostacyclin


Von Tissue inhibitors
Willibrand Factor
Factor
Fibrinogen Fibrin Natural heparin like molecules
that inactivate thrombin

Thrombin
Anti-thrombotic
Thrombosis
mechanisms
Thrombomodulin Fibrinolysis
When bound to thrombin Breakdown of fibrin
1.Activates Protein C Plasmin
2.Inactivates clotting (Plasminogen)
Cell based model of coagulation
Cell Based Theory
Platelets and IIa are central

Initiation Thrombin
Storm
Amplification

Propagation
Tissue factor bearing cell

VIIa
TF
Xa
Initiation
Xa
Va
IIa

IIa
IIa
IIa

Plt
Plt
Amplification

Xa Fg Plt Fb Plt

IXa Xa IIa
Plt
VIIIa Va Propagation Fb Fb

Plt Fb Plt
Fb
Subendothelial collagen vWF vWF
Platelet activation
Triggered by
Sub-endothelial collagen
IIa
ADP
TXA2
5HT
Epinephrine
Platelet activation
Results in;
Greatly increased surface area

Dense granules release Ca2+, 5HT, TXA2,


ADP

Alpha granules release factor V, fibrin, VWF


Platelet activation

Platelet phospholipid bilayer is actively


controlled
Resting internal surface is procoagulant
Bilayer everts during activation, exposing
procoagulant surface
Tissue factor bearing cell

VIIa Xa Xa IIa
TF Va

IIa
IIa

Plt IIa
IIa ADP VIIIa
IIa
IIa

Plt IIa
IIa
Plt TXA2 Plt Va
Plt
IXa
IIa
VIIIa XIa
vWF 5HT IIa

Fg Plt IXa

Xa Fg Plt Fb Plt

IXa Xa IIa
Plt
VIIIa Va Propagation Fb Fb

Plt Fb Plt
Fb
Subendothelial collagen vWF vWF
Tests for Clotting
APTT
PT
INR
ACT
BT
Desmopressin (DDAVP)
TEG
APTT
AKA: thromboplastin time with kaolin, PTTK,
Tests the intrinsic (and common) pathways.
4.5 ml blood is added to 0.5 ml citrate.
Method: Recalcification of platelet-poor plasma at 37C
in the presence of an activator and platelet substitute.
Measure time to clot.
Reference interval:Commonly 25-35 seconds, but
varies with reagents and method. The therapeutic
interval for continuous infusion heparin is generally 1.5-
2.5 x the baseline or control APTT
Application:
Inappropriate as a routine preoperative screening test
Limited sensitivity and specificity.
Used as an initial test when the personal and/or family history
suggests a coagulation factor deficiency or when the history
suggests a coagulation factor inhibitor.
A baseline APTT prior to heparin therapy
APTT used to monitor full-dose continuous infusion IV
heparin therapy
Not be used to monitor prophylactic subcutaneous heparin
or low molecular weight heparin.
Interpretation:
A normal APTT does not exclude mild, but clinically significant,
coagulation factor deficiency
Many reagents give a prolonged APTT
An isolated prolongation of the APTT (PT normal) suggests
deficiency of factor VIII, IX, XI or XII.
Prolongation of both the APTT and PT suggests factor X, V, II or I
(fibrinogen) deficiency, all of which are rare.
APTT is normal in factor VII deficiency (PT prolonged) and factor
XIII deficiency.
APTT which is not corrected by the in vitro addition of normal
plasma suggests a coagulation factor (VIII or IX) inhibitor or a lupus
inhibitor.
Artefactual prolongation of the APTT :
-heparin in the sample,
-difficult or slow collection,
-addition of an incorrect volume of blood to the tube,
-delay in mixing blood with the citrate anticoagulant,
-suboptimal specimen storage
Prothrombin Time
Tests the extrinsic and common pathways.
Measure time to clot.
Reference interval: Reagent dependent- 11-15 seconds.
Application: More sensitive than the APTT for the detection
of coagulation factor deficiencies due to vitamin K deficiency,
liver disease.
Screen for deficiency of factor VII and, with APTT, factors X,
V, II, I. The results are expressed as an international
normalised ratio (INR) when the test is used to monitor oral
anticoagulant therapy.
Interpretation: An abnormal result is most often due to liver
disease, vitamin K deficiency or oral anticoagulant therapy.
INTERNATIONAL NORMALISED RATIO
(INR)
PT expressed as a ratio (clotting time for patient plasma
divided by time for control plasma)
Correction factor is applied to the prothrombin ratio and the
result issued as an INR.
Therapeutic interval: Therapeutic interval for oral
anticoagulant therapy: 2.0-4.5.
British Society for Haematology recommended
2.0-2.5. -Prophylaxis of DVT, including high risk surgery:
2.0-3.0 - Prophylaxis of DVT for hip surgery, surgery for
femoral fracture; Tx DVT, PE, TIA
3.0-4.5 - Recurrent DVT and PE; arterial disease, MI, arterial
grafts, cardiac prosthetic valves and grafts.
The European literature recommends an INR of 2.5-4.8, with
a level of 3.6-4.8 for mechanical valves
Thromboelastography
THROMBOELASTOGRAPHY

What is Thromboelastography?

