Diagnosis and Management of Hemorrhage in Oral Surgery DR MOHAMMAD AKHEEL OMFS PG
What is meant by Hemorrhage ?Prolonged or uncontrolled bleeding is oftenreferred to as hemorrhage.The amount of blood lost as a result ofhemorrhage can range from minimal tosignificant quantities.
Hemorrhage in SurgeryHemorrhage can occur to a greater or lesserdegree during all surgical procedures and it’smanagement depends upon whether the patient ishematologically normal or suffers from somedisturbance in the normal clotting mechanism.
Hemorrhage in Oral Surgery
Hemorrhage in Oral SurgeryThe overwhelming majority of patients whoundergo oral surgical procedures are those whohave normal haemostatic mechanism.Therefore, significant or major hemorrhages arenot that common in oral surgery except in patientswho have a bleeding / clotting disorder or thosewho are on anticoagulants.
Hemorrhage in Oral SurgeryHowever, uncontrolled and persistent bleedingcan occur in some healthy patients after dentalextraction.Therefore, it is still important to achieve properhemostasis in all patients during oral surgicalprocedures, so as to prevent excessive post-operative blood loss.
Normal Mechanism of HemostasisHemostasis is a complicated process.It involves a number of events
Hemostasis - Normal Mechanism1. VASCULAR PHASE2. PLATELET PHASE3. COAGULATION PHASE
VASCULAR PHASEWhen a blood vessel is damaged,vasoconstriction results.
PLATELET PHASEPlatelets adhere to the damaged surface and form a temporary plug.
COAGULATION PHASEThrough two separate pathways, theIntrinsic and Extrinsic, the conversion offibrinogen to fibrin is complete. Fibrintightly binds the platelets to form a clot
THE CLOTTING MECHANISM INTRINSIC EXTRINSIC Collagen Tissue Thromboplastin XII XI VII IX VIII X V FIBRINOGEN (I)PROTHROMBIN THROMBIN (II) (III) FIBRIN
HEMOSTASISDEPENDENT UPON: Vessel Wall Integrity Adequate Numbers of Platelets Proper Functioning Platelets Adequate Levels of Clotting Factors Proper Function of Fibrinolytic Pathway
Hemorrhage in Oral SurgeryHemorrhage following Oral Surgical procedurescan occur due to local or systemic causes.In healthy patients the postoperative bleeding ismainly due to local causes.
Local causes of hemorrhage in oral surgeryLocal causes of hemorrhage originate in eithersoft tissue or bone.
Local causes of hemorrhage 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 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 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 surgeryTroublesome bone bleeding originates either fromnutrient canals in the alveolar region, centralvessels, such as the inferior alveolar artery, orfrom central vascular lesions (Hemangioma orVascular malformation)
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 e.t.c., are also at risk of prolonged bleeding after surgery. Patients with uncontrolled hypertension.
Systemic causes of hemorrhage 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.
Types of Hemorrhage - Primary HemorrhageThis occurs during the surgery, as a result of injury likecutting or laceration of the artery or bleeding frombone.This also occurs when surgery is done in an infectedarea with a lot of granulation tissue.It can also occur after a very short period of timeimmediately after surgery.This type of bleeding is really normal and can becontrolled easily.
Types of Hemorrhage - Intermediate / Reactionary HemorrhageThis type of bleeding occurs within a few hours aftersurgery.This type of bleeding occurs as a result of failure ofcoagulation to occur (as in patients with systemicbleeding problems or those on anticoagulants)Patients who have unknowingly disturbed / dislodged theclot are also prone for this type of bleeding.
Types of Hemorrhage - 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 (Like patient’s who undergo radical neck dissection e.t.c.,). This type of bleeding is not very frequently encountered after oral surgery procedures.
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) Hypotensive anaesthesia (G.A) and use of vasoconstrictors in L.A.
Local Measures ( Synthetic Materials)There are several materials that are commerciallyavailable that are used locally for achievingadequate hemostasis.
Local Measures: Surgicel (Oxidised Regenerated Cellulose)
Local measures: Gelfoam with activated thrombin
Local Measures: Avitene (Microfibrillar Collagen)
Local Measures:Etik Collagen (Packed collagen)
Local Measures: Tranexamic acid 5%
Local Measures: Tranexamic acid 5% in Syringe
Local Measures: Irrigation of wound with Tranexamic acid
Local Measures: Suturing the wound
Local Measures: Pressure with oral packs
Management of Intermediate Hemorrhage 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.(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 secondary bleeding. Surgical stents can be placed over extraction sockets for stabilization of clot and prevention of wound contamination.
Management of Hemorrhage in patients withbleeding disorders / and those on anticoagulant therapyThe usual protocol involved in the treatment of thisgroup of patients consists of pre-operative bloodinvestigations and preoperative correction of theunderlying deficiency (Replacement of Clotting factors /platelets) if any in these patients.Subsequently, after this appropriate local measures areused to decrease the chances of post-operative bleeding.
LABORATORY EVALUATION PLATELET COUNT BLEEDING TIME (BT) PROTHROMBIN TIME (PT) PARTIAL THROMBOPLASTIN TIME (PTT) THROMBIN TIME (TT)
BLEEDING TIME PROVIDES ASSESSMENT OF PLATELET COUNT AND FUNCTIONNORMAL VALUE 2-8 MINUTES
PROTHROMBIN TIME Measures Effectiveness of the Extrinsic PathwayNORMAL VALUE 10-15 SECS
PARTIAL THROMBOPLASTIN TIME Measures Effectiveness of the Intrinsic PathwayNORMAL VALUE 25-40 SECS
THROMBIN TIMETime for Thrombin To ConvertFibrinogen FibrinA Measure of Fibrinolytic PathwayNORMAL VALUE 9-13 SECS
Management of Hemorrhage in patients withuncontrolled 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 hemorrhage is controlled.