Common bleeding and coagulation issues

Thursday, March 12, 2020

There’s an art to taking a thorough bleeding history. In this episode, Adam Cuker, MD, director of the Hemophilia and Thrombosis Center at the University of Pennsylvania, Philadelphia, shares the most important questions to ask and the challenges in assessing risk in patients about to undergo surgery and those with active bleeding.

In Clinical Correlation, Ilana Yurkiewicz, MD, of Stanford (Calif.) University, talks about delivering good news to patients.

Practice points:

  • Always take a thorough bleeding history.
  • Ask patients about bleeding from head to toe.
  • Even if the basic laboratory evaluation is normal, the patient may still have a bleeding disorder.

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Assessing bleeding risk before surgery

How do you advise patients about to go into surgery who say they bruise easily?

  • This situation comes up frequently.
  • In the case of emergency/urgent surgery, there’s not time for a prolonged evaluation.
  • Take a careful bleeding history: Always ask patients about any history of spontaneous bleeding. Ask about epistaxis, gingival bleeding, rectal bleeding, heavy menstrual periods. Go down the body from head to toe.
  • It’s also important to ask about hemostatic challenges. Has the patient had any prior surgeries? If it’s a woman, has she had pregnancies and deliveries? Did the patient experience abnormal bleeding with those challenges?
  • Prompt patients to consider whether they have had surgery that they might not think about, such as tooth extraction, tonsil removal, or polyps removed from their colon.
  • Seek to establish the time course: Is this a patient who has had abnormal bleeding for their entire life, or did it start later in life? This can provide clues about whether this is a congenital bleeding disorder or an acquired condition.
  • Ask about such comorbidities as liver and kidney disease, which can be associated with an increased bleeding risk.
  • Get a complete medication list. Anticoagulants and antiplatelets are the obvious culprits but consider fish oil and selective serotonin reuptake inhibitors (SSRIs) for bleeding.
  • Ask about family history: Is there a family member who has a diagnosed bleeding disorder or even a history of abnormal bleeding?
  • Ask about social history: Are you engaged in any activities associated with an increased risk of trauma?
  • Challenges to taking a bleeding history: Some bleeding symptoms are very common to the normal population. A surprisingly high percentage of people with no bleeding disorders report easy bruising, frequent nose bleeds as a child, heavy menstrual bleeding.

Laboratory work-up

What’s the basic lab evaluation?

  • Complete blood count (CBC)
  • Prothrombin time (PT) and partial thromboplastin time (PTT)
  • Comprehensive metabolic panel to make sure the patient doesn’t have liver or kidney disease

If the basic lab evaluation is normal can they have a bleeding disorder? Yes.

  • The most common conditions are von Willebrand disease and platelet function disorder.
  • Less common are rare disorders of fibrinolysis or blood vessel disorders that can lead to abnormal bleeding.

Assessing patients with active bleeding (post catheterization)

  • Consider whether bleeding is a complication of the procedure or a bleeding disorder.
  • An efficient but thorough bleeding history is critical.
  • Order a basic lab work-up and review medications looking for antiplatelet medications in particular.
  • This approach is a very similar to a patient without active bleeding who is going into surgery.

Direct oral anticoagulants (DOACs) and bleeding

  • PT and PTT are insensitive to DOACs but order them anyway if the patient is bleeding.
  • If the test is prolonged, that could suggest that there are substantial levels of drug in circulation.
  • If the test results come back normal, that doesn’t rule out the possibility that there are clinically meaningful levels of drug circulation that are contributing to bleeding.
  • Getting a rapid anti-Xa assay could provide more information, but many clinicians don’t have access to that test.
  • If you can’t get the definitive lab test and the patient is having a serious bleed, err on the side of giving the reversal agent.

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David Henry on Twitter: @davidhenrymd

Ilana Yurkiewicz on Twitter: @ilanayurkiewicz

Podcast Participants

David Henry, MD
David Henry, MD, FACP, is a clinical professor of medicine at the University of Pennsylvania and vice chairman of the department of medicine at Pennsylvania Hospital in Philadelphia. He received his bachelor’s degree from Princeton University and his MD from the University of Pennsylvania, then completed his internship, residency, and fellowship at the Hospital of the University of Pennsylvania. After 2 years as an attending in the U.S. Air Force, he was drawn to practicing as a hem-onc because of the close patient contact and interaction, and his belief that, win or lose with each patient, one can always make a difference in their care and lives. Follow Dr. Henry on Twitter: @davidhenrymd.
Ilana Yurkiewicz, MD
Ilana Yurkiewicz, MD, is a fellow in hematology and oncology at Stanford University, where she also completed her internal medicine residency. Dr. Yurkiewicz holds an MD from Harvard Medical School and a BS from Yale University. She went into hematology and oncology because of the high-stakes decision-making, meaningful relationships with patients, and opportunity to help people through some of the toughest challenges of their lives. Dr. Yurkiewicz is also a medical journalist. She is a former AAAS Mass Media Fellow and Scientific American blog columnist, and her writing has appeared in numerous media outlets including Hematology News, where she writes the monthly column Hard Questions. Dr. Yurkiewicz is on Twitter: @ilanayurkiewicz.