Excerpts of talk by Dr. Anupam Jaggi, Clinical Hematologist, Sir Ganga Ram Hospital (IMSA update)

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  • Whenever doing surgery under spinal or epidural anesthesia, always get bleeding profile done as any bleeding in these areas can be detrimental. The safest anesthesia in such a situation is General Anesthesia or Local Anesthesia. Bleeding time, clotting time and PEG tests are of no use.
  • Safe surgery is possible when the total leukocyte count is more than one thousand.
  • Safe surgery is possible when the platelet count is more than 1 lakh. Laparoscopic surgery is safe if the platelet count is more than 30 thousand.
  • When the patient is on warfarin and he needs a surgery, one should stop warfarin 72 hours before surgery and start enoxaparin (LMW heparin) 1ml/kg. The last dose of LMW heparin should be given 12 hours before surgery. After surgery LMW heparin should be restarted 24 hours later.
  • If the PT-INR is raised and surgery is contemplated, one should give 1mg Vitamin K intravenous. Wait for six hours and repeat INR. PT should normalize by this time and the patient can be operated after that.
  • If the patient has arterial thrombosis, do the following tests: Lupus anticoagulant (or lupus antibody), homocysteine, A1c and abdominal fat.
  • If there is an active bleeding due to bleeding disorder, one should give 15 ml/kg of FFP in 45 minutes altogether. Wait for 6 hours and repeat INR.
  • In acute venous thrombosis, factor C, factor S and factor 5 Leyden are reduced for three weeks and therefore testing at this moment is not reliable.
  • If a patient has spontaneous DVT, he should be on lifelong oral anticoagulants.
  • If a patient has normal PT and abnormal APTT, do a mixing test. Take patient plasma with equal amount normal plasma and repeat APTT. If it is normal, there is a factor deficiency (8, 9, 11, 12, and 13). Factor 12 deficiency does not cause bleeding; it increases thrombosis not bleeding. Patient can undergo surgery safely. If the APTT is still abnormal, it indicates presence of inhibitor or antibody. In such cases, test for lupus anticoagulant.
  • Buff count can prepared in a lab by using two units of blood.
  • Granulocyte colony stimulating factor can be given for 15-20 days. GCSF, if given for 7-10 days, can increase TLC to up to 30000.  This is done for harvesting stem cells.
  • Patient with negative bleeding history does not require routine coagulant screening prior to surgery.  Bleeding history means details of previous surgery and trauma, family history, details of any anti-clotting medicine.
  • If the bleeding history is positive or there is a clear clinical indication, tests are required.
  • The first-line tests are APTT and PT.