History Physical and Laboratory Evaluation

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Recognition of a patient with a bleeding or clotting disorder involves taking an adequate history. A screening questionnaire, such as that provided in Table 5.1 is useful and may help to direct further investigation. Obtaining a history of mucosal bleeding involving epistaxis, gum bleeding, or menorrhagia may be more consistent with platelet disorders (thrombocytopenia, von Willebrand disease, etc.) than, for instance, bleeding into a joint or muscle, which occurs more commonly with hemophilia. Patients with a history of myeloproliferative, myelodysplastic, and lymphoproliferative disorders may also have increased bleeding through several mechanisms, which may not appear in routine pre-operative testing. Renal failure predisposes to bleeding tendencies based on platelet dysfunction, whereas, for instance, recent splenectomy may induce thrombocythemia predisposing to abnormal clotting. An abnormal history of clotting, such as multiple episodes of deep venous thrombosis (DVT), may warrant screening for thrombophilia.

Medications can influence both bleeding and clotting. Commonly used drugs such as aspirin and other nonsteroidal antiinflamma-tory drugs (NSAIDs) affect platelet function, as do Aggrenox and Plavix. Herbal remedies and various vitamin combinations may also increase bleeding risks (Table 5.2). Furthermore, malnutrition and vitamin deficiencies, such as vitamin C deficiency, may contribute to abnormal bleeding tendencies. Estrogen or estrogen-like medications including phytoestrogens predispose to thrombotic episodes. PC-SPES is an herbal preparation with several components used for treatment of prostate carcinoma. It contains phytoestrogens, which may induce thrombosis. However, it also contains Baikal skull cap (Scutellaria baicalensis georgi), which is a coumarin (a naturally occurring group of substances, structurally similar to warfarin). These examples illustrate the importance of querying the use of herbal medications as well as more conventional pharmacotherapies when

VASCULAR SURGERY

Table 5.1. Screening survey for abnormal bleeding or clotting

Do you suffer from a bleeding disorder?

Do you have bleeding from the gums or from the nose?

Have you ever coughed up or vomited blood?

Do you notice easy or spontaneous bruising or does it take you a long time to stop bleeding when cut? Do you have excessive bleeding with menstrual cycles? Have you had any blood in the urine or with stools? Have you had any bleeding into muscles or joints?

Have you had a tooth extraction or any other procedure after which bleeding has taken a long time to stop? Have you needed to receive any blood products, plasma, or vitamin K to help stop bleeding? Do you have any problems with your liver or kidneys? Has anyone in your family had any of the above problems?

Have you or anyone in your family had a history of clots in the blood vessels, either artery or veins?

Do you take oral contraceptives?

Do you take aspirin or any medications for pain or arthritis?

Do you take any steroid medications?

Do you take any herbal medications or vitamins?

Do you take Coumadin or other blood thinners?

Do you take any medications to prevent stroke or heart attacks?

Do you have any blood diseases?

Table 5.2. Common medications, herbs, and vitamins associated with increased bleeding

Medication

Mechanism of action

When to stop preoperatively

Medications that may increase bleeding

Aspirin

Inhibits platelet aggregation via

5-7 days before major surgery

thromboxane B2

3-4 days before minor surgery

Persantine

Inhibits phosphodiesterase to increase

Omit dose before surgery

cyclic AMP

Aggrenox

Combined Persantine and aspirin: increased

As aspirin

effects of aspirin

Plavix

Irreversible binding to platelet inhibits ADP

Stop 7-10 days before surgery

binding to platelet

NSAIDs

Various mechanisms

24 hours prior to surgery

Herbs/vitamins that may

increase bleeding

Feverfew

Used for migraines, ? inhibits platelet

Stop at least 1 week before surgery

aggregation via thromboxane B2, may be

irreversible

Garlic

Inhibits platelet function by inhibiting

Stop at least 7-10 days before surgery

thromboxane synthesis; may be

irreversible

Gingko

Inhibition of platelet activating factor

Stop at least 36 hours prior to surgery

Ginseng

Inhibits platelet aggregation; prolongs PT

Minimum of 24 hours prior to surgery

and PTT; may be irreversible

Vitamin E

May decrease platelet adhesiveness; may

Unclear; should stop around

effect vascular endothelium

5 days before surgery

Willow bark

Salicylate precursors

Stop 7-10 days before surgery, similar to aspirin

Oil of wintergreen

Affects platelet function

Meadowsweet flower

ADP, adenosine diphosphate; AMP, adenosine monophosphate; NSAID, nonsteroidal antiinflammatory drug; PT, prothrombin time; PTT, partial thromboplastin time.

ADP, adenosine diphosphate; AMP, adenosine monophosphate; NSAID, nonsteroidal antiinflammatory drug; PT, prothrombin time; PTT, partial thromboplastin time.

BLEEDING AND CLOTTING DISORDERS

assessing the patient with a bleeding or clotting disorder.

Table 5.3. Thrombophilia screen

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