Download management of hemorrhage in dental surgery

Management Of Hemorrhage In
Dental Surgery
Hemorrhage(bleeding):
Extravasation of blood due to rupture of blood vessels,
which could be capillary, artery or vein.
The effect of bleeding depends on:
1.Amound of blood loss.
2.Site of bleeding.
Vascular phase:
When a blood vessel is damaged, vasoconstriction results.
Platelet phase:
Platelet adhere to the damaged surface and form a temporary plug.
Coagulation phase:
Through two separate pathways the conversion of fibrinogen to fibrin
is complete.
Fibrinolytic (metabolic) phase:
Anti clotting mechanisms are activated to allow clot disintegration
and repair of the damaged vessels.
Timing of clinical bleeding
The hemostasis depend upon:
1) Vessel wall integrity.
2) Adequate number of platelets.
3) Proper functioning platelets.
4) Adequate levels of clotting factors.
5) Proper function of fibrinolytic pathway.
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Bleeding disorders can be defined
as those disorders that alter the ability
of
blood
vessels,
platelets
and
coagulation
factors
to
maintain
haemostasis. These can either be
congenital or acquired (2ndry to
disease,
drugs,
radiation
or
chemotherapy
Purpura
NTCP
Vascular wall alteration
- Scurvy
- Infections
- Chemicals
- Allergy
Disorders of platelet function
- Genetic (Bernard-Soulier disease)
- Drugs (Aspirin ,Cephalosporin ,Penicillin's ,NSAIDS,
Beta-Lactam antibiotics and Alcohol).
- Allergy
- Autoimmune
- vW disease (2ndry factor 8 deficiency)
- Uremia
Purpura
TCP
1- Primary (idiopathic –Autoimmune)
2- Secondary
- Chemicals
- Physical agents (radiation)
- Leukemia
- Metastatic cancer to bone
- Splenomegaly
- Drugs (Alcohol,Thiazide diuretics,Estrogens,Gold
salts)
- Prosthetic heart valve
- Viral or bacterial infections
Clotting or Coagulation defects
Congenital
1- Hemophilia A (Factor 8 Def.)
2- Hemophilia B (Factor 9 Def.)
3-VW disease
Clotting or Coagulation defects
Acquired
1-Liver disease
2-Vit K deficiency
- Biliary tract obstruction
- Malabsorption
- Excessive use of broad spectrum antibiotics
4- Anticoagulants
- Heparin
- Coumarin
- Warfarrin and NSAIDS
5- Primary fibrinolysis
Notes
1- Congenital deformities involves def. of one factor.
2- Acquired coagulation defects involve multiple factors
3- Hemophilia A is the most commonly inherited
coagulation disorder (80%).
4 –Anticoagulants are used to prevent thrombosis in:
- MI
- CVA
- Thrombophlebitis
- Atrial fibrillation
- Open heart surgery
- Hip or Knee replacement
- Asprin is also used in Rheumatoid arithritis
Notes
6-The liver produces all the protein coagulation factors.
7-Patients with liver disease who develop portal
hypertension and hypersplenism may be
thrombocytopenic as a result of splenic over activity.
8-Vitamin K is needed by the liver to produce factors 2,7,9
and 10.
Hemorrhage in Oral Surgery
 Hemorrhage following Oral Surgical procedures can occur
due to local or systemic causes. In healthy patients the
postoperative bleeding is mainly due to local causes.
 Local causes of haemorrhage in oral surgery Local causes of
hemorrhage originate in either soft tissue or bone.
Types of bleeding.
Immediate bleeding
.Reactionary bleeding
.Secondary bleeding
.
Go
 Immediate bleeding: which occur at the time of 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
 Reactionary bleeding: During the first 48 hours because a clot
in a vessel has been displaced, or a ligature has slipped due to
increase in blood pressure
 Secondary bleeding: 8 to 14 days later when the wound has
become infected and eroded a vessel, usually quite a small
one.
Management of Primary Hemorrhage in
Normal patients
 The management of bleeding during surgery (Primary
bleeding) can be achieved by the following means,
(i)
Securing / ligation of blood vessels with silk sutures.
(ii) Use of pressure swab to achieve hemostasis.
