HAEMORRHAGE

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HAEMORRHAGE: 

HAEMORRHAGE Rohit Singh Intern | 438

What is meant by Haemorrhage ?: 

What is meant by Haemorrhage ? Prolonged or uncontrolled bleeding is often referred to as haemorrhage. The amount of blood lost as a result of haemorrhage can range from minimal to significant quantities.

Haemorrhage in Surgery: 

Haemorrhage in Surgery Haemorrhage can occur to a greater or lesser degree during all surgical procedures and it’s management depends upon whether the patient is hematologically normal or suffers from some disturbance in the normal clotting mechanism.

Haemorrhage in Surgery: 

Haemorrhage in Surgery The overwhelming majority of patients who undergo oral surgical procedures are those who have normal haemostatic mechanism. Therefore, significant or major haemorrhages are not that common in oral surgery except in patients who have a bleeding / clotting disorder or those who are on anticoagulants. However, uncontrolled and persistent bleeding can occur in some healthy patients after dental extraction. Therefore, it is still important to achieve proper hemostasis in all patients during oral surgical procedures, so as to prevent excessive post-operative blood loss.

Normal Mechanism of Hemostasis: 

Normal Mechanism of Hemostasis Hemostasis is a complicated process. It involves a number of events 1. VASCULAR PHASE 2 . PLATELET PHASE 3 . COAGULATION PHASE 4 . FIBRINOLYTIC PHASE

Normal Mechanism of Haemostasis: 

VASULAR PHASE When a blood vessel is damaged, vasoconstriction results. PALATELET PHASE Platelets adhere to the damaged surface and form a temporary plug. COAGULATION PHASE Through two separate pathways, the Intrinsic and Extrinsic, the conversion of fibrinogen to fibrin is complete. Fibrin tightly binds the platelets to form a clot. FIBRINOLYTIC PHASE Anticlotting mechanisms are activated to allow clot disintegration and repair of the damaged vessel. Normal Mechanism of Haemostasis

The Clotting Mechanism : 

The Clotting Mechanism INTRINSIC EXTRINSIC PROTHROMBIN THROMBIN FIBRINOGEN FIBRIN (II) ( IIa ) V X Tissue Thromboplastin Collagen XII XI IX VIII (I) (Ia)

Clotting Factors: 

Clotting Factors

List of coagulation factors: 

List of coagulation factors Factors Name Half life Biosynthesis Vitamin K dependency I Fibrinogen 1.5-6.3 days Liver No II Prothrombin 2-4 days Liver, Brain Yes III Tissue Factor Unknown - No IV Calcium - - No V Proaccelerin 12-24 Hours Liver, Megakaryocytes No VII Proconvertin 1-5 Hours Liver Yes VIII Anti Heamophilic 8-12 Hours Liver, Spleen, Endothelium No Reticuloendothelium cells IX Christmas factor 15-24 Hours Liver Yes X Stuart- Prower factor 2-9 Hours Liver Yes XI Plasma thromoboplastin 40-84 Hours Liver No Actecedent XII Hageman Factor 48-52 Hours Liver No XIII Fibrin-Stabilizing factor 4.5-12 days Liver No

Haemostasis: 

Haemostasis Primary Haemostasis Secondary Haemostasis

Primary Haemostasis: 

Primary Haemostasis Primary haemostasis is a process of platelet plug formation at the site of injury. It occurs within seconds of injury and its important in stoppage of blood from small arterioles, venules and capillaries. There is platelet adhesion, release of granules and platelets aggregation resulting in formation of haemostatic plug.

Secondary Haemostasis: 

Secondary Haemostasis Secondary haemostasis is the activation of clotting process in plasma, that ultimately results in formation of fibrin, which strengthens the primary haemostasis. It is completed in several minutes and is important in bleeding from larger vessels Coagulation is a continuous process and there are approximately 40 substances, which affect clotting, some promote clotting called procoagulatant and others prevent clotting called anticoagulant.

