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Surgery in Bleeding Diathesis

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Surgeons are doing surgeries because of normal blood clotting and wound healing. Suppose if your patient’s blood doesn’t clot properly and you come to know this only on the table, it would be a nightmare to any surgeon irrespective of their subspecialty. In this PPT, I am discussing about how to handle a patient with bleeding diathesis during and after surgery. Indeed it is a challenging and fascinating problem. I hope you will enjoy the video. You can watch all my teaching videos in the following links: surgicaleducator.blogspot.com; youtube.com/c/surgicaleducator.

Published in: Health & Medicine
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Surgery in Bleeding Diathesis

  1. 1. SURGERY IN BLEEDING DIATHESIS Dr.B.Selvaraj MS;Mch;FICS; Professor of Surgery Melaka Manipal Medical College Melaka 75150 Malaysia
  2. 2. SURGERY IN BLEEDING DIATHESIS  Introduction  Physiology Of Hemostasis  Pre-op Evaluation  Cases Managed  Common Bleeding Disorders  Surgery In Hemophiliacs  Clinical vignettes PLAN
  3. 3. SURGERY IN BLEEDING DIATHESIS  A challenging & fascinating problem  Pre-existing hemostatic defects can be detected with proper H&P and screening lab tests  Occasionally the first sign of the defect would be excessive intra-op bleeding  Nightmare to any surgeon
  4. 4. SURGERY IN BLEEDING DIATHESIS
  5. 5. PHYSIOLOGY OF HEMOSTASIS FOUR COMPONENTS:  VESSEL WALL RESPONSE  PLATELET ACTIVITIES  COAGULATION CASCADE  FIBRINOLYTIC SYSTEM
  6. 6. PHYSIOLOGY OF HEMOSTASIS  VESSEL WALL RESPONSE - Intact endothelium maintain fluidity of blood - Endothelial disruption initiates hemostasis  PLATELET ACTIVITIES - Adhesion to denuded endothelium by VWBF - Aggregation into an unstable mass by fibrinogen&Thromboxane A2
  7. 7. PHYSIOLOGY OF HEMOSTASIS PLATELET ACTIVITIES
  8. 8. COAGULATION FACTORS
  9. 9. COAGULATION PATHWAY
  10. 10. FIBRINOLYTIC SYSTEM
  11. 11. PRE-OPERATIVE EVALUATION  Thorough personal medical history, family history& drug ingestion history  Physical Exam:  Skin: Petechiae Thrombocytopenia Ecchymosis & Hematomas Platelet dysfunction  Joints: Hemarthrosis severe coagulation defect  Organomegaly: Hepatomegaly Coagulopathy of Cirrhosis Spleenomegaly Possible thrombocytopenia
  12. 12. PRE-OPERATIVE EVALUATION
  13. 13. LAB SCREENING TESTS
  14. 14. CASE NO: 1  2 Yrs old 1st born male child was brought with obstructed RIH  H/O Epistaxis & easy bruisability  Ear boring ceremony resulted in prolonged bleeding  Emergency, so extensive workup was not done  Emergency herniotomy was done
  15. 15. CASE NO: 1  Basic screening tests for bleeding diathesis:  Hb  11Gms  Bleeding time >15mts  Prothrombin time 12 sec  Partial thromboplastin time 39 sec  Blood group B +ve
  16. 16. CASE NO: 1  Only B.T. was prolonged  Provisional Diagnosis: Functional Platelet problem -Thrombocytopathy  Emergency Herniotomy with 200 ml of fresh whole blood  Readmitted after 10 days for prolonged bleeding from a small cut to upper lip  Managed by multiple WB transfusions
  17. 17. CASE NO: 1  Hematological workup:  Hb 11.5 GMs  PCV 36%  TC 12000/Cmm  DC P33,L43,E18, M4  Platlets200,000/  Bleeding time > 15 mts Clotting time13 mts  Clot retraction Nil  Clot lysis Nil  PT 12 sec  PTT 40 sec  Plasma fibrinogen 280 mgms  Factor xiii activity normal
