The document provides an overview of managing patients with bleeding disorders. It discusses hemostasis, common lab tests used to evaluate clotting mechanisms, and causes of bleeding disorders including platelet disorders and factor deficiencies. Guidelines are presented for identifying patients with bleeding disorders based on their history. Techniques to maintain hemostasis during surgery include using a harmonic scalpel. The document also reviews recommendations for treating patients taking antiplatelet drugs, anticoagulants, or fibrinolytic drugs and discusses hemophilia and conclusions.

1. MANAGEMENT OF PATIENTS
WITH BLEEDING DISORDERS.
Presented by :
Dr. Ameera salahudheen
JR Academic
JAN 2021 BATCH

2. CONTENTS :
• Introduction
• Hemostasis
• Lab measures associated with clotting mechanism.
• Causes of bleeding disorder
• How to identify a person with bleeding disorder.
• Techniques for maintenance of hemostasis.
• BCSH recommendations.
• Hemophilia
• Conclusion
• References.

3. INTRODUCTION
• What is bleeding disorder?
‘group of conditions in which there is a problem with the body’s blood clotting process’.
• Dental procedures involves many surgical procedures such as extractions, flap surgeries
etc. so it plays an important role in dental practice.
• Patients with minor bleeding disorder are under-recognized and frequently present in
the practice of dentistry.

4. HEMOSTASIS
• Hemostasis is the mechanism that leads to cessation of bleeding from a blood vessel.
• Involves multiple interlinked steps; like
Vascular phase
Platelet phase cascade culminates into the
Coagulation phase formation of ‘plug’ that closes
Fibrinolytic phase up the damaged site of BV.

5. • VASCULAR PHASE :
Blood vessel damage vasoconstriction.
• PLATELET PHASE :
Platelet adhere to form the temporary plug

6. • COAGULATION PHASE :

7. • FIBRINOLYTIC PHASE :

8. • LAB MEASURES ASSOCIATED WITH CLOTTING MECHANISMS :
A. Platelet count
• Normal = 1,00,000 – 4,00,000 cells/mm3
• If <1,00,000 – thrombocytopenia
• 50,000- 1,00,000 – mild thrombocytopenia
• <50,000 – severe thrombocytopenia
B. BT(bleeding time)
• Normal = 2 – 8 mnts.
• Measures how long it takes the vessels cut to constrict and how long it takes for
platelets in the blood to seal off the hole.

9. C. CLOTTING TIME :
• Normal = 8 – 15 mnts.
• Time required to form a clot.
• Abnormalities indicates decreased quantity or function of the coagulation factors
• Two most commonly used measures are PT (prothrombin time), PTT (partial thromboplastin time)
D. PT (prothrombin time) :
• Normal = 10 – 15 sec.
• Screens the activity of the proteins in the extrinsic pathway (7,10,5,2,1)
• INR (international normalized ratio ):
# INR is a calculation that adjusts for changes in the PT reagents and allows for results from different laboratories to be
INR used to monitor the effectiveness of the blood-thinning medication, warfarin.
# normal = <1.1
# 1.5 or below considered suitable for surgery.
# if 1.8 or above for 3 days, vit.K(oral preparation of 1-2.5mg) was given.
E. PTT (partial thromboplastin time):
• Normal = 25 – 40 sec
• Screens the activity of the proteins in the intrinsic pathway (12,11,9,8,10,5,2,1)
F. TT (thrombin time) :
• Normal = 9 -13 sec
• Time for thrombin to convert fibrinogen to fibrin

10. WHAT CAUSES BLEEDING DISORDER?
Vessel
defects
Factor
deficiencies
Other
disorders
Platelet
disorders

11. • VESSEL DEFECTS :
I. Vit. C deficiency
II. Bacterial & viral infections
III. Acquired(vasculitis).
• PLATELET DISORDERS :
1. thrombocytopenia
Drug induced
Alcohol,
Thiazide diuretics
hypersplenism
Increase in size leads to
destruction of platelets
Other causes
HIV,
ITP
Viral infections,
Nutritional deficiency,
Chemotherapy,
Radiation therapy,
Bone marrow failure Infiltration of abnormal cells

