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7/21/2019 08 Hemostasis
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HEMOSTASIS
Made Suandika S.Kep.,Ns.,M.Kep.,CWCCA
HEMOSTASIS
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HEMOSTASIS
Def:- stoppage of bleeding from the bloodvessels
Mechanisms
(I) v! of blood vessels
(II) platelet pl"g formation
(III) #lood !oag"lation (fibrinogen fibrin)
(I$) %lot retra!tion
($) fibrinol&sis to dissolve the !lot
HEMOSTASIS
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PRIMARY HEMOSTASIS
in!l"des the pro!esses that res"lt in the
formation of the platelet pl"g
'e!essar& fa!tors-:-The blood vessels : the vessel alls esp the
s"bendothelial la&er
-The platelets-plasma gl&!oproteins:
-fibrinogen
-*illebrand fa!tor +hi!h also
presents inside the platelets
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Mechanisms:
,-v! of the bl vessel
-latelets adhesion to s"bendothelial la&er+ ( *illebrand
fa!tor is ne!essar& for this stage)
adhesion of platelets-
.- platelets se!retion: their a!tivation and se!retion of AD+adrenaline+
noradrenaline /0 aggregation 1 a!tivation of other
platelets
2- Aggregation of platelets3-4ormation of !apillar& pl"g
HEMOSTASIS
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E5ploration of the ,r& homeostasis
,) Important points in the histor&of an& bleeding patients :
HEMOSTASIS
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- 4amil& histor&
- D"ration (re!ent onset or sin!e !hildhood)
- D"ration of the bleeding episode- %ir!"mstan!e of bleeding
(spontaneo"s+ after tra"ma+ or s"rger&)
HEMOSTASIS
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T&pe and !hara!ter of bleeding:
-- "rp"ri! spots
(!apillar& or platelets defe!t not !hara!teristi! ofhemophilia)
- Hematoma+ hemarthrosis or large e!!h&moses at
the site of tra"ma :s"ggests hemophilia (!oag"lation defe!t)
- S"dden severe bleeding from m"ltiple sites afterprolonged s"rger& or d"ring obstetri! pro!ed"res
s"ggests a!6"ired fibrinogen defe!t
HEMOSTASIS
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) Investigations :
HEMOSTASIS
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,) %apillar& resistan!e test of Hess
) latelets !o"nt
.) #leeding time time needed for the platelet pl"g formation
If ' ------ 'ormal ,r& homeostasis
7 ------ platelet or vas!"lar defe!t
HEMOSTASIS
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%apillar& resistan!e test of
Hess:
sph&gmomanometer !"ff above the !"bital
fossa and raise the press"re to ,88 mm Hg
(or mida& beteen s&stoli! 1 diastoli! if
s&stoli! press"re 9,88) for 3 - ; min"tes-
deflation ;. min"tes later !o"nt the
n"mber of peti!hea in area of . !m diameter+
, !m belo the !"bital fossa 'ormall& "p,8 if more than 8+ means platelets or
!apillar& all defe!t
HEMOSTASIS
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2) Other tests
onl& done if there is a prolonged bleedingtime ith normal platelet !o"nt
- Meas"rement of !apillar& resistan!e
- Meas"rement of *illebrand fa!tor- latelets f"n!tion tests (Adhesiveness+
Aggregation)
- other tests for platelets (!lot retra!tion+ <prothrombin !ons"mption)
HEMOSTASIS
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%oag"lation of #lood
Def :- represent the !onversion of fibrinogen
(sol"ble protein) to fibrin (insol"ble)meshor= hi!h o!!l"des the point or
vessel r"pt"re
HEMOSTASIS
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i!s" S"ep :A!tivation of fa!tor #
#> One of s&stems:
I-"rgent s&stem II-dela&ed s&stem(E5trinsi! s&stem) (Intrinsi! s&stem)
