08 Hemostasis

7/21/2019 08 Hemostasis

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HEMOSTASIS

Made Suandika S.Kep.,Ns.,M.Kep.,CWCCA

HEMOSTASIS



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



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



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



E5ploration of the ,r& homeostasis

,) Important points in the histor&of an& bleeding patients :

HEMOSTASIS



- 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



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



) Investigations :

HEMOSTASIS



,) %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



%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



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



%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



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



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



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



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



%onta!t S&stem:

4oreign s"rfa!e

--------------------------------------------------Balierne @II =ininogene

4ragmentation

@IIa

@I @Ia

est of intrinsi! patha&

I@

HEMOSTASIS



est of intrinsi! patha&

I@

latelets

%a CC

I@a

@ $IIIa

$III

@a

II IIa

HEMOSTASIS



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



%!d S"ep :4ibrin 4ormation

4ibrin 4ormation:-

------------------------

IIa

@III @IIIa

(4ibrinogen) -------------------- Ia

(Sol"ble fibrin)

Insol"ble 4ibrin

HEMOSTASIS



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



,-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



-'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



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



HEMOSTASIS



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)



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



() 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



(.) 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



(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



(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



() 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



A%TI%A I'$ESTIATIO' O4

HEMOSTATI% TON#E

#T

latelets !o"ntJ"i!= test

%BT

Thrombin timeDosage of fibrinogen

HEMOSTASIS




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




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)

HEMOSTASIS




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




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




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



?-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


HEMOSTATI% TON#E

HEMOSTASIS



Thank You

HEMOSTASIS

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08 Hemostasis