CHAPTER 90: Bleeding Disorders

KEY POINTS

• Bleeding disorders and hemorrhagic complications are common in ICU patients.

• Bleeding disorders may be divided into thrombocytopenias, soluble coagulation factor deficiencies, and combined disorders.

• Initial management approaches to thrombocytopenias vary considerably and create the necessity for early recognition of distinct disorders including heparin-induced thrombocytopenia, thrombotic thrombocytopenic purpura, disseminated intravascular coagulation, and other common thrombocytopenias.

• Disorders of soluble coagulation factors are revealed by abnormal results in the prothrombin time, activated partial thromboplastin time, and other tests including thromboelastography.

• Factor deficiencies, factor inhibitors, von Willebrand disease, and other complex coagulopathies including disseminated intravascular coagulation, HELLP syndrome, massive transfusion, and anticoagulant-related syndromes have specific therapies to reduce the rate and risk of bleeding.

• There are specific indications and appropriate applications for platelet transfusion, cryoprecipitate, fresh frozen plasma, concentrated and activated factors, as well as other medications, including inhibitors of fibrinolysis.

INTRODUCTION

Coagulation disorders and complications of bleeding are common and require proactive assessment and management. Intensive monitoring of ICU patients demonstrates that a substantial majority will have either a coagulation defect or bleeding. Furthermore, the coagulation abnormalities convey important prognostic information and a substantial number of patients will have severe, major bleeding.^1,2 Because of the particularly high prevalence and significant impact of bleeding disorders in critically ill patients, effective and efficient ICU care requires timely recognition and mitigation of disorders of platelets, soluble coagulation factors, and vascular lesions. Appropriate management of bleeding disorders depends on recognition and adherence to specific treatment guidelines for a wide variety of patients such as those with massive transfusion and trauma, disseminated intravascular coagulation, thrombotic thrombocytopenic purpura, and anticoagulant-related hemorrhage.

CLINICAL ASSESSMENT OF BLEEDING IN CRITICALLY ILL PATIENTS

Reliable monitoring and reporting of bleeding in critically ill patients is essential for accurate safety and performance assessments. Careful assessment of the risk and impact of hemorrhage is also critical for the appropriate selection of evidence-based treatments. However, the standards for monitoring, assessment, and treatment of ICU bleeding are highly variable. Furthermore, clinical studies utilizing bleeding assessment scales are usually constrained by application in homogenous, single-disease patients.³ The World Health Organization (WHO) took an early initiative to sponsor and develop standard grading scales for reporting complications of cancer treatment including bleeding.⁴ While the WHO scale (Table 90-1) is one of the most commonly reported scales, the routine use of this grading system is limited in its application in general ICU patients because it is not specifically linked to anatomic, physiologic, and therapeutic response.

ICU-based definitions of bleeding primarily rely on a dichotomy of ...