Plasma Transfusions Prior to Central Line Placement in People with Abnormal Coagulation.

Editor's note: This is a summary of a nursing care-related systematic review from the Cochrane Library. For more information, see http://nursingcare.cochrane.org.

Trauma-induced coagulopathy.

Coagulopathy is the inability of blood to coagulate normally; in trauma patients, it is a multifactorial and complex process. Seriously injured trauma patients experience coagulopathies during the acute injury phase. Risk factors for trauma-induced coagulopathy include hypothermia, metabolic acidosis, hypoperfusion, hemodilution, and fluid replacement. In addition to the coagulopathy induced by trauma, many patients may also be taking medications that interfere with hemostasis. Therefore, medication-induced coagulopathy also is a concern. Traditional laboratory-based methods of assessing coagulation are being supported or even replaced by point-of-care tests. The evidence-based management of trauma-induced coagulopathy should address hypothermia, fluid resuscitation, blood components administration, and, if needed, medications to reverse identified coagulation disorders.

Prekallikrein deficiency.

Nurses often encounter abnormal laboratory assays that require them to investigate further to ensure that appropriate patient care is provided. A prolonged activated partial thromboplastin time (PTT) with a normal prothrombin time (PT) assay demand further examination, to rule out laboratory error or bleeding disorders. Prekallikrein deficiency is a rare coagulation deficiency that presents itself with a prolonged PTT and a normal PT. It was first identified in 4 of the 11 Fletcher family children in 1965, coincidentally when one of the Fletcher children was undergoing a workup for an adenoidectomy. Both the Fletcher parents had normal coagulation laboratory assays with no history of bleeding tendencies. The term Fletcher factor deficiency was used until Fletcher factor was later identified as plasma prekallikrein. A prekallikrein deficiency is inherited as an autosomal recessive trait. The purpose of this article is to provide a basic review for nurses on hemostasis, identify the 6 causes of a prolonged PTT with a normal or slightly prolonged PT, and to present 2 recently diagnosed adult cases, not previously reported in the medical literature.

Why don't haemophilia nurses do research?

Clinical research should form a core component of the role of haemophilia nurse specialists. The UK Haemophilia Nurses Association sought to determine the barriers that prevent nurse specialists from engaging in research and to seek ways to promote clinical research by haemophilia nurses in the UK. Web-based survey with subsequent workshop discussion was conducted. Responses were received from 32 nurses (a 50% response rate), all of whom agreed that haemophilia nurses should be actively involved in nursing research although only 21 had actually participated in research specifically related to haemophilia practice. Of these, most research had been related to educational programmes or (less commonly) was limited to data collection as part of multidisciplinary studies. Involvement in research rarely resulted in publication. Some barriers to involvement in nursing research and subsequent publication were suggested by survey respondents. They also identified key practice areas that warranted nurse-based research including carriership and antenatal decision-making, along with the role and impact on care of the specialist haemophilia nurse, education and empowerment. To overcome the barriers to engaging in research and publishing, nurses require dedicated research time, mentorship and collaboration with more experienced haemophilia nurse researchers.

Hypothermia in the trauma patient: how vital is this sign?

Recognizing the adverse impact that trauma has on a patient's overall well-being and hemodynamic stability is key to successful management and improved outcomes for this patient population. It is well established that trauma is accompanied by deadly pathophysiological sequelae, referred to as the "trauma triad." This triad is characterized by hypothermia, acidosis, and coagulopathy. This triad is cyclic and, moreover, each element of the triad builds upon one another to exacerbate the next. Hence, evidence demonstrates that it is important to recognize the cycle and intervene early to reduce or prevent negative outcomes.

Assessing the bleeding patient: factors affecting hemostasis and common coagulation studies.

This column discusses the factors affecting hemostasis and the common coagulation studies used to assess patients with bleeding disorders.

Damage control surgery for the patient who has experienced multiple traumatic injuries.

PATIENTS WHO HAVE EXPERIENCED multiple traumatic injuries present one of the greatest challenges for perioperative teams. IN A TRAUMA PATIENT who is hemorrhaging, increased risk of death arises from a vicious cycle of hypothermia, coagulopathy, and metabolic acidosis known as the triad of death. A STAGED SURGICAL APPROACH predicated on specific priorities for treating multiply injured patients can help save the lives of these patients.

Normal clotting.

