Bleeding & Hemostasis PDF

Bleeding & Hemostasis Dr. Elif Özcan Department of Oral&Maxillofacial Surgery • Before the invasive procedures, patient should be classified regarding to the risk of hemorrhage. • Control of bleeding is the most important integral part of any surgical treatment procedure. • Care must be taken in e...

Bleeding & Hemostasis Dr. Elif Özcan Department of Oral&Maxillofacial Surgery • Before the invasive procedures, patient should be classified regarding to the risk of hemorrhage. • Control of bleeding is the most important integral part of any surgical treatment procedure. • Care must be taken in every step of the operation, from incision to suturation, and hemostasis should be achieved in every step. • First, the source of the bleeding must be identified. Remove the clot if necessary. • When faced with a postextraction hemorrhage the clinician should ensure that the area can be well visualized. This will allow the best opportunity to make the correct diagnosis, identifying the type of postextraction hemorrhage and the site of the hemorrhage, therefore enabling quick and effective management. • Stabilization of the mobile tissues contributes the hemostasis, so suturing these tissues will provide a better control. • Primary Hemorrhage This occurs during the surgery, as a result of injury like cutting or laceration of the artery or bleeding from bone.This also occurs when surgery is done in an infected area with a lot of granulation tissue.It can also occur after a very short period of time immediately after surgery.This type of bleeding is really normal and can be controlled easily. • Intermediate / Reactionary Hemorrhage This type of bleeding occurs within a few hours after surgery.This type of bleeding occurs as a result of failure of coagulation to occur (as in patients with systemic bleeding problems or those on anticoagulants). Patients who have unknowingly disturbed / dislodged the clot are also prone for this type of bleeding. +Insufficient hemostatic measures • Secondary Hemorrhage This occurs after 7 to 10 days after surgery. This is mainly due to partial division of blood vessel in combination with infection of the wound. This type of bleeding is not very frequently encountered after oral surgery procedures. Elevation of patient's blood pressure enough to overcome pressure external to blood vessel is another common reason for reactionary bleeding. • Local Treatment of Intermediate or Recurrent Hemorrhage and Secondary Hemorrhage: • One or a combination of the following methods may be used: • 1. If the sutures have become loose, the area should be anesthetized and suturation over the bleeding area. • • 2. Direct pressure may be applied over the bleeding area. This is accomplished by having the patient bite firmly on gauze pressure pads over the bleeding area. • 3. A vasoconstrictor, such as epinephrine poured on a sponge, can be applied directly to the bleeding area; this results in a constriction of the lumen of the vessel until a new clot can form. • • 4. The surgeon can also apply a local agent to speed up blood coagulation. All these agents are placed on gauze sponges and held over the bleeding areas, or placed into the sockets with pressure. Reasons of Bleeding • In healthy patients the postoperative bleeding is mainly due to local causes. • Local -Anatomical structures -Vascular tumors and malformations -Trauma • Iatrogenic Preop history Preop exams Anesthesia (Hypotensive Anesthesia-general/ Epinephrine-local) Incision-Suture Postop exams Instable wound Reasons of Bleeding • Systemic -Anticoagulant therapy Low/Intermediate/High Risk for Thromboembolism INR at the day of the procedure. *Mechanism of Hemostasis & Bleeding Tests 1. VASCULAR PHASE 2. PLATELET PHASE 3. COAGULATION PHASE 2. INR PT aPTT Bleeding time, Thrombin time, Platelet count -Coagulopathies Hemorrhagic Diatesis: Hemophilia A&B (Factor VII & IX) Von Villebrand ITP (Idiopathic thrombocytopenic purpura) Thrombocytopenia Ca++ deficiency Leukemia -High Blood Pressure Hypertension: Essential Secondary 14/9 --> «normal» of the patient -Diseases Related to the Collagen synthesis -Vit K deficiency -Liver disease -Chemotherapy/Radiotherapy Internal Hemorrhage • • • • • • • • We should obtain hemostasis in all wound depths. Pressure Cold compress (Min. 36 hours 5/5-10/10 minutes) Elevated head Elimination of the systemic problems Pressure bandage A removable drain may be placed. In the presence of hematoma, formation of ecchymosis may start within 3 days. Patient should be instructed. • Management: - Within a few hours: Aspiration/Exploration-if active - After Clotting: Minor: Cold compress for 36 hours, then warm compress (accelerates resorption). Extensive: Exploration may be needed. External Hemorrhage Capillary: Bleeding from a surface, continuous oozing, red Arterial: From a focus, pulsative, bright red Venous: ~Focus, continuous, darker color Intraosseous: Pooling, oozing, variable. originates either from nutrient canals in the alveolar region, central vessels, such as the inferior alveolar artery. **Veins-embolism: Compress first. • Vascular hemorrhage may cause the most distress to a patient given the excessive amount of blood flow. A large vessel may require ligation, whereas smaller vessels can be cauterized. If the vessel is not visible, a flap may to be raised to allow access and identification. • If, during operations involving the bony processes, an artery is severed, the bleeding can be controlled by taking a blunt instrument and crushing the surrounding bone into the point of bleeding. Capillary oozing from the bone either stops spontaneously or is usually controlled when the mucoperiosteal flaps are reapproximated and sutured back over the alveolar ridges. If bleeding is profuse, tightly pack the sockets with gauze for 5 to 10 minutes under pressure, remove the gauze and then place pieces of absorbable hemostatic gauze in each socket before suturing the soft tissues into place. • Capillary bleeding from soft tissues at the time of operation is • • • • best controlled by suturing if, for example, after a flap surgery there is still bleeding following the insertion of the usual number of sutures, additional sutures should be inserted in that area in which bleeding occurs. • • The anterior floor of mouth is a very vascular area. It is supplied by the sublingual branch of the lingual artery which anastomoses with the submental artery, a branch of the facial artery, and the incisive arteries which are branches of the inferior alveolar artery. As a result of trauma (either external or from the operator's instrument), the sublingual artery in the floor of the mouth may be severed. This vessel is extremely difficult, if not impossible, to ligate when severed by a puncture wound, and the consequences can be fatal if the wound remains untreated. Bi-manual pressure (one hand inside and one hand outside the mouth) will usually control this bleeding until an appropriate ligation can be performed in the neck** Autogenous block grafting Implant External Hemorrhage • Management: • Simple compress: First step in all types of bleeding. • Local hemostatic agents -Surgicel (Oxidised Regenerated Cellulose) -Spongostan (Gelatin sponge) -Gelfoam -Gelatamp (gelatin sponge+colloidal silver) -Ankaferd**** (herbal) ****SHOULD NOT BE INJECTED**** -~Local anesthesia - Celox: Chitosan (polymer from seashells) - Tranexamic acid 5%-Transamine: Local&Systemic • Suturation • Wet gauze -Simple suture: Resorbable/Nonresorbable • Electrocautery&Laser in bone: bone necrosis Ligation of Blood Vessels: In the event of arterial bleeding from the soft tissues, the vessel should be grasped with a hemostat and ligated by tying it directly or indirectly by the use of a circumferential suture around the soft tissue. -Clamp tie-direct -Stick tie-indirect -Ligation clips (Indirect vessel ligation) Palatal artery: Stick tie, closing and securing the vessel with the suture pressure, distal ligation, removed 1 week after, collateral circulation. Palatal pressure, great enough to stop the bleeding, should first be applied along the course of the vessel posterior to the point of bleeding and held firmly for at least 5 to 10 minutes. • Cauterization&Laser • Bone wax: exposed bone marrow • Management of systemic problems