HEMOSTASIS
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s&stems of !oag"lation
I-"rgent s&stem II-dela&ed s&stem
E5trinsi! s&stem Intrinsi! s&stem
,-8;; (se!onds) 2-?; (min"tes)
In vivo onl& In vivo 1 in vitro
D"e to tiss"e damage d"e to !onta!t ith foreign s"rfa!e
< <
Tiss"e fa!tor a!tivation of !onta!t s&stem
< <
@ 9 ------------------------------------I@ a 9 ---------------- I@
<
@a<
- prothrombin thrombin
.-fibrinogen 4ibrin
HEMOSTASIS
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E@TI'SI% S>STEM
4A%TOS 'I%ESSO> AE:
4a!tor @
Tiss"e fa!tor and 4a!tor $II
Tiss"e 4
$IIa $II
@a @
#lood vessel
HEMOSTASIS
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I'TI'SI% S>STEM
'e!essar& fa!tors: -
@II (Hageman fa!tor)
- %onta!t s&stem @I
Balli=rene =ininogene
- 4 I@
- 4 $III
- 4 @- %a CC
- phospholipids of the platelets membrane
HEMOSTASIS
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%onta!t S&stem:
4oreign s"rfa!e
--------------------------------------------------Balierne @II =ininogene
4ragmentation
@IIa
@I @Ia
est of intrinsi! patha&
I@
HEMOSTASIS
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est of intrinsi! patha&
I@
latelets
%a CC
I@a
@ $IIIa
$III
@a
II IIa
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Sec$nd S"ep: of %oag"lation
Thrombin 4ormation: (IIa)
4a!tors needed:
- prothrombin (II) %aCC platelets - @a II $ %aCC
- $ (a!!eleririe) @a
- phospholipids- %a C C IIa
HEMOSTASIS
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%!d S"ep :4ibrin 4ormation
4ibrin 4ormation:-
------------------------
IIa
@III @IIIa
(4ibrinogen) -------------------- Ia
(Sol"ble fibrin)
Insol"ble 4ibrin
HEMOSTASIS
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Ph&si$'$(ica' an"ic$a(u'an"s
F ,- Serine protease inhibitors :inhibit the
!oag"lation !as!ade
F -'e"traliGers of a!tivated !oag"lationfa!tors (!omponents of protein % s&stem)
HEMOSTASIS
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,-Serine protease inhibitors:
F ,-Antithrombin (III)
F -Heparin and heparin li=es"bstan!e
F .-Alpha , antit&psin
F 2-Alpha ma!roglob"lin
HEMOSTASIS
'e"traliGers of a!tivated
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-'e"traliGers of a!tivated
!oag"lation fa!tors :
(c$mp$nen"s $) p!$"ein Cs&s"em)
F *+P!$"ein C: s&n"hesied in "he 'i-e!,
-i". K dependan", ac"i-a"ed &
"h!$min.
F /+Th!$m$m$du'in.F %+P!$"ein S and C0+indin( p!$"ein
HEMOSTASIS
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i!in$'&sis
is the pro!ess herein a fibrin !lot+ the
prod"!t of !oag"lation+ is bro=en donIts
main enG&me plasmin !"ts the fibrin mesh
at vario"s pla!es+ leading to theprod"!tion of !ir!"lating fragments that
are !leared b& other proteases or b& the
=idne& and liver
HEMOSTASIS
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HEMOSTASIS
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Measu!emen"
*hen plasmin brea=s don fibrin+ a
n"mber of sol"ble parts are
prod"!ed These are !alled fibrindegradation prod"!ts (4Ds) 4Ds
!ompete ith thrombin+ and so slo
don the !onversion of fibrinogen tofibrin (and th"s slos don !lot
formation)
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E5ploration of the !oag"lation
(I) hole blood !lotting time
'ormall& 2-,8 min"tes
enerall& ---0 ' in platelets defe!ts7 !oag"lation defe!t
#"t not ver& sensitive: - onl& Cve henblood !oag"lation is ver& defe!tive
HEMOSTASISHEMOSTA fibrinol&sis
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() One stage prothrombin time:
general e5ploration or the e5trinsi! patha&(J"i!= time)
' : ,K-,? se!
