Coagulation revisited: Special focus on Prothrombotic states and anticoagulation

In the daily practice of anaesthesia, it sometimes happens that case arises that requires investigation. This is a review of such case.A 35 year old female presented with a surgical history of bilateral above knee amputations. A subsequent diagnosis of antithrombin lll and protein C deficiency was made. As a consequence of inadequate anticoagulation the patient then presented for amputation of an arm.In recent years, our understanding of the coagulation cascade and its mechanisms has evolved significantly from a classic separation of “intrinsic” and “extrinsic” pathway to one of initiation, amplification, propagation and stabilisation of the clot. We now have greater insight than ever before on the degradation of clot and how the different mediators like thrombin, antithrombin and protein C and S act on the cascade.This review aims to provide an overview of the “new” coagulation pathway, consequences of abnormalities in the pathway and where the “new” anticoagulants act on the pathway so that we have an improved understanding for improved patient care.