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Life threatening bleeding in Uremic bleeding
1. Cardiac tamponade
2. GI bleeding
3. Intracranial bleeding
Routine tests of hemostasis - PT, aPTT, and platelet counts - are often normal,
although bleeding time will usually be prolonged. 出血時間延長
BT 主要是測血小板功能
機轉 : Decreased platelet function, abnormal platelet–vessel wall interactions, altered von Willebrand factor,
anemia, and abnormal guanidinosuccinic acid–dependent production of nitric oxide, create uremic bleeding
VWF 由內皮細胞所製造，有兩大功能：幫助血小板止血及運載第八凝血因子
1. Hemodialysis
2. Mechanical pressure 好好壓住
3. Desmopressin - 增加 Factor 8 + vWF
0.3 μg/kg IV/SC (benefit in 1 hour) : 4 amp in NS 50ml IVD > 30mins
可將凝血時間縮短 2-4 hrs, 作用時間 6-8 hrs
Minirin(針劑 DDAVP) 4mcg/amp(需冷藏) , 4 Amp , IVD, STAT
DDAVP 4 amp in NS 50 ml/hr, run 30 mins
The dose is 0.3 mcg/kg SC or IV
with a rapid onset and duration of action lasting at least 4 hours.
Side effects are generally mild and include headache, flushing, minor hypotension,
tachycardia, nausea, abdominal cramps, and local site reaction.
4. Cryoprecipitate 10 units given over 30 minutes (benefit in 4 hours)
5. Transamine
6. Estrogen
conjugated estrogens (0.6 milligram/kg IV daily)
25 milligrams IV or 6 milligrams/kg/d (benefit in 6 hours)
7. PLT transfusion 單獨使用效果不佳
Platelet transfusions alone are generally ineffective because the infused platelets quickly acquire the platelet defect
http://www.taiwan-pharma.org.tw/magazine/96/052-056.pdf
p.575
The bleeding diathesis of ESRD patients increases the risks of GI tract bleeding, subdural hematomas, subcapsular liver hematomas, and intraocular bleeding.
Several mechanisms, including decreased platelet function, abnormal platelet–vessel wall interactions, altered von Willebrand factor, anemia, and abnormal guanidinosuccinic acid–dependent production of nitric oxide, create uremic bleeding. The skin bleeding test is the best predictor of clinically important defects in hemostasis.
Patients receiving aspirin or warfarin are at greater risk of major bleeding.
Improvement in bleeding times is seen with infusions of desmopressin, 0.3 microgram/kg IV/SC (benefit in 1 hour), or cryoprecipitate, 10 units
given over 30 minutes (benefit in 4 hours). Conjugated estrogens, 25 milligrams IV or 6 milligrams/kg/d (benefit in 6 hours), are also described as an option.19 Tranexamic acid is another option.
p.1472
Desmopressin is the most common agent used to correct bleeding in patients with uremic platelet dysfunction, producing an increase in serum von Willebrand factor and enhancing the platelet’s ability to aggregate. The dose is 0.3 milligram/kg SC or IV, with a rapid onset and duration of action lasting at least 4 hours. Side effects are generally mild and include headache, flushing, minor hypotension, tachycardia, nausea, abdominal cramps, and local site reaction. Other strategies that improve platelet function include the use of cryoprecipitate, conjugated estrogens (0.6 milligram/kg IV daily), erythropoietin to improve anemia, and hemodialysis to remove toxins.
Platelet transfusions alone are generally ineffective because the infused platelets quickly acquire the platelet defect. Life-threatening bleeding in renal failure patients is treated using the combination of cryoprecipitate, platelet transfusions, packed red blood cell transfusions, desmopressin, and conjugated estrogens
Desmopressin (DDAVP) 主要作用於 V2, 有抗利尿作用, 增加腎小管對水分的再吸收
用來治療中樞性尿崩症 (CDI, central diabetes Insipidus), 須留意副作用低血鈉
Minirin (針劑 DDAVP) 4 mcg/amp(需冷藏) [Desmopressin acetate] 健 0.25 Amp Q12H PRN SC
仿單 : 2-4 mcg/day IV or SC in 2 divided doses
Desmopressin 另外一個作用為提高血中 von Willebrand factor, 第8凝血因子, 縮短 aPTT和出血時間
用來預防及治療 : A型血友病, Type I von Willebrebd's disease病患, 尿毒症患者的手術出血
使用的劑量比中樞尿崩症高很多
https://meddataspeaks.wordpress.com/2015/02/11/%E8%87%A8%E5%BA%8A%E8%97%A5%E5%AD%B8-pressin%E4%B8%89%E5%85%84%E5%BC%9F%E6%95%B4%E7%90%86/
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