This document discusses perioperative bleeding and homeostasis. It begins with defining bleeding and describing different types. It then covers preoperative bleeding risk assessment, including medication and bleeding history, physical exam, and tools to evaluate risk. Methods of achieving homeostasis during and after surgery are outlined, including mechanical, thermal, pharmacological, and TEG monitoring. Predictors of postoperative bleeding in cardiac surgery and guidelines for assessing bleeding risk from British and European societies are presented.

1. PERIOPERATIVE
BLEEDING AND
HOMEOSTASIS
ALTAF AHMED MEMON
Anesthesia specialist

2. OBJECTIVE
• Definition
• Preoperative bleeding risk assessment and intervention
• Homeostasis and Methods of homeostasis
• Thromboelastography (TEG)
• Predictors of Postoperative Bleeding in Cardiac Surgery
• British committee Recommendations on the assessment of
bleeding
• Guidelines from the European Society of Anesthesiology

3. INTRODUCTION.
Perhaps one of the most important tasks
that fall to the preoperative assessment
bleeding and homeostasis.
Despite advances in clinical laboratory
medicine and the advent of entirely new
technologies, little has changed in the tests
that are utilized for the assessment of
bleeding risk.
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4. They remain remarkably effective in
providing the information needed to
evaluate the risk of bleeding in the
surgical setting.
The challenge remains to make sure
that all patients at risk receive the
proper evaluation so that bleeding
complications are avoided.

5. UNIVERSAL DEFINITION OF PERIOPERATIVE
BLEEDING IN ADULT CARDIAC SURGERY.
PUBMED
Perioperative bleeding is common among
patients undergoing cardiac surgery
however, the definition of perioperative
bleeding is variable and lacks
standardization.

6. MEDICAL
DEFINITION OF BLEEDING.
•Bleeding also known as hemorrhaging,
is blood escaping from the circulatory
system.

7. ARTERIAL BLEEDING.
This type of bleeding, the blood is typically
bright red to yellowish in color, due to the
high degree of oxygenation.
Any wound to a major artery could result in
blood ‘spurting’ in time with the heart beat,
several meters and the blood volume will
rapidly reduce and difficulty to control .

8. VENOUS BLEEDING :.
•This type of bleeding the blood is
typically dark red in color, due to
the lack of oxygen, flow will be
slow and severely its will not spurt
and easily controlled .

9. CAPILLARY BLEEDING.
• Bleeding from capillaries occurs in all wounds.
Although the flow may appear fast at first, blood loss is
usually slight and is easily controlled.
• Bleeding from a capillary could be described as a
‘trickle’ of blood.

10. PREOPERATIVE BLEEDING RISK
ASSESSMENT AND INTERVENTION :
Assessing and managing the risk of bleeding in a
preoperative patient can be achieved by following the
key steps:
1.Review medications history .
Medications which might affect bleeding eg.
Platelet Inhibitors. Aspirin, ticlopidine,
clopidogrel,disopyramide,
Anticoagulants.Warfarin,Low molecular weight
Heprain (Enoxoparin ).
Manage as per evidence based guidelines

11. Recommendation :
•For thienopyridines such as clopidogrel ,
AHA guidelines recommend 5- to 7-day
drug holiday prior to surgery.
•If possible1,2 ƒfor reversal of
anticoagulants in emergent setting, can
be use like vitamin K, FFP,or rFVIIa

12. 2.Bleeding History including:
 Personal history:
Bleeding disorder or excessive bleeding
this may include Bleeding from minor
procedures, Easily bruising, prior ,blood
transfusions, tattoos, Problems with
previous surgeries, Family members had
difficult surgeries history of jaundice or liver
disease, or fever following
anesthesia,alcohol use (current, prior and
quantity).

13. Family history .
 Bleeding disorder or excessive bleeding primary, and most
evident, complication in patients with inherited bleeding
disorders such as hemophilia A, hemophilia B, and von
Willebrand disease(VWD).
Comorbidities.
which may increase bleeding risk
e.g. bone marrow, renal or liver disorder.
Note:
If positive use a Bleeding Assessment Tool
(BAT) consisting of a standardized bleeding
questionnaire and bleeding score or refer for
further assessment.