12. ii.
thrombocytopathy
Myeloproliferative
disorders
Chronic renal
failure
Drug induced
Aspirin,
NSAIDS

13. • FACTOR DEFICIENCIES :

14. • OTHER DISORDERS :
others
malabsorption
Intestinal disease interferes with
bile acid metabolism which is
required for vit . K absorption
Broad- spectrum antibiotics Change in intestinal flora
Oral anticoagulants
Heparin
1.(PTT)
Coumarin
(PT)
Liver disease 2,7,9,10
DIC
Advanced heart failure causing
liver failure

15. How do we identify a person with
blood disorder?
 Thorough review of history & complete clinical evaluation.
 Patient evaluation &history should begin with standard medical questionnaire.
 Should be queried about any previous unusual bleeding episode after injury/surgery, spontaneous
bleeding and easy / frequent bruising.
 For the purpose of history taking, a clinically significant bleeding episode is one that :
1) continue beyond 12 hours.
2) Causes the patient to call/return to dental practitioner/ to seek medical treatment/ emergency care.
3) Results in the development of hematoma/ ecchymosis with in the soft tissue.
4) Requires blood products support.

16. APPROACH TO A PATIENT WITH
BLEEDING DISORDER
• History taking
• Blood investigations
• Find out the cause
• Act accordingly.

17. • Most invasive surgical procedures can be carried out safely with a platelet count >50 *109 /L or
INR below 2.
• Guidelines for platelet transfusion threshold in thrombocytopenic surgical patients & patients undergoing
invasive procedures are largely based on expert opinion & clinical experience.
• Eventhough, when treatment is indicated, a single adult therapeutic dose (ATD) of platelets can be
trsansfused shortly before the procedure & the post transfusion count can be checked 10 min after
transfusion.
• GENERAL MEASURES TO STOP BLEEDING : (BCSH british committee for standards in
hematology guidelines 2012)
• General non-pharmacological measures :
1) Stop the antithrombotic drug
2) Document the timing & amount of last drug dose and presence of pre-existing renal/hepatic impairment.
3) Estimate the half life & length of functional defect induced by the drug
4) Assess the source of bleeding

18. 5) Request full blood count, PT, APTT, thrombin time, fibrinogen concentrate, creatinine
level
6) If available, request a specific lab test to measure the antithrombotic effect of the
drug.
7) Correct hemodynamic compromise with IVF & red cell transfusion.
8) Apply mechanical pressure; if possible.
9) Use endoscopic; radiological / surgical measures.
 Pharmacological & blood component pro-hemostatic therapies :
1) Tranexamic acid
2) Desmopressin
3) Fresh frozen plasma
4) Cryoprecipitate
5) Platelet transfusion
6) Fibrinogen concentrate
7) Prothrombin complex concentrate
8) Activated pcc
9) Recombinant factor VIIa

19. TECHNIQUES FOR MAINTAINING
HEMOSTASIS IN SURGERY:
Harmonic scalpel :
Surgical in used to simultaneously
cut and cauterize tissue using
ultrasonic energy.

20. BCSH(BRITISH COMMITTEE FOR STANDARDS IN
HEMATOLOGY) RECOMMENDATIONS :
I. Treating a patient taking an antiplatelet drug(s) :
1) Aspirin :
o Inhibits platelet activation by inactivating platelet cyclooxygenase.
o Plasma half life of 20min.
o Increases the risk of surgical bleeding 1.5 fold, but doesn’t increase severity.
II) P2Y12 antagonists :
o Includes clopidogrel and prasugrel & also the active drug ticagrelor.
o Ticagrelor is a potent P2Y12 antagonist that has plasma half-life of 8-12h is more reversible than
clopidogrel & prasugrel.
III) Glycoprotein IIb/IIIa inhibitors :
o Moderate thrombocytopenia (<50*109/l) was reported in 2.5% and severe thrombocytopenia(<20) in
0.3-0.5% of patients receiving abciximab.
o Tirofiban and eptifibatide are eliminated by kidneys, causes increased bleeding risk in patients with renal
impairment.