Where does it fit into our usual


coagulation monitoring and what (if any)
new information does it give us

Why is it useful
Functional Description
Thromboelastography monitors the thrombodynamic properties of
blood as it is induced to clot under a low shear environment
resembling sluggish venous flow. The patterns of change in shear-
elasticity enable the determination of the kinetics of clot
formation and growth as well as the strength and stability of the
formed clot. The strength and stability of the clot provide
information about the ability of the clot to perform the work of
haemostasis, while the kinetics determine the adequacy of
quantitative factors available to clot formation
So what does it do?
Clot formation

Clot kinetics

Clot strength & stability

Clot resolution
Basic Principles
Heated (37C) oscillating cup

Pin suspended from torsion


wire into blood

Development of fibrin strands


couple motion of cup to pin

Coupling directly
proportional to clot strength

tension in wire detected by


EM transducer
Basic Principles
Electrical signal amplified to
create TEG trace

Result displayed graphically


on pen & ink printer or
computer screen

Deflection of trace increases


as clot strength increases &
decreases as clot strength
decreases
Refinements to Technique
TEG accelerants / activators / modifiers
Celite / Kaolin / TF accelerates initial coagulation

Reopro (abciximab) blocks platelet component of


coagulation

Platelet mapping reagents modify TEG to allow analysis of


Aspirin / Clopidigrol effects

Heparinase cups
Reverse residual heparin in sample
Use of paired plain / heparinase cups allows identification of
inadequate heparin reversal or sample contamination
THROMBOELASTOGRAPHY
Where does the TEG fit into
coagulation monitoring and what new
information does it give us?

The TEG gives us dynamic information on


all aspects of conventional coagulation
monitoring
Sample display
The r time
r time
represents period of time of latency from
start of test to initial fibrin formation

in effect is main part of TEGs


representation of standardclotting studies

normal range
15 - 23 mins (native blood)
5 - 7 mins (kaolin-activated)
What affects the r time?
r time by r time by
Factor deficiency Hypercoagulability
Anti-coagulation syndromes
Severe
hypofibrinogenaemia
Severe
thrombocytopenia
The k time
k time
represents time taken to achieve
a certain level of clot strength
(where r time = time zero ) -
equates to amplitude 20 mm

normal range
5 - 10 mins (native blood)
1 - 3 mins (kaolin-activated)
What affects the k time?
k time by k time by
Factor deficiency Hypercoagulability
Thrombocytopenia state
Thrombocytopathy
Hypofibrinogenaemia
The angle

angle
Measures the rapidity of fibrin
build-up and cross-linking (clot
strengthening)
assesses rate of clot formation

normal range
22 - 38 (native blood)
53 - 67(kaolin-activated)
What affects the angle?

Angle by Angle by
Hypercoagulable Hypofibrinogenemia
state Thrombocytopenia
The maximum amplitude
(MA)
Maximum amplitude
MA is a direct function of the maximum
dynamic properties of fibrin and platelet
bonding via GPIIb/IIIa and represents the
ultimate strength of the fibrin clot

Correlates to platelet function


80% platelets
20% fibrinogen

normal range
47 58 mm (native blood)
59 - 68 mm (kaolin-activated)
> 12.5 mm (ReoPro-blood)
What affects the MA ?

MA by MA by
Hypercoagulable Thrombocytopenia
state Thrombocytopathy
Hypofibrinogenemia
Fibrinolysis

LY30
measures % decrease in amplitude 30
minutes post-MA

gives measure of degree of


fibrinolysis

LY60
60 minute post-MA data
What measurements are affected by
fibrinolysis?

