Internal Medicine

0521779407-16 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 21:18

Other Clotting Factor Deficiencies 1115

Signs & Symptoms

■excessive postoperative bleeding

■previous transfusions of red cells; anemia or iron therapy; excess

bleeding with NSAIDs, aspirin

tests

Screening

■prolonged PT, APTT, TT (thrombin time), RT (reptilase time), short-

ened euglobulin clot lysis

Confirmatory

■decreased factor I, II, V, VII, X, XI, XIII activity

differential diagnosis

■lupus anticoagulant, acquired anti-VIII – APTT mix

■hemophilia A or B – factor VIII or IX levels

■von Willebrand disease – ristocetin cofactor, vW antigen

■vitamin K deficiency – factor II, VII, IX, X deficiency

■thrombocytopenia, platelet dysfunction – platelet count, closure

time

■liver disease – may mimic factor deficiency

management

What to Do First

■use history, exam to assess severity, location of hemorrhage assess

pain, loss of motion, degree of blood loss, organ system damage

■initiate factor replacement 100% level immediately

■provide adequate pain relief and assess ongoing need

■monitor vital signs, blood pressure, heart rate, temperature

■obtain hemoglobin, platelet count, monitor factor level, PT, APTT

■keep patient at bed rest until assessment complete, improvement

occurs

General Measures

■estimate ongoing blood loss by vital signs, frequent CBC, APTT, PT,

and non-invasive tests, e.g. ultrasound

■maintain hemostasis with factor replacement on the half-life to start

■taper factor once bleeding slows

■avoid NSAIDs, ASA, platelet inhibitory drugs, heparin, or heparin

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