Haemorrage in oral surgery

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HAEMORRHAGE TREATMENT, BLEEDING ,, ORAL SURGERY TREATMENT

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Haemorrhage in oral surgery Submitted by- Dr. S.M.SUGANESH B.D.S, M.S

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Heamo+rrhage- escape of blood from vessels Prolonged or uncontrolled bleeding is referred to as haemorrhage. What is Haemorrhage ?

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TYPES OF HAEMORRHAGE DEPENDING ON TYPE OF BLOOD VESSEL INVOLVED: Arterial bleeding is pulsatile, brisk and bright red in colour. Venous bleeding is dark in colour. Due to lack of valves, blood flows in an even stream Capillary haemorrhage is bluish bright red in colour, blood oozes from the area and no bleeding point can be made out.

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Primary bleeding 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.

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Intermediate bleeding: This type of bleeding occurs within eight hours after surgery. Foreign body in the wound like calculus, broken bone piece, and granulation tissue in the socket causes intermediate bleeding

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Secondary bleeding In this bleeding starts after 24 hours to several days after surgery. I t may be due to -dislodgement of clot , -secondary trauma, -infection, -elevation of blood pressure.

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1. VASCULAR PHASE 2. PLATELET PHASE 3. COAGULATION PHASE 4. FIBROUS ORGANIZATION Normal HAEMOSTASIS undergoes following phases Cont….

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PLATELET PHASE It is a primary haemostasis in which platelet plug formed at site of injury. Occurs within seconds of injury. There is platelet adhesion , release of granules and platelet agregation resulting in formation of primary haemostatic plug VASCULAR PHASE Injured blood vessel, in an attempt to reduce blood flow undergoes constriction due to spasm in the vessel wall

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COAGULATION PHASE It is activation of clotting process in plasma, that results in formation of fibrin, which strengthens the primary haemostatic plug. List of coagulation factors -

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INTRINSIC ( PTT) EXTRINSIC ( PT) PROTHROMBIN THROMBIN FIBRINOGEN FIBRIN (II) (I) V X Tissue Thromboplastin Collagen VII XII XI IX VIII Clotting mechanism IV

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Local mechanical methods PRESSURE should be applied directly over the bleeding sites firmly over a gauze pack for atleast five minutes. USE OF HAEMOSTATS mosquito, artery forceps are specially designed to catch bleeding points in the surgical area. SUTURES AND LIGATION , when large pulsatile artery needs to tied, non absorbable material like 3-0 black silk is preferred. Smaller vessels are ligated with catgut, polygalactin. EMBOLIZATION of vessels with help of angiography, exact bleeding points can be localized. Agents used are steel coils, gel foam, silicon spheres, methyl methacrylate, polyvinyl alcohol foam.

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THERMAL AGENTS: CAUTERY ,Heat acheives haemostasis by denaturation of proteins which results in coagulation of large areas of tissue. Cont…. In ELECTROSURGERY ,heating occurs by induction from an alternating current source. This cannot control haemorrhage from large vessels which need to be ligated.

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CRYOSURGERY at - 20 ° c to - 180 °c , the tissues , capillaries, small arterioles and venules undergo cryogenic necrosis. Specially used to treat superficial haemangiomas.

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ARGON-BEAM COAGULATOR: in this monopolar current is transmitted to tissues through the flow of argon gas. There is possibility of gas embolism as there is stream of gas in direct contact with tissues. LASERS efectively coagulate the small blood vessels during cutting of tissues. THERMAL AGENTS:

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CHEMICAL METHODS ASTRINGENT AGENTS : Used in case of minimal capillary. Ex – Tannic acid, silver nitrate, ferric chloride BONE WAX : acts by mehanical occlusion of bleeding bony canal, large quantity of bone wax can lead to foreign body granuloma and infection

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THROMBIN : Topical use of thrombin acts by converting fibrinogen into fibrin clot. GEL FOAM : made from gelatin and is sponge like, because of its large surface area, which Comes in contact with blood and further swells on absorbing blood

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OXYCEL is an oxidized cellulose and on application releases celluloic acid, which has marked affinity for haemoglobin.leading to formation of artificial clot. SURGICEL it is glucose based sterile knitted fabric prepared by the controlled oxidation of regenerated cellulose.

