Surgical Bleeding

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Surgical Bleeding

  1. 1. Surgical Bleeding Presented by Nargess Tavakoli Guilan University of Medical Sciences
  2. 2. Excessive Intraoperative or Postoperative Bleeding
  3. 3. may be the result of: <ul><li>ineffective local hemostasis </li></ul><ul><li>complications of blood transfusion </li></ul><ul><li>a previously undetected hemostatic defect </li></ul><ul><li>consumptive coagulopathy, and/or fibrinolysis. </li></ul>
  4. 5. Ineffective Local Hemostasis Ineffective Local Hemostasis
  5. 6. <ul><li>Excessive bleeding from the field of the procedure </li></ul><ul><li>without bleeding from other sites </li></ul><ul><li>e.g. cvp line </li></ul><ul><li>intravenous line </li></ul><ul><li>tracheostomy </li></ul>
  6. 7. exception <ul><li>operations on the </li></ul><ul><li>Prostate </li></ul><ul><li>Pancreas </li></ul><ul><li>Liver </li></ul>
  7. 8. <ul><li>operative trauma => </li></ul><ul><li>local plasminogen activation => </li></ul><ul><li>increased fibrinolysis on the raw surface </li></ul>
  8. 9. <ul><li>EACA: 24-48-hour interruption of plasminogen activation </li></ul>
  9. 10. <ul><li>laboratory investigation must be confirmatory </li></ul><ul><li>number of plt </li></ul><ul><li>actual plt count: if the smear is equivocal </li></ul><ul><li>aPTT </li></ul><ul><li>PT </li></ul><ul><li>TT </li></ul>
  10. 11. complications of blood transfusion
  11. 13. complications of blood transfusion <ul><li>thrombocytopenia due to massive blood transfusion </li></ul><ul><li>hemolytic transfusion reaction </li></ul><ul><li>Transfusion purpura </li></ul>
  12. 14. thrombocytopenia due to massive blood transfusion
  13. 15. <ul><li>massive transfusion </li></ul><ul><li>a single transfusion greater than 2500 mL </li></ul><ul><li>5000 mL transfused over a period of 24 hours. </li></ul>
  14. 16. thrombocytopenia due to massive blood transfusion <ul><li>usually not associated with hemostatic failure </li></ul>
  15. 17. <ul><li>prophylactic administration of plt: not indicated </li></ul>
  16. 18. if evidence of diffuse bleeding: <ul><li>empiric transfusion of 8_10 packs of fresh platelet concentrates </li></ul><ul><li>no clear association between plt count,BT & the occurrence of profuse bleeding </li></ul>
  17. 19. hemolytic transfusion reaction
  18. 20. <ul><li>Example: </li></ul><ul><li>anesthetized patient : </li></ul><ul><li>diffuse bleeding in an operative field that had previously been dry </li></ul>
  19. 21. <ul><li>Pathogenesis: </li></ul><ul><li>red blood cells lysis=> </li></ul><ul><li>release of ADP=> </li></ul><ul><li>diffuse plt aggregation=> </li></ul><ul><li>the plt clumps are swept out of the circulation </li></ul>
  20. 22. <ul><li>Release of procoagulants => </li></ul><ul><li>progression of the clotting mechanism => </li></ul><ul><li>intravascular defibrination </li></ul><ul><li>The fibrinolytic mechanism may be triggered. </li></ul>
  21. 23. Transfusion purpura
  22. 24. Transfusion purpura <ul><li>uncommon </li></ul>
  23. 25. <ul><li>donor plt :uncommon Pl A 1 group </li></ul><ul><li>Recipient makes Ab to the foreign plt Ag </li></ul><ul><li>foreign plt antigen attach to the recipient's own plt </li></ul>
  24. 26. <ul><li>sufficient titer of Ab to destroy recipent’s plt: within 6 or 7 days </li></ul><ul><li>resultant thrombocytopenia & bleeding may continue for several weeks </li></ul>
  25. 27. <ul><li>bleeding follows transfusion by 5 or 6 days: </li></ul><ul><li>Transfusion purpura as DDx. </li></ul>
  26. 28. Management: <ul><li>Platelet transfusions : </li></ul><ul><li>little help </li></ul><ul><li>damage from the Ab </li></ul><ul><li>Corticosteroids: </li></ul><ul><li>some help </li></ul><ul><li>self-limited </li></ul>
  27. 29. DIC and disseminated fibrinolysis
  28. 30. DIC and disseminated fibrinolysis <ul><li>control mechanisms fail to restrain the hemostatic process to the area of tissue damage </li></ul>
  29. 31. Caused by: <ul><li>trauma </li></ul><ul><li>incompatible transfused blood </li></ul><ul><li>Sepsis </li></ul><ul><li>necrotic tissue </li></ul><ul><li>fat emboli </li></ul><ul><li>retained products of conception </li></ul><ul><li>toxemia of pregnancy </li></ul><ul><li>large aneurysms </li></ul><ul><li>liver diseases </li></ul>
  30. 32. <ul><li>distinguish between the two processes or the dominant element : important </li></ul>
