HEMOSTASIS

HEMOSTASIS COMPONENTS
Vessel wall
Platelets
Coagulation enzymes
Fibrinolytic system
Control mechanisms, including inhibitors

NOTE: Normal hemostasis involves the complex interaction of the vessel wall, circulating proteins and biochemical mediators,
cells, promoters and inhibitors. Activation of hemostasis usually begins with damage to the vessel wall, exposing the
subendothelium. Conversely, the intact vessel wall helps to maintain fluidity of blood, not simply through being a passive
container wall, but also by synthesizing chemicals and proteins that actively contribute to the process. When the vessel wall is
damaged, platelets are at the forefront of defense by sticking to the damaged area. The clotting enzymes contribute by
developing a fibrin mesh that holds the platelets in place. Control mechanisms come into play to limit hemostatic process to the
are of injury. Otherwise the whole body would clot up at the slightest stimulus.
 Sequence of Changes With
Vascular Injury
Injury to vessel wall (endothelium) with resultant
exposure of subendothelium
Platelet adhesion mediated by HMW vWF
Simultaneous activation of clotting enzymes
Platelet aggregation via fibrinogen receptors on
platelets
Anchoring of platelet plug by cross-linked fibrin

NOTE: Lets expand on the sequence of events that occur when a vessel wall is injured and define a few basic terms.
Injury exposes the subendothelial collagen and the soluble substances that are normally between the subendothelium and
collagen.
 Normal Hemostasis
Vessel Wall
Exposed collagen

vFW
Contraction Tissue TPL
large multimers

Platelet
adhesion
Activation of
Coagulation

Platelet
Aggregation Thrombin

Definitive
1 Hemostatic Hemostatic
Plug Plug

This slide gives a diagrammatic representation of the

whole process and the functional interrelationships. Limiting Reactions
We will now go on to dissect the various components
of this process in more detail.
 Platelet Components
Canaliculus Actin

Alpha granules RECEPTORS

Dense Granules vWF

Fibrinogen

Clotting Factors
 Platelet Granules
Alpha granules
vWF
Fibrinogen
PF4
Beta thromboglobulin
PDGF
Dense granules (delta)
ADP
Serotonin
 Platelet Role in Hemostasis
vFW binding sites- platelet adhesion
Fibrinogen binding sites- platelet aggregation
Multiple binding sites for coagulation
factors - enhances appropriate steric
relationships
Production of multiple chemical mediators
Binding sites for chemical mediators
First, lets look more closely at the role of platelets. They play multiple roles in the hemostatic process, and, contrary to the
view held 30 years ago, when they were thought to a small part of the process, many would now consider them to have a
central role. We already have alluded to this by indicating that the first step after injury is platelet adhesion to the
subendothelium. This is mediated by subendothelial HMW vWF binding to specific receptor sites on the platelet
membrane. In, addition there binding sites that play a role in virtually every step of the process. Also. chemical mediators
are synthesized by internal organelles, and they contain a contractile protein that is responsible for clot retraction. The
coagulation enzymes are present in relative low concentrations in plasma. Binding of certain of these factors to specific
receptors on the surface of activated platelets allows them to line up in appropriate steric configuration, catalyzing the
process and limiting the reactions to the area of injury.
 von Willebrands Factor
Synthesized in megakaryocytes and
endothelial cells - approx. 230,000 M.W.
Macromolecular multimer plasma:
M.W. 1 x 106 - 10 X106. Plasma carrier
of Factor VIII, stabilizes it
Large molecular forms:
a. Most effective in platelet adhesion
b. Predominate in endothelial cells and
subendothelium
 Coagulation Cascade
TISSUE FACTOR PT
APTT PHOSPHOLIPID
CONTACT ACTIVATION
FXII, FXI, FLETCHER, FACTOR VII VIIa (ACTIVATED)
FITZGERALD FACTORS
( XI?)
IX IXa IX IXa
TFPI
INHIBITION OF VIII VIII
CLOTTING
FACTOR X Xa