OBJECTIVE: To review the normal coagulation process and the mechanisms that lead to abnormal clotting. DATA SOURCES: Primary and tertiary literature and the authors' clinical experience. CONCLUSION: The process of coagulation is complex and can be easily misunderstood. It is important to be familiar with normal coagulation before one can comprehend the coagulopathies associated with malignancies. IMPLICATIONS FOR NURSING PRACTICE: A thorough understanding of the coagulation process is a critical prerequisite to caring for patients with clotting disorders. Once the normal clotting process is understood, the abnormal becomes easier to recognize and the cancer-associated dysfunctions more readily identified.

Thromboelastography: a means to transfusion reduction.

Consider using thromboelastography to improve care outcomes for cardiac surgery patients.

Inherited coagulation factor abnormalities: a pediatric review.

Clotting factor abnormalities in children provide an interesting challenge to the medical care team. Understanding the diagnostic process and the medical management of children with factor abnormalities is crucial, as life-threatening complications can occur. This article will familiarize the reader with symptoms, laboratory testing, diagnosis, and treatment of hereditary coagulation factor abnormalities.

Hematology in palliative medicine.

Advanced cancer and life-limiting chronic nonmalignant diseases are associated with a number of hematological problems. Anemia and coagulation disorders, principally venous thrombosis and thrombocytopenia, are most commonly observed. Patients undergoing chemotherapy and bone marrow transplant have unique problems that include neutropenias and chemotherapy-induced drug toxicities, which will not be covered in this article.

The trauma triad of death: hypothermia, acidosis, and coagulopathy.

With the organization of trauma systems, the development of trauma centers, the application of standardized methods of resuscitation, and improvements in modern blood banking techniques, the ability to aggressively resuscitate patients in extremis has evolved. The concept of the "golden hour" has translated into unprecedented speed and efficiency of trauma resuscitation with the ultimate goal of short injury-to-incision times. As the shift in care of patients in extremis has continued to move from the street to the emergency department and beyond, the focus of trauma resuscitation has shifted to the operating room and ultimately to the intensive care unit. The "new" golden hour may well be the time in the operating room before the patient reaches the physiologic limit, defined as the onset of the triad: hypothermia, acidosis and coagulopathy. Critical care nurses must understand this triad, because it forms the basis and underlying logic on which the damage control philosophy has been built. This article explores the pathogenesis and treatment of acidosis, hypothermia, and coagulopathy as it applies to the exsanguinating trauma patient.

Altered bleeding time associated with ibuprofen and zidovudine use.

The purpose of this article is to describe a patient who was HIV-positive, had a massive venous ulcer, and developed a prolonged bleeding time with marked blood loss from the ulcer. The patient underwent a workup to rule out possible causes for this prolonged bleeding time; all studies were negative. A review of his history identified that he was self-medicating with ibuprofen while taking zidovudine. A potentiated effect of these two medications on the bleeding time has been reported in the literature. This case illustrates the importance of revisiting a patient's history while working up an acute problem as well as clinically monitoring for blood loss if a person takes ibuprofen and zidovudine.

Recognition and management of bleeding following cardiac surgery.

The major hemorrhagic disorders are associated with malfunction of three physiologic systems either separately or in combination: (1) abnormalities of platelets, (2) abnormalities of blood vessels, and (3) abnormalities of plasma coagulation factors. Platelets contribute to hemostasis not only by participating physically by occluding rents and tears in small vessel but also by involving the coagulation process through their biochemical activities. It is small wonder that platelet dysfunction is the most common cause of nonsurgical bleeding following CPB; however, the potential for hyperfibrinolysis cannot be overlooked. New laboratory tests and therapeutic approaches have allowed for more accurate diagnosis and more appropriate therapy in a variety of bleeding events following CPB.

Postoperative bleeding. Current nursing management.

The critical care nurse caring for the postoperative bleeding patient must have a thorough knowledge of basic hemostatic principles and inherited and acquired disorders. Early recognition and treatment of bleeding problems reduces surgical morbidity and mortality; therefore astute clinical observations and a thorough understanding of selected laboratory testing are imperative. Because of the risk of disease transmission associated with homologous blood transfusion, new alternatives in blood therapy--autologous blood from preoperative and perioperative salvage; the conservative and individualized use of homologous blood and its components; blood substitutes to support oxygen transport (e.g., modified hemoglobin solutions and perfluorochemical emulsions); new pharmacologic approaches for minimizing blood loss (e.g., desmopressin); and increasing the body's ability to produce blood (e.g., recombinant erythropoietin)--must be considered and the patient response carefully assessed. A broad knowledge base and clinical expertise are requisite in meeting the critical needs of the postoperative bleeding patient in a climate of rapidly developing diagnostic and therapeutic alternatives.