14. • BLEEDING ASSESMENT TOOL (BAT):
• 1.0 Have you ever had a nosebleed? [ ] Yes [ ] NO
• 2.0 Have you ever had a bruise? [ ] Yes [ ] NO
• 3.0 Have you ever had bleeding from a small cut, for
example, from a paper cut or shaving?
[ ] Yes [ ] NO.
4.0 Have you ever seen blood in the urine? (If you are a
female, this does NOT mean from a period.)
[ ] Yes [ ] NO.
5.0 Have you ever had bleeding from the stomach or
bowel? [ ] Yes [ ] NO.
6.0 Have you ever had bleeding from the mouth? (This
does NOT include tooth extraction at the dentist.) [ ] Yes
[ ] NO

15. 7.0 Have you ever had a tooth pulled by the dentist? [ ]
Yes [ ] NO.
8.0 Have you ever had surgery? [ ] Yes [ ] NO.
9.0 Have you ever had a period? [ ] Yes [ ] NO.
10.0 Have you ever had a baby or been pregnant? [ ]
Yes [ ] NO.
11.0 Have you ever had bleeding into a muscle? [ ] Yes [
] NO.
12.0 Have you ever had bleeding into a joint? [ ] Yes [ ]
NO.
13.0 Have you ever had bleeding into the head (brain) or
spine? [ ] Yes [ ] NO.

17. 3.Physical examination:
Signs of bleeding, e.g.. petechiae,
purpura,ecchymoses, hematomas,
Signs of increased risk of bleeding, e.g.
Jaundice pruritus, fatigue, increased abdominal
girth, splenomegaly, palmar erythema, spider
telangiectasia's, gynecomastia and testicular
atrophy in men) arthropathy, joint and skin laxity
should be evaluated.
Note:
If positive or comorbidities associated with
increased risk of bleeding use a refer for further
assessment concerned specialty .

18. ASSESSING SURGICAL RISK IN
PATIENTS WITH LIVER DISEASE
Patients with liver disease who require
surgery are at greater risk for surgical and
anesthesia-related complications than
those with a healthy liver .
 The magnitude of the risk depends upon
the type of liver disease and its severity
the surgical procedure, and the type of
anesthesia.

19. •Homeostasis in the surgical
patient is an important topic

20. Homeostasis
A Process which causes bleeding to
stop also called coagulation proceed
steps .
Primary Homeostasis :
Arteriolar Vasoconstriction
Formation of platelet plug
Secondary Homeostasis:
Activation of Coagulation Cascade
Formation of Permanent Plug

21. STEP 1.Arteriolar Vasoconstriction:
process of Vasoconstriction after damage
vessel.

22. STEP 2.
Formation of platelet plug :
A process of aggregation of platelet at site of Damage vessel .

23. STEP 3.
Activation of coagulation cascade:
The coagulation factors circulate as inactive
zymogens the coagulation cascade is
therefore classically divided into three pathways.
The tissue factor and
contact activation pathways both activate the
"final common pathway" of factor X, thrombin
and fibrin.

25. STEP 4
• Formation of Permanent Plug:
Fibrin is a tough protein substance that is
arranged in long fibrous chains it is formed from
fibrinogen, a soluble protein that is produced by
the liver and found in blood plasma.
When tissue damage results in bleeding,
fibrinogen is converted at the wound
into fibrin by the action of thrombin,
a clotting enzyme .

27. Surgical Homeostasis

28. • Surgical homeostasis:
• It is crucial to minimize blood loss
intraoperatively to maintain the patient’s
physiology and to enable the surgeon to
preserve a clear operative field.
• A degree of hemorrhage is a normal part of most
surgical interventions. Managing unanticipated
or uncontrolled bleeding is a vital skill for a
surgeon to acquire, so that haemostatic
maneuvers become second nature.
• Bleeding following surgery is classified as
reactionary (up to 48 hours) or secondary (days
after).

29. Methods
of homeostasis

30. MECHANICAL METHODS
Direct pressure.
Fabric pads, sponges or gausses.
Sutures, staples or Ligateing clips.
 Bone wax
 Digital Pressure

31. THERMAL
ENERGY/BASED
METHODS
• electrosurgery:
monopolar
Bipolar
Bipolar vessel sealing device
Argon enhanced coagulation
• Ultrasonic device
• Laser
Cryogenic Cauetry

32. PHARMACOLOGICAL
METHODS
• Epinephrine (Local )
• Vitamin k
• Protamine
• Desmopressin
• rFVIIa
• Tranexamic Acid

33. EPINEPHRINE:
is the active sympathomimetic
hormone from the Adrenal
Medulla. It stimulates both the
alpha- and beta- adrenergic
systems, causes systemic
Vasocontriction and
gastrointestinal relaxation,
stimulates the HEART, and
dilates BRONCHI and cerebral
vessels.