21. RECOMMENDATIONS :
• Decisions to withhold antiplatelet drugs or to administer pro-hemostatic agents should be made after a careful
multi-disciplinary assessment of the risks and benefits of intervention.
• Bleeding in patients during treatment with aspirin, P2Y12 antagonists or GP IIb/IIIa inhibitors should be
managed in the first instance with general hemostatic measures. If necessary, drug cessation and reversal of the
effect of co-prescribed anticoagulants should also considered.
• Platelet transfusion(2-3 adult dose) should be considered as an additional measure for critical bleeding or
prevention of bleeding before emergency surgery.
• Platelet transfusion should be considered to prevent bleeding in severe thrombocytopenia caused by
abciximab(<10).
• SDCEP (Scottish dental clinical effectiveness programme) recommendations :
• for a patient who is taking single or dual antiplatelet drugs, treat without interrupting their medication
especially for patients with a coronary artery stent.

22. II. Treating a patient taking parenteral anticoagulants :
o Stopping an UFH(unfractionated heparin) infusion and general hemostatic measures are often
to stop or prevent bleeding.
o Protamine sulphate(1mg per 80-100 units UFH)will fully reverse UFH, but should
Be given slower than 5mg/min to minimize the risk of adverse reactions.
o Maximum recommended dose of 50mg protamine is sufficient to reverse UFH in
Most settings.
LMWH(low molecular weight heparin) administration within 8h of the time of requirement for
of anticoagulation: give protamine sulphate (1mg per 100 anti-Xa units of LMWH).
If ineffective, consider further protamine sulphate 0.5mg per 100 anti-Xa units. Protamine should be
given slower than 5mg/min to minimize the adverse reactions.
LMWH administration greater than 8h from the time of requirement for correction of anticoagulation:
consider smaller doses of protamine.

23. III) Treating a patient taking oral anticoagulants :
o All hospitals managing patients on warfarin should stock a licensed 4-factor PCC.
o Emergency anticoagulation reversal in major bleeding should be with 25-50 U/Kg
Four-factor PCC and 5 mg IV vit.K.
o Recombinant factor VIIa is not recommended for emergency anticoagulation
reversal.
o Fresh frozen plasma produces suboptimal anticoagulation reversal & should only be
Used if PCC is not available.
o Anticoagulation reversal for non-major bleeding should be with 1-3mg IV vit.K.
o Patients with an INR>5 but who are not bleeding should have 1-2 doses of warfarin withheld & their
maintenance dose should be reduced. The cause of the elevated INR should be investigated.
o Asymptomatic patients with an INR >8 should receive 1-5mg of oral vit.K. the INR should be rechecked the
following day in case an additional dose of vit.K is required.
o for surgery that requires reversal of warfarin & that can be delayed 6-12h, the INR can be corrected by
giving IV vit.K.
o For surgery that requires reversal of warfarin & which can’t be delayed for vit.K to have time to take effect,
the INR can be corrected by giving PCC and IV vit.K.

24. • ACCP (American college of chest physicians Evidence- based clinical practice)
guidelines for the management of supratherapeutic INR :

25. • IV) treating a patient taking fibrinolytic drugs :
o For major bleeding(eg : intracerebral) within 48h of administration, BCSH Recommend :
1) Stop infusion of fibrinolytic drugs and other antithrombotic drugs.
2) Administer FFP 12 ml/Kg.
3) Administer intravenous tranexamic acid 1g TDS
4) If there is depletion of fibrinogen, administer cryoprecipitate or fibrinogen
5) Further therapy should be guided by the results of coagulation tests.