THROMBOMODULIN V, Ca
PROTEIN C PLATELET
FACTOR II IIa ACTIVATION

FIBRINOGEN FIBRIN MONOMERS

FACTOR XIII

IN VITRO CROSS-LINKED FIBRIN

PT (STABLE FIBRIN CLOT)
APTT
 Coagulation Cascade- PT
TISSUE FACTOR PT
APTT PHOSPHOLIPID
CONTACT ACTIVATOR
FXII, FXI, FLETCHER, FACTOR VII VIIa (ACTIVATED)
FITZGERALD FACTORS
( XI?)
IX IXa IX IXa
TFPI
INHIBITION OF VIII VIII
CLOTTING PHOSPHOLIPID
FACTOR X Xa

THROMBOMODULIN V, Ca
PROTEIN C PLATELET
FACTOR II IIa ACTIVATION

(ENDPOINT
FIBRINOGEN FIBRIN MONOMERS
)
FACTOR XIII

IN VITRO CROSS-LINKED FIBRIN

PT (STABLE FIBRIN CLOT)
APTT
 Coagulation Cascade- APTT
TISSUE FACTOR PT
APTT
PHOSPHOLIPID
CONTACT ACTIVATOR
FXII, FXI, FLETCHER, FACTOR VII VIIa (ACTIVATED)
FITZGERALD FACTORS
( XI?)
IX IXa IX IXa
TFPI
INHIBITION OF VIII VIII
CLOTTING
FACTOR X Xa

THROMBOMODULIN V, Ca
PROTEIN C PLATELET
FACTOR II IIa ACTIVATION

FIBRINOGEN FIBRIN MONOMERS (ENDPOINT)

FACTOR XIII

IN VITRO CROSS-LINKED FIBRIN

PT (STABLE FIBRIN CLOT)
APTT
 Control Mechanisms
Intact endothelial cells
Chemical mediators
Membrane bound receptors
Synthesizes activators of fibrinolysis
Circulating inhibitors
Protein C system
Fibrinolytic system
Endothelial component
plasma protein component
 Intact Endothelium Limits
Hemostasis
INHIBITS PLATELET ACTIVATION INACTIVATES FIBRINOLYSIS
PAI

INACTIVATES Va + PLASMINOGEN PLASMIN

VIIIa

NO PGI2 ADPase INHIBITS Xa + THROMBIN

PROTEIN S

PROTEIN C PROTEIN Ca ATIII PLASMINOGEN

ACTIVATORS (tPA)
THROMBIN + (uPA)
THROMBOMODULIN HEPARAN

Subendothelium
vFW
multimers
 Intact Endothelium Limits
Hemostasis Fibrinolysis
INHIBITS PLATELET ACTIVATION INACTIVATES FIBRINOLYSIS
PAI

PLASMINOGEN PLASMIN
INACTIVATES Va +
VIIIa

NO PGI2 ADPase INHIBITS Xa + THROMBIN

PROTEIN S

PROTEIN C PROTEIN Ca ATIII PLASMINOGEN

ACTIVATORS (tPA)
THROMBIN + (uPA)
THROMBOMODULIN HEPARAN

Subendothelium
vFW
multimers
Intact Endothelium Limits Hemostasis
Protein C System
INHIBITS PLATELET ACTIVATION INACTIVATES FIBRINOLYSIS
PAI

PLASMINOGEN PLASMIN
INACTIVATES Va + VIIIa

NO PGI2 ADPase INHIBITS Xa + THROMBIN

PROTEIN S

PROTEIN C PROTEIN Ca ATIII PLASMINOGEN

ACTIVATORS (tPA)
THROMBIN + (uPA)
THROMBOMODULIN HEPARAN

Subendothelium
vFW
multimers
Intact Endothelium Limits Hemostasis -
Chemical Mediators
INHIBITS PLATELET ACTIVATION INACTIVATES FIBRINOLYSIS
PAI