  18. 18. CASE NO: 1  PLATELET FUNCTION TESTS: -Invivo Platelet Adhesion10.8% -ADP Aggregation Absent Aggregometer Studies -ADP No Aggregation -Collagen No Aggregation  Thrombin Time 8sec  Blood group B+ve
  19. 19. CASE NO: 1  Normal Platelet count&morphology  Normal Clotting tests  Prolonged Bleeding Time  Absent Platelet Aggregation with ADP and Collagen  Absent Clot Retraction  GLANZMAN`S THROMBASTHENIA
  20. 20. CASE NO: 2  11 yrs old boy with no known H/O any bleeding diathesis underwent emergency appendicectomy  He started oozing from the operated site in immediate post- operative period  In subsequent interrogation parents came out with the H/O ingestion of aspirin tablet by the boy  Labs: BT- prolonged; PT, PTT- Normal; Platelet count- Normal  Since this is a functional disorder of Platelets(Thrombocytopathy) the boy was treated with Platelet concentrate
  21. 21. CASE NO: 3  4 yrs old boy was brought with pain abdomen and fever for 1 day  O/E: Abdomen- diffuse tenderness with rigidity  AXR- erect revealed free gas under diaphragm  Boy is a known Hemophiliac  Laparotomy and ileal perforation closure was done with Anti hemophilic factor  On 2nd POD boy was oozing from the surgical site. So factor8 assay was done in hematology lab and dose of AHF was adjusted.
  22. 22. CASE NO: 4  5 yrs old boy with a H/O fall over cycle bar presented with retention of urine  O/E: Drop of blood at uretheral meatus, perineal hematoma and extravasation of urine were present  Emergency SPC was done after confirming rupture urethra with Retrograde urethrogram  The next day the boy started bleeding from SPC site  On subsequent interrogation parents told the boy is a known Hemophiliac  He was managed with AHF
  23. 23. Hematological Disorders Commonly Encounter by surgeons  Thrombocytopenia  Thrombocytopathy  Hemophilia- A  Hemophilia- B- Christmas disease  Von Willebrand Disease  Disseminated Intravascular Coagulation  Liver Disease– Factor vii & x deficiency
  24. 24. THROMBOCYTOPENIA  Low Platelet Count  Acquired or Inherited  Purpura & Ecchymosis superficial bleeding  Labs: BT- prolonged, PC- decreased, PT, PTT- Normal  Treatment: Platelet concentrates
  25. 25. THROMBOCYTOPATHY  Functional Platelet Abnormality  Acquired due to drugs like Aspirin and Uremia  Inherited Defective Platelet adhesion Bernard Soulier Syndrome Defective Platelet aggregation Glanzman’s Thrombasthenia  Labs: BT- Prolonged; PC,PT,PTT Normal  Ecchymosis & Epistaxis Superficial hemorrhage  Treatment: Platelet concentrates
  26. 26. HEMOPHILIA- A  Factor viii procoagulant deficiency  Sex linked recessive inheritance  Deep tissue bleed & hemarthrosis  LABS: PTT- Prolonged; PC,PT,BT- Normal Individual factor assay  Treatment: AHF- 1U/Kg raises the level by 2% For 5 Kg baby 250U for 100% raise Cryoprecipitate & FFP
  27. 27. HEMOPHILIA- B  Factor ix deficiency Christmas disease  Sex linked recessive inheritance  Deep tissue bleed&Hemarthrosis  LABS: PTT- Prolonged; BT,PC,PT- Normal Individual factor assay  Treatment: Factor 9 concentrates or FFP
  28. 28. VON WILLEBRAND’S DISEASE  Factor viii vwf deficiency  Autosomal Dominant Inheritance  Epistaxis, easy bruising and prolonged bleeding from dental extraction  LABS: BT & PTT- Prolonged; PC,PT- Normal Individual factor assay  Treatment: Cryoprecipitate or FFP or DDAVP
