What coagulation problems are anticipated and how are they managed?

What coagulation problems are anticipated and how are they managed?

ORIF of the hip has potential for significant blood loss, even in patients with normal liver function. Prolongation of the PT by even as little as 2 seconds over control is a sig-nificant elevation in this patient. Her elevated PT coupled with a decreased platelet count suggests the possibility of hemostatic problems. To avoid massive blood loss and potential associated morbidity, optimization of coagula-tion is required, and prior consultation with a hematolo-gist, although not required, is reasonable.

This patient’s prolonged PT is probably related to her liver disease and diminished liver function. Administration of vitamin K several hours before surgery may be partially effec-tive, if at all. Her hemostatic defect may respond to transfu-sion of fresh frozen plasma. Fresh frozen plasma contains significant amounts of soluble coagulation factors. Fibri-nogen deficiency may be corrected with cryoprecipitate, which contains fibrinogen, fibronectin, von Willebrand’s fac-tor and factor VIII. Factor VIII deficiencies are usually not a problem in liver disease unless the patient has hemophilia or is in DIC.

Patients with severe preoperative thrombocytopenia may benefit from prophylactic platelet transfusion. Typical thresholds for such prophylaxis are set at platelet counts between 50,000 and 80,000/mm³. If nonsurgical bleeding develops in the setting of massive transfusion, a dilutional thrombocytopenia can be expected to have developed and the appropriate laboratory test should be ordered to con-firm the diagnosis. Patients with a dilutional thrombo-cytopenia can be expected to stop bleeding after an appropriate platelet transfusion.

Platelets, fresh frozen plasma, and cryoprecipitate carry the risk of disease transmission and must be used appro-priately. Furthermore, fresh frozen plasma contains signif-icant quantities of citrate and may cause citrate toxicity in patients with significant liver disease. Therefore, because of the associated risk inherent in the use of blood products, in this particular case there are those who might refrain from transfusing blood products until nonsurgical intraopera-tive bleeding occurs.