Surgical bleeding ,haemostasis

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Surgical Bleeding & Haemostasis : 

Surgical Bleeding & Haemostasis DR. SANDEEP V. KANSAL Associate Professor Department Of Surgery G.M.C, SURAT

Slide 2: 

All bleeding (eventually) stops

If you do not know it - what Happens - : 

If you do not know it - what Happens -

Why Haemostasis Lecture ?AIMS : 

Why Haemostasis Lecture ?AIMS What it mean ? Different methods and Systemic approach to achieve haemostasis ? Mechanism of action ? Advantage & Disadvantage of Each method ?

Slide 8: 

Why Use Hemostats?

Why Use Hemostats? : 

Why Use Hemostats? Minimize intra-operative blood loss Improve intra-operative visualization Avoid transfusion Manage increasing numbers of anti-coagulated patients

The Burden of Surgical Blood Loss : 

The Burden of Surgical Blood Loss Potential negative outcomes of intra-operative blood loss Impaired intra-op visualization Anemia Hypovolemia Potential negative outcomes of blood transfusion Increased post-op infection rates1 Increased mortality in CABG2 Allergic and hemolytic transfusion reactions Viral transmission

Hemostasis : 

Hemostasis Arteriolar vasoconstriction Formation of platelet plug Activation of coagulation cascade Formation of permanent plug Secondary Hemostasis Primary Hemostasis

Hemostatic Cascade : 

Hemostatic Cascade

Hemostatic Cascade : 

Hemostatic Cascade

Hemostatic Cascade: Blood Vessel : 

Hemostatic Cascade: Blood Vessel Platelets do not stick to endothelial cells Endothelial tissue prevents blood from coming in contact with collagen, the main component of connective tissue Subendothelial tissue prevents blood from coming in contact with Tissue Factor (FIII) WBC = White blood cell RBC = Red blood cell CF = Coagulation factor

Hemostatic Cascade: Vessel Injury : 

Hemostatic Cascade: Vessel Injury Endothelium disruption exposes subendothelial structures — collagen and smooth muscle Smooth muscle contracts leading to contraction of the vessel This physical response is called vasoconstriction Vessel injury also exposes collagen, which is a major component of vessel walls, and tissue factor (FIII) WBC = White blood cell RBC = Red blood cell CF = Coagulation factor

Steps to Hemostasis : 

3. Platelet Adhesion 1. Vessel Injury 2. Vasoconstriction 4. Platelet Aggregation 5. Platelet or Hemostatic Plug 6. Mixed – Platelet / Fibrin Clot 7. Fibrin Clot 8. Clot Retraction 9. Recanalization Steps to Hemostasis

Slide 17: 

Method of Hemostasis

Slide 19: 

1. SYSTEMIC- a. VITAMIN-K b. coagulation factors intrinsic: IX/Nonacog alfa · VIII extrinsic: VII/Eptacog alfa common: X · II/Thrombin · I/Fibrinogen c. Other systemic – Trenexamic acid, Etamsylate , Inj Adrenaline LOCAL- Topical Absorbable Hemostats (TAH)

Trenexamic acid : 

Trenexamic acid It is an antifibrinolytic inhibits the activation of plasminogen to plasmin a molecule responsible for the degradation of fibrin. Therapeutic uses – Menstrual bleeding Orthopedic Surgery Dentistry Other uses- cardiac surgery, haemophilia Disadvantage- Risk of DVT

Mechanical Methods : 

Mechanical Methods Direct Pressure - Pack. Pack. Pack Clamps Ligating clips Staples Sutures Bone wax ---- Digital pressure External bandages

Cauterization Methods : 

Cauterization Methods Thermal Cautery Laser Cryosurgery Harmonic scalpel Vessel sealing device Electrocautery Monopolar / Bipolar RF Energy


ELECTROCAUTRY Standard alternate current is delivered at 60 HZ Excessive neuromusculau activation & electrocution can result Electrocautry unit converts 60Hz to 200 Hz Minimal risk of neuromuscular stimulus & no risk of electrocution

Bi- polar electrosurgery : 

Bi- polar electrosurgery Two prongs of forcep: active & inactive electrodes Current travel thru one tip, passes thru tissue, & disperse to the other No patient return electrode required


