Disturbances of a hemostasis represent rather seldom found problems in routine anesteziologo-resuscitation practice, and the pathology which more often is found in intensive care units. Nevertheless, the anesthesiologist has to be able to distinguish these disturbances, together with the surgeon to define admissibility of performing surgery and also to carry out correction of disturbances of a hemostasis in the operating room.
For exact treatment of disturbances of a hemostasis it is necessary to understand accurately in what link takes place to be a problem and as it is possible to eliminate it effectively. Unfortunately, situations when at disturbances in a platelet link of a hemostasis correction of a plasma link by a transfusion of freshly frozen plasma or cryoprecipitate is carried out quite often meet.
In the course of survey of the patient to which expeditious treatment is planned it is necessary to specify whether it has blood coagulation disturbance symptoms, namely the increased tendency to bleedings or fibrinferments. In certain cases the family anamnesis is important. It is important to reveal such patients at a stage of collecting the anamnesis then to conduct more detailed examination. It is necessary to find out whether bleeding in time or after surgical intervention, or bleeding after the delivery was observed at the patient sometime, multiple abortions whether menorrhagias took place, whether long bleeding after insignificant cuts or extraction of teeth is observed at it. It is also necessary to find out whether spontaneous bleedings were observed at the patient ever. Chronic diseases, such as liver or renal failure can also be the cause of disturbances of a blood coagulation. Especially carefully it is necessary to find out the medicinal anamnesis: whether the patient takes any drugs which can influence a hemostasis also.
When carrying out preoperative inspection of the patient the standard gemostaziogramma is surely included in the list of necessary laboratory researches. In need of it it is possible to add with other researches, such as quantity of thrombocytes, research of aggregation of thrombocytes, tromboelastometriya, researches of maintenance of separate blood-coagulation factors and others. It is necessary to understand that the standard gemostaziogramma and its such tests as MNO or AChTV are the screening researches intended for assessment of effect of anticoagulants therefore do not reflect a condition of a system of a hemostasis and the patient can have serious violations of a blood coagulation at a normal gemostaziogramma. The much bigger diagnostic value has researches of separate links of a chain of a blood coagulation. Rather often pathology is in a platelet link of a hemostasis that can lead to the fact that it will remain unnoticed if the research of quantity of thrombocytes and, in some cases, their modular activity is not conducted.
At identification of patients with a thrombophilia planning of tactics of anticoagulating therapy in the perioperatsiony period is of great importance. It is necessary to agree on this issue with the surgeon. The neglect tromboprofilaktiky in the perioperatsiony period can increase considerably risks of a deep vein thrombosis and thromboembolism of a pulmonary artery. At the same time regional techniques of anesthesia and early activization of patients have advantage.
If to the patient with a coagulopathy expeditious treatment according to the emergency indications is planned, it is necessary to try to correct disturbances of coagulation by impact on that link of a hemostasis in which there are problems. For example, at deficiency of plasma blood-coagulation factors transfusion of freshly frozen plasma, cryoprecipitate or the combined drugs on the basis of blood-coagulation factors is shown. At deficiency of thrombocytes or decrease in their activity transfusion of a platelet concentrate is shown.
Important issue in work of the practical anesthesiologist is carrying out regional anesthesia against the background of intake of antitrombotichesky drugs (antiagregant and anticoagulants). According to the modern recommendations of the leading anesthesiology communities, it is necessary to avoid regional anesthesia at patients with disturbances of a hemostasis. If the patient received low-molecular heparins, then the safe period from the moment of their last introduction before carrying out regional anesthesia is 12 hours or 24 hours at the preventive and medical mode of dosing respectively. After regional anesthesia it is possible to enter the next dose of anticoagulant not earlier than in 6 hours, at traumatic blockade — in 24 hours.