(iii) Use of electrocautery to achieve hemostasis.
(iv) Use of hemostatic agents like bone wax, surgicel,e.t.c.,
(v) use of vasoconstrictors in L.A.
 Local Measures ( Synthetic Materials)There are several
materials that are commerciallyavailable that are used locally
for achievingadequate hemostasis.
Surgicel (Oxidised Regenerated
Cellulose)
Etik Collagen (Packed
collagen)Regenerated Cellulose)
Gelfoam with activated thrombin
Tranexamic acid 5%)
Management of reactionary Hemorrhage
 in Normal patients The management of (Reactionary
bleeding involves proper examination of the surgical wound
to identify the site of bleeding (i.e ) from bone or soft tissue.
(i)
If bleeding is from bone then the hemostatic agents like
bone wax or gelfoam is usually used.
(ii) 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 Hemorrhage
 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 reactionary bleeding.
Surgical stents can be placed over extraction sockets for
stabilization of clot and prevention of wound contamination.
Management of Hemorrhage 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.
Dental evaluation:
1.
2.
3.
4.
5.
6.
7.
Good thorough medical , family and personal history.
Physical examination.
Medication
Past and present illness.
Spontaneous bleeding.
Consult physision
Screening clinical lab tests.
Laboratory evaluation
Platelet count.
Bleeding time (BT(.
Prothrombin time(PT(.
Partial thromboplastin time (PTT(.
Thrombin time (TT(.
International normalized ratio(INR).
Platelet function analyzer 100 (PFA100(.
Platelet Count:
Normal
mm3
100,000 – 400,000 cell /
less than 100,000
Thrombocytopenia.
50,000 – 100.000 Mild thrombocytopenia.
Less than 50,000 Sever thrombocytopenia.
Home
Bleeding time:
•Provides assessment of platelet count and function.
•Normal value: 1-6 minutes.
Partial thromboplastin time:
• Measures the effectiveness of the intrinsic pathway.
• Important in hemophilic status.
• Normal value: 20-35 sec.
PROTHROMBIN TIME
Measures Effectiveness of the Extrinsic Pathway NORMAL VALUE 10-15
SECS
THROMBIN TIMETime
for Thrombin To ConvertFibrinogen FibrinA Measure of
Fibrinolytic PathwayNORMAL VALUE 9-13 SECS
International normalized ratio (INR(
INR formula:
• INR value of 2.5-3.0 considered as in patient on anticoagulant
therapy.
• INR value of 3.4-4.0 is acceptable in patient prosthetic heart valve
disease.
• INR value of 4.0 used as upper limit for simple surgical procedure.
• INR value of 3.0 used as maximal level for surgery with extensive
blood loss such as extraction with alveolplasty.
Platelet function analyzer 100:
An in vitro system used for detection of platelet
dysfunction, it produces quantitative measure of
platelet function in anticoagulation whole blood.
Systemic measures:
I. platelet disorders:
1. Platelet transfusion (alloimmunization(:
2. One unit of platelet concentrate(equal to platelet derived from
one unit of whole blood) elevates the platelet count in adult
from 4000 to 10,000 cell/mm3.
3. Drug induced thrombocytopenia treated primarily by with drawl
the affecting drugs.
4. Idiopathic thrombocytopenia may benefit from corticosteroid
administration, spleenectomy,
5. Patient receiving aspirin therapy should reduce or discontinuing
there aspirin intake for 4-7days before surgery
• II.Hemophilia:
• Antihemophilic factor (bioclate, refractor)*
correct or
prevent bleeding episodes or allow necessary surgery.
• Coagulation factor VIIa (novoseven)
* Treat bleeding episodes with hemophilia A or B.
• Factor IX complex (benefix, profilnine SD(
* Prevent or treat hemophilia B, control bleeding
episodes in hemophilia A
Review patient's medications:
Five drugs that interfere with hemostasis
1.
2.
3.
4.
5.
Aspirin
Anticoagulants
Antibiotics
Alcohol
Anticancer
Oral manifestation:
• Petechiae , ecchymosis
• Gingival hyperplasia
• Spontaneous gingival bleeding
• Ulceration of oral mucosa
• Lymphadenopathy
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