MONOPOLAR ELECTROSURGERY FLOW OF CURRENT GENERATOR CONDUCTOR CORD Active electrode Surgical site Thru Patients Patient return electrode

Cutting & coagulating current : 

Cutting & coagulating current Different wave forms Cutting: cotinuous low voltage current - less charring -less lateral thermal spread Coagulatioing: intermittent high voltage current -More fulgration _Greater lateral thermal spread

Electrosurgery & tissue Effect : 

Electrosurgery & tissue Effect Coagulation current CAN CUT and vice versa Design of instrument tissue tension Advantage of cutting current -Lower voltage - Less thermal spread - Less charring

Ultra sonic Blade : 

Ultra sonic Blade Max motion at blade tip 55,500 times per sec.

Harmonic V/S Electrosurgery : 

Harmonic V/S Electrosurgery Harmonic Scalpel Electrosurgery Tissue Dessication 150* c Vaporisation of water dessicates the tissue 100*c 50*c Protein coagulation Protein disorganise to form a coagulum

Advantage of Ultrasonic energy : 

Advantage of Ultrasonic energy Precise cutting & coagulation Cavitational effect Minimum tissue damage Less smoke No stray energy No electrical energy transferred to or through patient

Vessel sealing devices : 

Vessel sealing devices Bipolar energy with low voltage & high amperage Reliable, consistent permanent vessel wall fusion producing a translucent seal seals vessel up to 7 mm Seal strength more than Standard bipolar Minimal lateral thermal spread- 2mm Reduced sticking & charring

Slide 32: 

Oxidized Regenerated Cellulose (ORC) Gelatin Sponge/Powder- Gelfoam , Surgifoam Collagen Thrombin Fibrin Glue Topical Absorbable Hemostats

Methylcellulose : 

Methylcellulose Gelfoam Absorbable (4-6)wks Liquefies in 2-5 days Serves as a scaffold for coagulation Contra-indiacted in infected field Foreign body Risk of embolisation

Oxidized regenerated cellulose : 

Oxidized regenerated cellulose Surgicel, Fibrillar,™ Nu-Knit™ (Ethicon) Binds platelets and chemically precipitates fibrin, denature blood protein Use in capillary venous small arterial bleed Absorbed in 14 days Can form cyst with # bone , stenosis if used around vascular anastomosis

Microfibrillar collagen : 

Microfibrillar collagen Decellularized bovine source Haemostasis time 1-5 min. Stimulates latelet adhesion Stops venous ooze Absorbed in 90 days Potential nidus for infection Adhesion formation Conta-indiacted in closed cavity

Thrombin + Gelfoam + CaCl(surgiflo) : 

Thrombin + Gelfoam + CaCl(surgiflo) Thrombin for cleavage/activation Gelfoam as matrix Foreign body Very useful in vascular surgery Absorbed in 6-8 wks Contraindicated for any one with known allergic to human blood product (anaphylaxis, hepatitis A, blood cloting disorder) Risk of embolisation and toxic shock shock syndrome

Fibrin glue : 

Fibrin glue Tiseel™ FDA approved in 1998 Concentrated fibrinogen and f VIII Thrombin and calcium Aprotinin to prevent clot dissolution Takes time to prepare Good for diffuse oozing, needle punctures, parenchymal injuries

Fibrin sealant : summary : 

Fibrin sealant : summary Reduce perioperative & post operative complications like- Prevent seroma formation, fistula formation, reduce fluid , air leakage Adeherent to skin flap reduces dead space Safety concern- No intravascular injection No entry to blood salvage Potential for viral transmission

Tropical Thrombin : 

Tropical Thrombin Key clotting protein Stimulate conversion of fibrinogen to fibrin-=CLOT 3 forms as per source of protein 1. Bovine 2. Human 3. Recombinant

Now Haemostasis Lecture I Know : 

Now Haemostasis Lecture I Know What it mean Yes / No Different methods and Systemic approach to achieve haemostasis Yes / No Mechanism of action Yes / No Advantage & Disadvantage of Each method Yes / No

Yes I know it & can do it : 

Yes I know it & can do it

Slide 42: 


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