INACTIVATES Va + PLASMINOGEN PLASMIN

VIIIa

NO PGI2 ADPase INHIBITS Xa + THROMBIN

PROTEIN S

PROTEIN C PROTEIN Ca ATIII PLASMINOGEN

ACTIVATORS (tPA)
THROMBIN + (uPA)
THROMBOMODULIN HEPARAN

Subendothelium
vFW
multimers
 Production of Coagulation
Factors
Synthesized in the liver-
All except Factor VIII
Vitamin K dependent
II, VII, IX, and X
Protein C, Protein S
Factor VIII- unknown
Vitamin K Dependent Enzymes:
Factors II, VII, IX, X

Synthesized in liver
Serine proteases, inactivated by AT3
Activation on surface of biologic
membranes
Have an affinity for binding calcium
 Coagulation Cascade- PT
TISSUE FACTOR PT
APTT PHOSPHOLIPID
CONTACT ACTIVATOR
FXII, FXI, FLETCHER, FACTOR VII VIIa (ACTIVATED)
FITZGERALD FACTORS
( XI?)
IX IXa IX IXa
TFPI
INHIBITION OF VIII VIII
CLOTTING PHOSPHOLIPID
FACTOR X Xa

THROMBOMODULIN V, Ca
PROTEIN C PLATELET
FACTOR II IIa ACTIVATION

(ENDPOINT
FIBRINOGEN FIBRIN MONOMERS
)
FACTOR XIII

IN VITRO CROSS-LINKED FIBRIN

PT (STABLE FIBRIN CLOT)
APTT
 Coagulation Cascade- APTT
TISSUE FACTOR PT
APTT
PHOSPHOLIPID
CONTACT ACTIVATOR
FXII, FXI, FLETCHER, FACTOR VII VIIa (ACTIVATED)
FITZGERALD FACTORS
( XI?)
IX IXa IX IXa
TFPI
INHIBITION OF VIII VIII
CLOTTING
FACTOR X Xa

THROMBOMODULIN V, Ca
PROTEIN C PLATELET
FACTOR II IIa ACTIVATION

FIBRINOGEN FIBRIN MONOMERS (ENDPOINT)

FACTOR XIII

IN VITRO CROSS-LINKED FIBRIN

PT (STABLE FIBRIN CLOT)
APTT
 Prothrombin Time

Poor reproducibility from lab to lab in US

No good assayed standards
Many manufacturers
Many chemically different reagents
Many different types of instruments
Poor lot-to-lot reproducibility even from same
manufacturer
 Reporting Protime Results
Each laboratory must establish its own normal
range using the instrument and reagents that it
is using
It may have to be redone with each new lot of
reagents, certainly, at least rechecked and
verified- insist on it from the laboratory you use
Results should be expressed in seconds, not
INR
Results should be compared to the normal
range. The true Control value is meaningless
for clinical use.
 Prothrombin Time
The INR is the answer to our prayers-
Hallelujah- NOT!!
Poor calibration by reagent manufacturers
is the weak link in the chain
Intended only for inter laboratory
comparisons in patients who are on steady
state anticoagulation with coumadin: at
least two weeks of therapy, ambulatory,
normal activity and diet
Widely misapplied to express protime
results in all other situations
 Bleeding Time

Widely misused as a screening test for

platelet function abnormalities
Can predict trends when used to study
large populations
Cannot predict bleeding risk in
individual patients - use for this
purpose has been discredited
 Screening for Hemostatic
Defects
PT, APPT- sensitivity is too poor to pick
up mild defects
Bleeding time- poorly reproducible, too
many false positives and false
negatives, Most common cause of a
prolonged bleeding time- improperly
performed
Best screen: good history
 Screen for Platelet
Abnormalities
No good tests, history
Immediate bleeding
Mucous membrane bleeding
Easy bruising
Petechiae
 Screen for Clotting Factor
Deficiencies
Delayed onset of bleeding
Large ecchymoses or hematomas
Bleeding into joints
Screening History for Bleeding
Problems
Do you think you have a bleeding problem?
Does anyone in your family have a bleeding
problem?
Easy bruising?
Previous hemostatic challenges:
o Major surgery
o Trauma
o Extraction of impacted teeth
 Bleeding Problems