  31. 33. <ul><li>No single test </li></ul><ul><li>can confirm or exclude the diagnosis or distinguish between the two disorders </li></ul>
  32. 34. strong indications for DIC <ul><li>The combination of </li></ul><ul><li>Thrombocytopenia </li></ul><ul><li>plasma protamine test for fibrin monomers:+ </li></ul><ul><li>fibrinogen level : LOW </li></ul><ul><li>FDP : ELEVATED </li></ul>
  33. 35. <ul><li>The euglobulin lysis time </li></ul><ul><li>detects diffusefibrinolysis </li></ul>
  34. 36. Biliary tract surgery in cirrhotic patients & Bleeding <ul><li>Related to: </li></ul><ul><li>portal hypertension </li></ul><ul><li>coagulopathy associated with chronic liver disease </li></ul>
  35. 37. <ul><li>The tests used to distinguish DIC from fibrinolysis pertain </li></ul>
  36. 38. <ul><li>The therapeutic approach </li></ul><ul><li>IV vasopressin : temporary reduction in portal hypertension </li></ul><ul><li>EACA to correct the increased fibrinolysis </li></ul>
  37. 39. The therapeutic approach <ul><li>IV vasopressin : temporary reduction in portal hypertension </li></ul><ul><li>EACA to correct the increased fibrinolysis. </li></ul>
  38. 40. Intra/Postoperative Bleeding & sepsis <ul><li>Endotoxin-induced thrombocytopenia </li></ul><ul><li>Defibrination </li></ul>
  39. 41. Endotoxin-induced thrombocytopenia <ul><li>Gram Neg. sepsis </li></ul><ul><li>a labile factor (possibly factor V) </li></ul>
  40. 42. Defibrination <ul><li>meningococcemia </li></ul><ul><li>Clostridium perfringens sepsis </li></ul><ul><li>staphylococcal sepsis </li></ul><ul><li>Hemolysis leading to defibrination </li></ul><ul><li>Evaluation:plt count, INR, aPTT,TT </li></ul>
  41. 43. Preoperative Evaluation of Hemostasis
  42. 44. Ask the patient 8Qs
  43. 45. <ul><li>prolonged bleeding or swelling after biting the lip or tongue? </li></ul>
  44. 46. <ul><li>bruises without apparent injury? </li></ul>
  45. 47. <ul><li>prolonged bleeding after dental extraction? </li></ul>
  46. 48. <ul><li>excessive menstrual bleeding? </li></ul>
  47. 49. <ul><li>bleeding problems associated with major and minor operations? </li></ul>
  48. 50. <ul><li>medical problems receiving a physician's attention within the past 5 years? </li></ul>
  49. 51. <ul><li>medical problems receiving a physician's attention within the past 5 years? </li></ul>
  50. 52. <ul><li>medications including aspirin or remedies for headache taken within the past 10 days ? </li></ul>
  51. 53. <ul><li>a relative with a bleeding problem? </li></ul>
  52. 54. Four levels <ul><li>Based on: </li></ul><ul><li>History </li></ul><ul><li>surgical procedure </li></ul>
  53. 55. level I <ul><li>History: negative </li></ul><ul><li>procedure: relatively minor </li></ul><ul><li>e.g., breast biopsy </li></ul><ul><li>hernia repair </li></ul><ul><li>no screening tests are recommended </li></ul>
  54. 56. level II <ul><li>history:negative </li></ul><ul><li>major operation but usually is not attended by significant bleeding </li></ul><ul><li>platelet count </li></ul><ul><li>PBS </li></ul><ul><li>PTT </li></ul>
  55. 57. Level III <ul><li>history : suggestive of defective hemostasis </li></ul><ul><li>procedure :hemostasis may be impaired, e.g., operating using pump oxygenation or cell savers </li></ul><ul><li>procedures : a large, raw surface is anticipated </li></ul><ul><li>situations :minimal postoperative bleeding could be injurious(intracranial operations) </li></ul>
  56. 58. Level III <ul><li>plt count & bleeding time test : platelet function; </li></ul><ul><li>aPTT & INR : coagulation </li></ul><ul><li>the fibrin clot should be incubated to screen for abnormal fibrinolysis </li></ul>
  57. 59. Level IV <ul><li>history highly suggestive of a hemostatic defect </li></ul><ul><li>consult with ahematologist </li></ul><ul><li>tests prescribed for level III </li></ul><ul><li>BT test :4 hours after ingestion of 600 mg of aspirin operation is scheduled to take place 10 or more days after this study. </li></ul>
  58. 60. Level IV <ul><li>emergency procedure: </li></ul><ul><li>platelet aggregation tests ADP, collagen, epinephrine, and ristocetin </li></ul><ul><li>TT : detect any dysfibrinogenemia or a circulating, weak, heparin-like anticoagulant. </li></ul>
  59. 61. <ul><li>uremic patients </li></ul><ul><li>Qualitative platelet abnormality </li></ul><ul><li>most common deficit </li></ul><ul><li>best detected by the bleeding time test . </li></ul>
  60. 62. Thanks for your attention

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