Faddition of tiss"e thromboplastinCF!aCC to de!al!ified plasma ---0 meas"re
the time till !oag"lation o!!"r
F Affe!ted b& fa!tors $II+ @+ $+ II 1fiboinogen (onl& severe defe!t)
HEMOSTASIS
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(.) partial thromboplastin time (TT)
or %BT(!ephaline =oalin time)
eneral e5ploration of the intrinsi! patha&!lotting time of re!al!ified plasma in the
presen!e of phospholipid (!ephaline)+
hile =oalin poder for a!tivation ofHageman fa!tor; Affe!ted b& fa!tors @II+
@I+ I@+ $III+ @+ II
HEMOSTASIS
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(2) Thrombin time
dete!t the defe!ts in the !onversion of
fibrinogen ---0 fibrin
Meas"red b& addition of thrombin to !itrated
patients plasma
If polongedF Abnormalities of fibornogen
(h&po or h&per or d&sfibrinogenemia)
F Heparin
F resen!e of some abnormal proteinshi!h inhibits thepol&merisation of monomers of fibrin (eg m&eloma protein
F
HEMOSTASIS
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(3) Defi!ien!& of 4 @III (fibrin stabiliGing
fa!tor ) dete!ted b& noting the sol"bilit& of fibrin
in 3M "rea or ,L mono!hloroa!eti! a!id (!an;t
dissolve fibrin in the presen!e of fa!tor @III)In!ongenital defe!t of f @III ---0 dissol"tion of the
!lot in 9,8
(K) Assa& for ea!h !og"lation fa!tor isavailable
HEMOSTASIS
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() Dete!tion of !oag"lation inhibitors:
,-Inhibitors for a spe!ifi! fa!tor (espe!iall& 4 $III)
"s"all& ---0 severe hemorrhage
-Inhibitors against platelets or tiss"e phospholipids---0 prolongation of tests of !oag"lation (J"i!=
or %BT) eg Eb"t "s"all& no hemorrhagi! manifestations
.- if there is 7of J"i!= test or %BT or thrombine:-
38L of normal plasma C 38L of patient plasma
(in!"bation at .8! for I ho"r) repeat the test
If be!ome normal ---0 fa!tor defe!t
if no !orre!tion ---0 presen!e of inhibitors
HEMOSTASIS
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A%TI%A I'$ESTIATIO' O4
HEMOSTATI% TON#E
#T
latelets !o"ntJ"i!= test
%BT
Thrombin timeDosage of fibrinogen
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A%TI%A I'$ESTIATIO' O4
HEMOSTATI% TON#E
I- #T7+ platelets <( <?8888 mm.)
Thrombo!&topenia
- #T7+ platelets normal
J"alitative platelets abnormalities *illebrand disease
!ongenital or a!6"ired
platelet fa!tor tests dosage of fa!tor $III
HEMOSTASIS
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A%TI%A I'$ESTIATIO' O4
HEMOSTATI% TON#E
.- 7J"i!= C 7%BT Other tests are '
A!6"ired defe!t of several defe!t of fa!tor !ommon for
fa!tors (II+ $II+ @+$) patha&s e5 @ or $ or II
2- J"i!= '+ 7 %BT: either:
I- Hemophilia Aor #
- arel& ---0 defe!t of one fa!tor of the !onta!t s&stem(@II+ or @I or others)
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A%TI%A I'$ESTIATIO' O4
HEMOSTATI% TON#E
3- J"i!= 7+ %BT '
isolated defe!t of fa!tor $II
in .+ 23 dosage of the fa!tors ith s"spe!ted defi!ien!&+also sear!h for inhibitors E5:
- 7 J"i!=+ normal dosage of fa!tors---0h&perfibriongenemia hi!h inhibit the test
- 7J"i!= C7%BT C no 4 defe!t ---0P Inhibitors+ egantiphospholipides
HEMOSTASIS
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A%TI%A I'$ESTIATIO' O4
HEMOSTATI% TON#E
K-7TT either:
Q heparine in the blood or in the t"be Here TT!an be !orre!ted b& adding either
a-tol"idine bl"e
b-eptilase time (in!omplete thrombin notsensitive to heparin and not inhibited b&antithrombin III)
Q If (a-b also defe!tive) ---0 tro"bles of fibrinpol&merisation :either d"e to abnormal fibrin(d&sfibrinogenimia) or inhibition eg b& ---0m&eloma protein or 4D
HEMOSTASIS
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A%TI%A I'$ESTIATIO' O4
HEMOSTATI% TON#E
- <fibrinogen
Q !ongenital afibrinogenimia orh&pofibrinogenimia
F A!6"ired h&pofibrinogenimia egliver!irrhosis
F !ons"mption of fibrinogen: eg DI$%+fibrinol&sis
HEMOSTASIS
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?-All tests ate 'ormal:
Q %apillar& fragilit& ("s"all& onl&e!!h&moses ) ---0 meas"rement of
!apfragilit&
Q defi!ient fa!tor @IIIQ no hemostati! tro"bles
A%TI%A I'$ESTIATIO' O4
HEMOSTATI% TON#E
HEMOSTASIS
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Thank You
HEMOSTASIS