Pre-operative screening
Patient with suspicious history
Actively bleeding patient
 Pre-operative Screening

Most common hereditary bleeding

problems?
Acquired bleeding problems?
Sensitivity of screening tests?
Hereditary Bleeding Disorders

von Willebrands disease - platelet

function
Storage pool disease (delta granule
deficiency) - platelet function
Factor VIII deficiency (Hemophilia A)
Factor IX deficiency (Christmas disease)
Factor XI deficiency
 Patient with Suspicious
History

Refer to laboratory or specialist that

specializes in bleeding disorders.
 Actively Bleeding Patient

Focal bleeding - catgut insufficiency

Generalized bleeding -
o Thrombocytopenia
o Vitamin K deficiencies - common
o DIC - most over-diagnosed cause of bleeding in
the acute care/ICU setting. Primary
fibrinolysis - rare
Acquired Bleeding Problems
drug-induced platelet function defects
Thrombocytopenia
vitamin K deficiency
Liver disease
Coagulation inhibitors
Post viral
Misc. others
Idiopathic
 Vitamin K Deficiency

Appropriate clinical setting:

a. Poor or no oral intake
b. Broad spectrum
antibiotics
Prolonged PT, PTT with a normal
platelet count and fibrinogen -
presumptive diagnoses of Vitamin
K deficiency
 Acute DIC:
A clinical-pathologic Dx

Severely, acutely ill patient (not

clinically stable).
Decreasing platelet count and/or
fibrinogen.
 Acute DIC Principles
Most over-diagnosed cause of bleeding in
a hospital/ICU setting.
Should be approached as a diagnosis of
exclusion
If it is the only diagnosis you can think of,
you are over your head. GET HELP
Vitamin K deficiency is much more
common.
Many other factors are more likely to be
the cause of thrombocytopenia.
 Possible DIC

Run all tests on the same specimen:

PT, PTT, Fibrinogen, FDP Platelets
(Factor V, Factor VIII).
It may take sequential testing to
establish diagnosis.
 Sources of Vitamin K
Diet- Fresh, green leafy vegetables
Synthesis by bacteria in the intestinal track
Typical ICU/acutely ill, hospitalized patient
No or poor oral intake
Broad spectrum antibiotic therapy
Increased vitamin K requirement because
of illness
Result: Acquired vitamin K deficiency within
two to three days of admission
Vitamin K Dependent Factors

II, VII, IX, X

PT - II, VII, X
APTT - II, IX, X
 Vitamin K Deficiency vs.
Acute DIC
Vitamin K DIC

PT Prolonged N or prolonged

APT Prolonged N or prolonged

FDP Normal Usually elevated

Fibrinogen Normal N or decreased

*Platelets Normal Usually decreased

 Elevated Levels of FDP
Recent surgery
Acute thromboembolic event
Renal failure
Hepatic failure
Acute myocardial infarction
DIC
TTP/HUS
Primary fibrinolysis
Suggested Approach to the Bleeding
Hospitalized Patient

Draw PT, APTT, FDP, fibrinogen and platelet

count on same specimen as a panel. Do
not try to use values drawn at different times.
Immediately give Vitamin K
Redraw panel in 4-6 hours.
o K deficiency should show some degree of
correction of PT and APTT within this time period
o DIC should manifest itself by a decreasing
fibrinogen without any significant correction of PT<
APTT
 Diagnostic Approach to
Thrombocytopenia
Good history; medication - dont forget
heparin; Acuteness of onset; Underlying
diseases
Physical - splenomegaly
Examination of blood smear by an
experienced individual; platelet morphology,
Other hematologic abnormalities
Bone marrow examination - almost never
helpful in the absence of other hematologic
abnormalities