Secondary Haemostasis: 

Secondary Haemostasis For the purpose of simplicity and understanding coagulation mechanism can be broken into a series Reactions 1 this is intrinsic or contact phase of coagulation. In this phase, mainly factors VIII, IX, XI, XII along with calcium and plasma proteins take part. Partial thromboplastin time (PTT) screens this intrinsic limb of the coagulation. Reaction 2 this is extrinsic pathway for initiation of coagulation. In this phase, there is release of tissue thromoboplastin , which activates factor VII, calcium and tissue thromboplastin , which activates factor X and take part in reaction III – the common pathway. Prothrombin time screens the extrinsic limb of coagulation. Reaction 3 In this phase, factor X is activated by proteases generated in previous two reactions. Reaction 4 In this phase, prothrombin is converted into thrombin in the presence of factor V, calcium and phospholipids. Thrombin has got multiple role in haemostasis. Its main role is conversion of fibrinogen into fibrin.

LABORATORY EVALUATION: 

LABORATORY EVALUATION PLATELET COUNT PROTHROMBIN TIME (PT )/International normalized ratio(INR) PARTIAL THROMBOPLASTIN TIME (PTT ) THROMBIN TIME (TT ) BLEEDING TIME (BT) Platelet Function Analyzer(PFA-100)

Platelet Count: 

Platelet Count NORMAL 140,000 - 400,000 CELLS/MM 3 < 100,000 Thrombocytopenia < 50,000 Sev Thrombocytopenia < 20000 spontaneous bleeding

Prothrombin Time: 

Prothrombin Time Measures Effectiveness of the Extrinsic(VIII) & Common( X,V,II,I) Pathway The test results is abnormal when a factor is 10%below its normal value NORMAL VALUE 11-15 SECS INR(International Normalized Ratio)=1

INR(International Normalized Ratio): 

INR(International Normalized Ratio ) Measure the extrinsic pathway of coagulation Normal Range- 0.8-1.2 For patients on anti- coagulant- 2-3 INR= ( PT test / Pt normal ) ISI ISI is International sensitivity index Higher INR value indicate higher chance of bleeding

Partial Thromboplastin Time: 

Partia l Thromboplastin Time Measures Effectiveness of the Intrinsic(VIII,IX,XI,XII) & Common(X,V,II,I) Pathway The test results is abnormal when a factor is 15% to 30% below its normal value Best single screening test NORMAL VALUE 25-35 SECS

Thrombin Time: 

Thrombin Time Time for Thrombin To Convert Fibrinogen Fibrin A Measure of Fibrinolytic Pathway NORMAL VALUE 9-13 SECS

Bleeding Time: 

Bleeding Time PROVIDES ASSESSMENT OF PLATELET FUNCTION NORMAL VALUE 1-6 MINUTES

Local causes of haemorrhage in oral surgery –Soft tissue bleeding: 

Local causes of haemorrhage in oral surgery – Soft tissue bleeding Soft tissue bleeding is either arterial, venous, or capillary in nature.

Local causes - Soft tissue bleeding in oral surgery: 

Local causes - Soft tissue bleeding in oral surgery Arterial bleeding is bright red and spurting in nature. Arteries in the soft tissues at risk during oral surgical procedures are the lies posterior portion of hard palate) greater palatine artery and the buccal artery (lies lateral to the retromolar pad)

Local causes - Soft tissue bleeding in oral surgery: 

Local causes - Soft tissue bleeding in oral surgery Venous blood is dark red in color and flows steadily and heavily especially if the vein is large . Capillary bleeding is bright red in color and is more of a minimal ooze.

Local causes – Osseous (Bony) bleeding in oral surgery: 

Local causes – Osseous (Bony) bleeding in oral surgery Troublesome bone bleeding originates either from nutrient canals in the alveolar region, central vessels, such as the inferior alveolar artery , or from central vascular lesions ( Hemangioma or Vascular malformation)

Systemic causes of haemorrhage in oral surgery: 

Systemic causes of haemorrhage in oral surgery Some patients with heriditary conditions such as hemophilia, Von Willebrand’s disease are susceptible for haemorrhage following oral surgical procedures. Patients with thrombocytopenia (decreased platelet count) , Leukemia e.t.c ., are also at risk of prolonged bleeding after surgery. Patients with uncontrolled hypertension.