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FIBRIN GLUE: It is biological adhesive containing thrombin, fibrinogen, factor XII and aprotinin(antifibrinolytic). Thrombin converts fibrinogen to unstable fibrin clot, factor XIII stabilizes the clot and aprotinin prevents its degradation. ADRENALIN: the drug is applied with help of gauze pack in the concentration of 1:1000 over oozing sites

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SYSTEMIC AGENTS: Whole blood: when there is exessive blood loss due to haemorrhage and symptoms of hypovolaemic shock, whole blood transfusion is indicated Fresh frozen plasma : A unit (150ml) of fresh frozen plasma is usually collected from one donar. It is stored at 30 ° c and should be infused within two hours once defrosted. Cryoprecipitate: Cryoprecipitate is prepared by slow thawing of fresh frozen plasma at 4˚C for 10–24 hours. A 15ml vial contains 100 unit of factor VIII, 250mg fibrinogen, factor XIII and von willibrand factor. It has risk of viral transmission. Platelet rich plasma: one unit of it raises the platelet count aproximately by 7000-10,000 cells per cu mm

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PLATELET COUNT BLEEDING TIME (BT) CLOTTING TIME(CT) PROTHROMBIN TIME (PT) PARTIAL THROMBOPLASTIN TIME (PTT) THROMBIN TIME (TT) LABORATORY EVALUATION

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NORMAL 150,000 - 400,000 CELLS/MM 3 50,000 - 100,000 Mild Thrombocytopenia < 50,000 Severe Thrombocytopenia PLATELET COUNT

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BLEEDING TIME It is the lag between the start of bleeding and the beginning of clot formation It Provides assessment of platelet count and function NORMAL VALUE 3-5 MINUTES

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CLOTTING TIME It indicates the time interval beginning from the formation of platelet plug to the completion of vasoconstriction and clot formation NORMAL VALUE 4 to 10 min

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PROTHROMBIN TIME Measures Effectiveness of the Extrinsic Pathway NORMAL VALUE 12-14 SECS The INR is a test of blood clotting, which is primarily used to monitor warfarin therapy, In healthy people, the INR is about 1.0. For patients on anticoagulants, the INR should be between 2.0 and 3.0 AND between 3.0 and 4.0 for patients with mechanical heart Valves

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PARTIAL THROMBOPLASTIN TIME Measures Effectiveness of the Intrinsic Pathway NORMAL VALUE 25-45 SECS

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

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Systemic causes of hemorrhage in oral surgery Some patients with heriditary conditions such as hemophilia, Von Willebrand’s disease are susceptible for hemorrhage following oral surgical procedures. Patients with thrombocytopenia (decreased platelet count) , Leukemia are also at risk of prolonged bleeding after surgery. Patients with uncontrolled hypertension. Patients with H/O prosthetic heart valve replacement, 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.

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Haemophilia A Hemophilia is caused by a deficiency of coagulation factor VIII (hemophilia A) or factor IX (hemophilia B) frequency of about one in 10,000 births Severity Bleeding episodes Severe 1% (< 0.01 IU/ml) Spontaneous bleeding predominantly in joints and muscles Moderate1%-5%(0.01-0.05) Occasional spontaneous bleeding. Severe bleeding with trauma,surgery Mild 5%-40% (0.05-0.40) Severe bleeding with major trauma or surgery

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Factor VIII concentrate: • Each FactorVIII unit per kilogram of body weight infused intravenously will raise the plasma FactorVIII level 2%. The half-life is 8–12 hours. Calculate the dosage by multiplying the patient’s weight in kilograms by the factor level desired multiplied by 0.5. This will indicate the number of units required. Example: 50 kg x 40 (% level desired) x 0.5 = 1,000 units Infuse FactorVIII by slow IV at a rate not to exceed 3 ml per minute in adults and 100 units per minute in young children.