Fibrinolysis leads to:


LY30 / LY60
EPL
A30 / A60
Quantitative analysis
Clot formation
Clotting factors - r, k times

Clot kinetics
Clotting factors - r, k times
Platelets - MA

Clot strength / stability


Platelets - MA
Fibrinogen - Reopro-mod MA

Clot resolution
Fibrinolysis - LY30/60; EPL
A30/60
Qualitative analysis
TEG v CONVENTIONAL
STUDIES
Conventional tests TEG
test various parts of global functional
coag cascade, but in assessment of coagulation
isolation / fibrinolysis
out of touch with current more in touch with
thoughts on coagulation current coagulation
plasma tests may not be concepts
accurate reflection of use actual cellular
what actually happens in surfaces to monitor
patient coagulation
difficult to assess gives assessment of
platelet function platelet function
static tests dynamic tests
take time to complete rapid results rapid
best guess or delay monitoring of intervention
treatment
Advantages of TEG over conventional
coagulation monitoring

It is dynamic, giving information on entire


coagulation process, rather than on isolated part

It gives information on areas which it is normally


difficult to study easily fibrinolysis and platelet
function in particular

Near-patient testing means results are rapid


facilitating appropriate intervention

It is cost effective compared to conventional tests


We know the problems Can the TEG help us?
Bloody surgery Clot formation
Anticoagulants Clotting factors

Clot kinetics
Clotting factors
Platelets
Abnormal platelet
function
Clot strength &
stability
Damaged / ineffective
Platelets
platelets

Clot resolution
Fibrinolysis
Abnormal fibrinolysis
CLINICAL STUDIES OF TEG USE
Thromboelastography-guided transfusion algorithm reduces
transfusions in complex cardiac surgery. Shore-Lesserson,
Manspeizer HE, DePerio M et al; Anesth Analg 1999; 88 : 312-9

Reduced Hemostatic Factor Transfusion using Heparinase


Modified TEG during Cardiopulmonary Bypass. Von Kier S,
Royston .; DBr J Anaesthesia 2001 ; 86 : 575-8

Quantifying the effect of antiplatelet therapy: a comparison of the


platelet function analyzer( PFA- 100) and modified
thromboelastography (mTEG) with light transmission platelet
aggregometry. Agarwal S, Coakley M, Reddy K, Riddell A, Mallett
SV. Anaestheisology 2006; 105: 676-83
The prevalence of a heparin-like effect shown on the
thromboelastograph in patients undergoing liver transplantation.
Agarwal S, Senzolo M, Melikian C, Burroughs A, Mallett SV.
Liver Transpl. 2008 Jun;14(6):855-60.
Reduced Hemostatic Factor Transfusion using Heparinase
Modified TEG during Cardiopulmonary Bypass
von Kier S, Royston D, Br J Anaesthesia 2001 ; 86 : 575-8

Group 1 - conventional therapy Group 1 - TEG predicted therapy


60 patients 60 patients

22/60 given blood component 7/60 predicted to need component


therapy therapy (p<0.05)

17 units Platelets 2 units Platelets


(p<0.05)
Reduced Hemostatic Factor Transfusion using Heparinase Modified
TEG during Cardiopulmonary Bypass
von Kier S, Royston D, Br J Anaesthesia 2001 ; 86 : 575-8

Sampling protocol
all celite-activated heparinase modified samples
Baseline (BL)
Post-warm (PW)
Post-protamine (PP) + celite-activated plain sample

TEG treatment algorithm


r>7 min but <10.5 min mild clotting factors 1 FFP
r>10.5 min but <14 min mod clotting factors 2 FFP
r>14min severe clotting factors 4 FFP
MA<48mm mod in platelet no / function 1 platelet pool
MA<40mm severe in platelet no / function 2 platelets pools
LY30 >7.5% fibrinolysis Aprotinin
TEG studies - cautions
studies looked at wide range of procedures & patient management -
difficult to extrapolate study findings to all units

considerable variability in pre-study management across units

concomitant introduction of postoperative transfusion protocols at


same time as TEG may cloud TEG outcomes

variability in TEG-guided protocols and sources of derived data-


what exactly is normal in post-cardiac surgery population?

by its very nature use of TEG facilitates early intervention, whereas


use of conventional tests delays intervention. Is this enough in itself
to explain apparent differences?
THROMBOELASTOGRAPHY
Summary
Thromboelastography (TEG) provides near-patient, real-time,
dynamic measurements of coagulation and fibrinolysis

It is ideally designed to provide useful information amidst the


cauldron of factors which contribute to post-cardiac surgical
bleeding

Use of TEG to drive post-cardiac surgery protocols for


management of bleeding has been shown to be cost-effective
and will decrease the patients exposure to blood and blood
component therapy with its concomitant well-documented risks

Appropriate use of TEG can result in genuine cost savings in


Cardiac Surgery patients