The Coagulation

Abstract

In contrast to hypocoagulability, hypercoagulability is difficult to detect clinically. In most cases, hypercoagulability is detected during or after insertion of a central venous catheter. Rarely, blood clots occlude the puncture needle resulting in several “dry” puncture attempts. Similarly, blood aspirated into an empty syringe upon vessel puncture rapidly clots in patients with hypercoagulability and cannot be ejected (Fig. 12.1). It is meaningful to use an empty syringe to puncture a blood vessel and routinely eject the blood from it at the end of the procedure to screen for hypercoagulability. In surgical patients with drains in place, visible or sometimes even palpable clots in drainage bags (Fig. 12.2) or containers can be a sign of hypercoagulability. Hypercoagulability is typically encountered during the initial phases of critical illness, particularly in conditions associated with a pronounced pro-inflammatory response such as sepsis, trauma or surgery. It is important to remember that bleeding may still occur despite clinical signs of hypercoagulability. These bleeding sources are usually amenable to surgical repair.

Clinical Practices

Box 1 Structured Patient History in Patients with a Suspected Inherited or Acquired Coagulation Disorder

Yes	No
□	□	History of epistaxis without previous trauma or manipulation? If yes: consider platelet disorder or antiplatelet drug intake, uncontrolled hypertension, allergic rhinitis (if seasonal) or nasopharyngeal pathology (if unilateral)
□	□	History of easy bruising (without previous trauma)? If yes: consider antiplatelet or anticoagulation therapy or coagulation disorder.
□	□	History of (spontaneous) joint or deep muscle bleedings? If yes: consider anticoagulation therapy or coagulation factor deficiency
□	□	History of prolonged (>5 min) bleeding from superficial wounds or after tooth extractions? If yes: consider antiplatelet/coagulation therapy or coagulation disorder
□	□	History of bleeding complications during or after surgery? History of blood transfusion for surgery or trauma? If yes: consider platelet disorder (intraoperative or immediate postoperative bleeding) or coagulation factor deficiency (delayed bleeding)
□	□	Family history of coagulation disorder? If yes: consider inherited coagulation disorder.
□	□	Intake of antiplatelet or anticoagulation drugs? Intake of analgesics? If yes: consider drug-induced coagulation disorder
□	□	In females: history of prolonged (>7 days) or increased menstrual bleeding? If yes: consider inherited von Willebrand disease if primary hypermenorrhoea (since menarche) and secondary hypermenorrhoea mostly due to gynaecological pathologies

Consider inherited coagulation disorder if onset of bleeding history is in childhood, and consider acquired (e.g. factor VIII inhibitor, acquired von Willebrand disease) coagulation disorder if onset is in adulthood.

Adjusted from ÖGARI.

Box 2 Clinical Manifestations of Bleeding Disorders

	Platelet disorder	Clotting factor deficiency
Drug effects	Antiplatelet drugs (e.g. aspirin, clopidogrel)	Anticoagulation drugs (e.g. vitamin K-antagonists, direct thrombin inhibitors)
Bleeding type	Cutaneous and mucosal bleeding	Cutaneous, deep tissue and joint bleedings
Relevant bleeding after minor trauma	Common	Rarely
Petechiae	Common	Uncommon
Ecchymoses	Mostly small	Can be very large
Deep muscle hematomas	Uncommon	Common in severe disease or drug overdose
Joint bleeding	Uncommon	Common in severe disease
Postoperative bleeding	Frequent, early postoperative bleeding	Frequent, delayed postoperative bleeding