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Other Pharmacological Options Are • Desmopressin; • Tranexamic acid; and • Epsilon aminocaproic acid Desmopressin Synthetic analogue of antidiuretic hormone Dose of 0.3 microgram/kg is diluted in 50-100 ml of normal saline and given by slow intravenous infusion over 20-30 minutes. Rapid infusion may result in, flushing, tremor, and abdominal discomfort. Desmopressin does not affect FactorIX levels and is of no value in hemophilia B.

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Tranexamic acid is usually given in tablet form, dose of 3 or 4 grams (in divided doses) daily for an adult It may also be given by intravenous injection (0.5-1 g), but it must be infused slowly, as rapid injection may result in dizziness and hypotension. A syrup formulation available for pediatric use: contains 500 mg tranexamic acid in each 5 ml, and usual dose for children is 25 mg/kg three times daily. It is contraindicated for the treatment of hematuria in severe hemophilia, as treatment may cause obstruction of the outflow from the renal pelvis Tranexamic acid is an antifibrinolytic agent that competitively inhibits theactivation of plasminogen to plasmin.

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adults dosage: 5 gm immediately followed by 1 gm every hour for 8 hours or till bleeding stops pediatric dosage is 50-100 mg/kg (maximum 5 gms) IV every 6-8 hours. Myopathy is a rare adverse reaction specifically reported in association with aminocaproic acid therapy Epsilon aminocaproic acid (EACA) is a drug similar to tranexamic acid but it is less widely used nowadays as it has a shorter plasma half-life, is less potent, and is more toxic.

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DENTAL CARE FOR HAEMOPHILIAC PATIENT Deep injections, surgical procedures – particularly those involving bone (extractions,dental implants) – or regional local anesthetic blocks should be performed only after clotting factor level has been appropriately increased. Local use of fibrin glue and swish-and-swallow rinses of tranexamic acid before and after dental extractions are safe and cost-effective methods to help control bleeding. For people with mild or moderate hemophilia, non-surgical dental treatment can be carried out under antifibrinolytic cover (tranexamic acid or epsilon aminocaproic acid) For those with severe hemophilia, factor replacement is necessary before surgery or regional block injections or scaling.

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Oral surgery for heart patients on warfarin prothrombin time must be within a range of 17–19 secs on the day of surgery, with gradual reduction of the therapeutic dosage at least 2 days before surgery. After surgery, the prothrombin time is restored to the previous therapeutic levels with a gradual increase over a period of 2 days. INR must be between 2.0 to 3.0 for all conditions except for patients with mechanical prosthetic valves, for which the INR is 2.5 to 3.5. after this, appropriate local measures are used to decrease the chances of post-operative bleeding

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Patients must be treated always under consultation with the hematologist, because these patients are susceptible to severe infection and postoperative hemorrhage. Avoidance of nerve block because, due to the blood cell disorder, extensive hematoma may result. Surgical procedures (e.g., tooth extraction) may be performed with administration of large doses of a broad-spectrum antibiotic and with meticulous measures for the control of bleeding. Antibiotic prophylaxis should be administered. Oral surgery on patient with leukemia

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Management of Hemorrhage in patients with uncontrolled hypertension . If the blood pressure values remain high even after premedication (e.g., over 180/110 mmHg) the dental session is postponed and the patient is referred to physician for further treatment. To avoid uncontrollable blood pressure, following preventive measures are taken : Blood pressure should be monitored before anesthesia and during the surgical procedure Preliminary aspiration to avoid intravascular administration, especially when the local anesthetic contains a vasoconstrictor used Avoiding noradrenaline in patients receiving antihypertensive agents Short appointments, as painless as possible

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THANK YOU Submitted by- Dr. S.M.SUGANESH B.D.S, M.S