Systemic causes of haemorrhage in oral surgery: 

Systemic causes of haemorrhage in oral surgery Patients with H/O prosthetic heart valve replacement, Stroke (Cerebrovascular accident ) e.t.c ., take oral anticoagulants like Aspirin or Warfarin to prevent the occurrence of a thromboembolic episode. These patients are also at risk of prolonged severe bleeding during and after an oral surgical procedure.

Type of Haemorrhage: 

Type of Haemorrhage

Types of haemorrhage - Primary haemorrhage : 

Types of haemorrhage - Primary haemorrhage 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.

Types of haemorrhage - Intermediate / Reactionary haemorrhage: 

Types of haemorrhage - Intermediate / Reactionary haemorrhage 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.

Types of haemorrhage - Secondary haemorrhage : 

Types of haemorrhage - Secondary haemorrhage 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 (Like patient’s who undergo radical neck dissection e.t.c .,). This type of bleeding is not very frequently encountered after oral surgery procedures.

Local Measures ( Synthetic Materials): 

Local Measures ( Synthetic Materials) There are several materials that are commercially available that are used locally for achieving adequate hemostasis.

Local Measures: Surgicel (Oxidised Regenerated Cellulose): 

Local Measures: Surgicel ( Oxidised Regenerated Cellulose)

Local measures: Gelfoam with activated thrombin: 

Local measures: Gelfoam with activated thrombin

Local Measures: Avitene (Microfibrillar Collagen): 

Local Measures: Avitene ( Microfibrillar Collagen)

Local Measures: Etik Collagen (Packed collagen): 

Local Measures: Etik Collagen (Packed collagen)

Local Measures: Tranexamic acid 5%: 

Local Measures: Tranexamic acid 5%

Local Measures: Tranexamic acid 5% in Syringe: 

Local Measures: Tranexamic acid 5% in Syringe

Local Measures: Irrigation of wound with Tranexamic acid: 

Local Measures: Irrigation of wound with Tranexamic acid

Local Measures: Suturing the wound: 

Local Measures: Suturing the wound

Local Measures: Pressure with oral packs: 

Local Measures: Pressure with oral packs

Management of Intermediate haemorrhage in Normal patients: 

Management of Intermediate haemorrhage in Normal patients The management of bleeding that occurs immediately after surgery (Reactionary bleeding) involves proper examination of the surgical wound to identify the site of bleeding ( i.e ) from bone or soft tissue. If bleeding is from bone then the hemostatic agents like bone wax or gelfoam is usually used. If bleeding is from soft tissues then, ligation / cauterization of blood vessels along with the use of hemostatic agents like surgicel and suturing of the wound is carried out.

Management of Secondary haemorrhage in Normal patients: 

Management of Secondary haemorrhage in Normal patients The management of this type of bleeding that occurs a few days after surgery involves the removal of any debris from the wound surface that promotes the infection of the wound . Identify the source of bleeding and treat as would be done in a patient with secondary bleeding. Surgical stents can be placed over extraction sockets for stabilization of clot and prevention of wound contamination.

Management of haemorrhage in patients with bleeding disorders / and those on anticoagulant therapy: 

Management of haemorrhage in patients with bleeding disorders / and those on anticoagulant therapy The usual protocol involved in the treatment of this group of patients consists of pre-operative blood investigations and preoperative correction of the underlying deficiency (Replacement of Clotting factors / platelets) if any in these patients. Subsequently, after this appropriate local measures are used to decrease the chances of post-operative bleeding.

Management of haemorrhage in patients with uncontrolled hypertension. : 

Management of haemorrhage in patients with uncontrolled hypertension. This group of patients need appropriate medical consultation for initiation of medical treatment to decrease their Blood Pressure. Thus once their B.P is controlled, then the bleeding decreases and with local measures the haemorrhage is controlled.

Management for-Hemophilia: 

Management for -Hemophilia Transfusion of factors for replacement of missing coagulation factors Variable plasma half-lives of 8 to 12 hours for VIII & 18 to 24 hours for IX Local hemostatic agent (pressure ,packs ,vasoconstrictors ,sutures ,surgical stents) Anti- fibrinolytic drugs (EACA): blocking conversion of plasminogen to plasmin.( reduce the quantity of factor required)

Hemophilia: 

Hemophilia

Thank You: 

Thank You