  29. 29. Disseminated Intravascular Coagulation  Thrombohemorrhagic disorder  Acquired: Abruptio placenta, septic abortion, toxemia, Gram-ve sepsis, massive tissue injury, snake bite Etc  Activation of coagulation cascade Microthrombi throughout the micro circulation  Consumption of coagulation factors, platelets and fibrin  Activation of fibrinolytic system
  30. 30. Disseminated Intravascular Coagulation  Mucosal bleeding, oozing from wound sites and ecchymosis  LABS: BT,PC,PT,PTT,TT- all prolonged; FDP- increased  Treat the underlying causes  FFP & Platelete concentrates
  31. 31. Advanced Liver Disease  Acquired  Factor vii & x deficiency  Epistaxis, Menorrhagia and Hemarthrosis  LABS: BT,PC- normal; Factor x  PT,PTT both elevated Factor vii PT- Prolonged; PTT- Normal; Specific factor assays  Treatment: FFP & Vitk
  32. 32. Treatment Algorithm
  33. 33. Surgery in Hemophiliacs  Give Factor viii, dose calculated to bring patient’s plasma level to 100% 1 hour prior to surgery(50 units/kg q12h); Assay daily prior to dose  For Minor Surgery: Maintain plasma level > 60% for 1st 4days Maintain plasma level > 20% for next 4days  For Major Surgery: Maintain plasma level > 60% for 1st 4days Maintain plasma level > 40% for next 4 days  For Orthopedic Surgery: Maintain plasma level > 80% for 1st 4days Maintain plasma level > 40% for next 4 days
  34. 34. Case Vignette 1  40yrs old man c/o bleeding PR  Colonoscopy revealed single polyp in descending colon  Colonoscopic snare polypectomy was done  Postop profuse bleeding+  Labs: only B.T is prolonged; PC,PT,PTT- Normal  Diagnosis& Treatment ?  Answer: Diagnosis Thrombocytopathy due to aspirin ingestion Treatment Platelet concentrates
  35. 35. Case Vignette 2  3 months old congenital Biliary Atresia baby  Was brought with purpuric skin lesions&oozing from gums  Labs: PT&PTT- prolonged; BT,PC- Normal  Diagnosis & Treatment ?  Answer: Diagnosis Advanced liver disease Treatment FFP & individual factors x & vii
  36. 36. Case Vignette 3  3 days old baby was brought with H/O Hemetemesis & Melena  O/E Well baby  Labs: Hb –N; B.T,P.C,PT,PTT -Normal  Diagnosis ?  Answer: Normal baby- No pathology Baby swallowed maternal blood during labour and subsequently vomiting the same. No need for any treatment
  37. 37. Case Vignette 4  60 yrs old man a case of ESRD on chronic hemodialysis  Called to see him for profuse oozing from puncture site @ AV fistula  LABS: BT,PC,PT- normal; PTT, TT- prolonged  Diagnosis and Treatment?  Answer: Diagnosis: Heparin overdosage Treatment: Protamine 1mgm counter 1 unit of heparin
  38. 38. Case Vignette 5  12 yrs old girl on chronic hemodialysis for ESRD  Uremia developed because of temporary interruption of dialysis  Developed brisk epistaxis  Labs:BUN-164 mgms, BT>20mts  Diagnosis & Treatment?  Answer: Diagnosis: Thrombocytopathy due to uremia Treatment: Platelet concentrates
  39. 39. Case Vignette 6  50 yrs old lady with severe burns injury became febrile & toxic  Epistaxis, Hemetemesis & melena  Wound Swab Gram –ve sepsis  Labs: BT,PC,PT&PTT,TT- all are prolonged  Diagnosis & Treatment?  Answer: Diagnosis: DIC Treatment: FFP
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