34. Vitamin K is used to treat and
prevent low levels of certain
substances (blood clotting factors)
that your body naturally produces.
These substances help your blood
to thicken and stop bleeding
normally (e.g., after an accidental
cut or injury)

35. Protamine.
Sulfate Injection,USP is a sterile,
non-pyrogenic, isotonic solution
of protamine sulfate in Water
for Injection.
It acts as a heparin antagonist. It
is also a weak anticoagulant.

36. Desmopressin,:
Trade name DDAVP among others, is a
medication used to treat diabetes insipidus,
bedwetting, hemophilia A, von Willebrand
disease, and high blood urea levels.
In hemophilia A and von Willebrand
disease, it should only be used for mild to
moderate cases.

37. Fibrinogen Concentrate:
(Human) is a human blood coagulation
factor indicated for the treatment of acute
bleeding episodes in patients with
congenital fibrinogen deficiency, including
afibrinogenemia and hypofibrinogenemia

38. Tranexamic acid
Trade name: Cyklokapron is a
medication used to treat or
prevent excessive blood loss from
major trauma, postpartum
bleeding, surgery, tooth removal,
nosebleeds, and heavy
menstruation. It is also used for
hereditary angioedema

39. • Thromboelastography (TEG)
• It is a method of testing the efficiency
of blood coagulation.
• It is a test mainly used
in surgery and anesthesiology, although few
centers are capable of performing it Fortunately
our center is capable to performing this test .
• More common tests of blood coagulation
include prothrombin time (PT,INR) and partial
thromboplastin time (aPTT) which measure
coagulation factor function, but TEG also can
assess platelet function, clot strength,
and fibrinolysis which these other tests cannot.

43. Predictors of Postoperative Bleeding in Cardiac Surgery:
Advanced age
Small body size
preoperative anemia (low RBC volume)
Antiplatelet,
Antithrombotic drugs
Prolonged operation ƒCPB time
Surgery type
Low preoperative fibrinogen level
Emergency surgery

44. Postoperative bleeding :
Definition.
Excessive bleeding was defined as ≥7 mL/kg/h for ≥2
consecutive hours in the first 12 postoperative hours
and/or ≥84 mL/kg total for the first 24 postoperative
hours and/or surgical re-exploration for bleeding or
cardiac tamponade physiology in the first 24
postoperative hours.
Note:
Excessive bleeding associated with longer length of
hospital stay and increased workload on blood
bank, increases consumption of blood products,
increase cost of patient increase complication
related with the blood transfusion postoperative
period.

45. Surgical re-exploration:
 Surgical re-exploration is a common rescue
technique when operative techniques or transfusions
fail to stop ongoing blood loss, but is not innocuous
and adversely affects outcomes after cardiac surgery.
 Surgical re-exploration can occur early or late, and
although the temporal relation to chest tube blood loss
may be variable, we consider it to always be a
significant negative clinical event.
 The incidence of postoperative re-exploration is
easily measured and frequently used as a quality
indicator.

46. BRITISH COMMITTEE FOR STANDARDS IN
HEMATOLOGY RECOMMENDATIONS ON THE
ASSESSMENT OF BLEEDING RISK PRIOR TO SURGERY
OR INVASIVE PROCEDURES
1.Indiscriminate coagulation screening prior to
surgery or other invasive procedures to predict
postoperative bleeding in unselected patients is
not recommended. (Grade B, Level III).
2.A bleeding history including detail of family
history, previous excessive post-traumatic or
postsurgical bleeding and use of anti-thrombotic
drugs should be taken in all patients
preoperatively and prior to invasive procedures.
(Grade C, Level IV). Continue

47. 3. If the bleeding history is negative, no
further coagulation testing is indicated.
(Grade C, Level IV).
4. If the bleeding history is positive or there
is a clear clinical indication (e.g. liver
disease), a comprehensive assessment,
guided by the clinical features is required.
(Grade C, Level IV).

48. MANAGEMENT OF SEVERE PERIOPERATIVE
BLEEDING GUIDELINES FROM THE
EUROPEAN SOCIETY OF ANESTHESIOLOGY
• Evaluation of coagulation status:
 We recommend the use of a structured patient
interview or questionnaire before surgery or invasive
procedures, which considers clinical and family
bleeding history and detailed information on the
patient’s medication. 1C
 We recommend the use of standardized
questionnaires on bleeding and drug history as
preferable to the routine use of conventional
coagulation screening tests such as a PTT, PT and
platelet count in elective surgery. 1C