26. HEMOPHILIA :
 Common hereditary coagulation blood disorder due to deficiency or reduced
activity of clotting factor 8 or 9.
 X – linked recessive disorder transmitted via females to men who are sufferers.
 Often called as ‘disease of kings’, because it was carried by many members of
Europe’s royal families. Queen Victoria of England was a carrier of hemophilia.
 TYPES :
1) Hemophilia A - factor 8 deficiency – X linked recessive
2) Hemophilia B - factor 9 deficiency – X linked recessive
3) Hemophilia C - factor 11 deficiency - autosomal recessive
4) Parahemophilia – factor 5 deficiency – autosomal recessive

28. In hemophilia A,
APTT – elevated
Platelet count
Bleeding time normal
Prothrombin time
Surgery in hemophilia patients should take place in a center with adequate laboratory
support for perioperative assessment of FVIII level including inhibitor screening &
optimal blood bank support to provide sufficient quantities of FVIII concentrates.
People with hemophilia A or B can develop inhibitors,
Bethesda Assay is used to detect inhibitors .
 <5BU – low titre – can be treated with human factor 8 concentrates.
>5BU – high titre – factor 8 bypassing agents should be used, like PCC(prothrombin
complex concentrates or recombinant activated factor VII

29. For major surgery, factor 8 level should be
>50 %. Postoperatively, >30% for atleast 10
days.
So, in patients with hemophilia, replacement
therapy should be performed prior to any
anesthesia
Dose of factor 8 concentrate is calculated
according to world federation of hemophilia
2012 is,
 =body wt(Kg)*desired factor level
(IU/dl)*0.5
Eg: for a 17 kg patient,
17*100*0.5 = 850 U
1 unit of F8 concentrate per Kg will increase
plasma activity by 2%.

30. IM medication & arterial puncture should be avoided.
Smooth induction of anesthesia is preferred.
Succinylcholine is avoided to prevent muscle fasciculation, which may worsen
muscle & joint hemorrhagic state.
Post induction manipulation/ intubation can cause submucosal hemorrhage, and
also nasal intubation is more traumatic; so the tube must be previously greased
with lubricant to decrease friction.
Use of a non-traumatic rubber catheter for aspiration is advisory,
 hyper tension and tachycardia can cause increased bleeding from the surgical
site.
Regional anesthesia is not recommended, literature reveals neuraxial blocks as
well as peripheral nerve blocks have been safely performed in moderate – severe
hemophilia.
For closure , absorbable sutures like vicryl is preferred.
Postoperatively, for analgesia PCM is considered due to the fact that NSAID can
cause GI complications like ulcer and bleeding.

31. Minor procedures like extractions in patients with mild hemophilia can be performed by
administering desmopressin for nasal sprays (4-5 mg/Kg in 50 mL of saline in 15 min
before surgery) or as a single IV infusion (0.3microgram/Kg diluted with 50-100mL of
saline ) infused over 30 min.
Desmopressin increases plasma levels of F8 &vWf for mild – moderate hemophilia A. it
is ineffective in patients with severe hemophilia or with high F8 antibody titre.
And antifibrinolytics (amino-caproic acid 100mg/Kg per or every 6h for 3-5 days or
tranexamic acid)
Antifibrinolytics act as an adjuvants, can be used as;
1) IV infusion
2) Oral tablets
3) 4.8% solution mouthwash
4) Application of solution/ paste of crushed tablet directly to the site of bleeding.

33. CONCLUSION
 Bleeding disorder is a disorder where there is a problem in body’s clotting
mechanism.
 Knowledge on the type of bleeding disorder and management is very
important among maxillofacial surgeons.
 A better case history including past medical, dental, drug history can avoid
complications.

34. References :
 Ganong’s Review of medical physiology – 24th edition
 Anesthesia :Essays and researches 2016 article.
 International journal of Environmental Research and Public Health 2019
(surgical risk on patients with coagulopathies: guidelines on hemophiliacs for
OMFS)
 JPAC (joint united kingdom blood transfusion & tissue transplantation services
professional advisory committee) transfusion handbook.
 BJCP (british journal of clinical pharmacology)
 BJH guideline (guideline on the management of bleeding in patients on
antithrombotic agents)
 SDCEP (Scottish dental clinical effectiveness programme)

35. Thank you