1. Excessive bleeding during or after surgery can be caused by ineffective local hemostasis, complications from blood transfusions, pre-existing coagulation disorders, or disseminated intravascular coagulation. 2. Ineffective local hemostasis can result in bleeding only from the surgical site, while other potential causes may lead to diffuse bleeding. 3. Various laboratory tests can help identify the underlying cause, guide treatment decisions, and distinguish between coagulation disorders and fibrinolysis.

1. Surgical Bleeding Presented by Nargess Tavakoli Guilan University of Medical Sciences

2. Excessive Intraoperative or Postoperative Bleeding

3. may be the result of: ineffective local hemostasis complications of blood transfusion a previously undetected hemostatic defect consumptive coagulopathy, and/or fibrinolysis.

5. Ineffective Local Hemostasis Ineffective Local Hemostasis

6. Excessive bleeding from the field of the procedure without bleeding from other sites e.g. cvp line intravenous line tracheostomy

7. exception operations on the Prostate Pancreas Liver

8. operative trauma => local plasminogen activation => increased fibrinolysis on the raw surface

9. EACA: 24-48-hour interruption of plasminogen activation

10. laboratory investigation must be confirmatory number of plt actual plt count: if the smear is equivocal aPTT PT TT

11. complications of blood transfusion

13. complications of blood transfusion thrombocytopenia due to massive blood transfusion hemolytic transfusion reaction Transfusion purpura

14. thrombocytopenia due to massive blood transfusion

15. massive transfusion a single transfusion greater than 2500 mL 5000 mL transfused over a period of 24 hours.

16. thrombocytopenia due to massive blood transfusion usually not associated with hemostatic failure

17. prophylactic administration of plt: not indicated

18. if evidence of diffuse bleeding: empiric transfusion of 8_10 packs of fresh platelet concentrates no clear association between plt count,BT & the occurrence of profuse bleeding

19. hemolytic transfusion reaction

20. Example: anesthetized patient : diffuse bleeding in an operative field that had previously been dry

21. Pathogenesis: red blood cells lysis=> release of ADP=> diffuse plt aggregation=> the plt clumps are swept out of the circulation

22. Release of procoagulants => progression of the clotting mechanism => intravascular defibrination The fibrinolytic mechanism may be triggered.

23. Transfusion purpura

24. Transfusion purpura uncommon

25. donor plt :uncommon Pl A 1 group Recipient makes Ab to the foreign plt Ag foreign plt antigen attach to the recipient's own plt

26. sufficient titer of Ab to destroy recipent’s plt: within 6 or 7 days resultant thrombocytopenia & bleeding may continue for several weeks

27. bleeding follows transfusion by 5 or 6 days: Transfusion purpura as DDx.

28. Management: Platelet transfusions : little help damage from the Ab Corticosteroids: some help self-limited

29. DIC and disseminated fibrinolysis

30. DIC and disseminated fibrinolysis control mechanisms fail to restrain the hemostatic process to the area of tissue damage

31. Caused by: trauma incompatible transfused blood Sepsis necrotic tissue fat emboli retained products of conception toxemia of pregnancy large aneurysms liver diseases

32. distinguish between the two processes or the dominant element : important

33. No single test can confirm or exclude the diagnosis or distinguish between the two disorders

34. strong indications for DIC The combination of Thrombocytopenia plasma protamine test for fibrin monomers:+ fibrinogen level : LOW FDP : ELEVATED

35. The euglobulin lysis time detects diffusefibrinolysis

36. Biliary tract surgery in cirrhotic patients & Bleeding Related to: portal hypertension coagulopathy associated with chronic liver disease

37. The tests used to distinguish DIC from fibrinolysis pertain

38. The therapeutic approach IV vasopressin : temporary reduction in portal hypertension EACA to correct the increased fibrinolysis

39. The therapeutic approach IV vasopressin : temporary reduction in portal hypertension EACA to correct the increased fibrinolysis.

40. Intra/Postoperative Bleeding & sepsis Endotoxin-induced thrombocytopenia Defibrination

41. Endotoxin-induced thrombocytopenia Gram Neg. sepsis a labile factor (possibly factor V)

42. Defibrination meningococcemia Clostridium perfringens sepsis staphylococcal sepsis Hemolysis leading to defibrination Evaluation:plt count, INR, aPTT,TT

43. Preoperative Evaluation of Hemostasis

44. Ask the patient 8Qs

45. prolonged bleeding or swelling after biting the lip or tongue?

46. bruises without apparent injury?

47. prolonged bleeding after dental extraction?

48. excessive menstrual bleeding?

49. bleeding problems associated with major and minor operations?

50. medical problems receiving a physician's attention within the past 5 years?

51. medical problems receiving a physician's attention within the past 5 years?

52. medications including aspirin or remedies for headache taken within the past 10 days ?

53. a relative with a bleeding problem?

54. Four levels Based on: History surgical procedure

55. level I History: negative procedure: relatively minor e.g., breast biopsy hernia repair no screening tests are recommended

56. level II history:negative major operation but usually is not attended by significant bleeding platelet count PBS PTT

57. Level III history : suggestive of defective hemostasis procedure :hemostasis may be impaired, e.g., operating using pump oxygenation or cell savers procedures : a large, raw surface is anticipated situations :minimal postoperative bleeding could be injurious(intracranial operations)

58. Level III plt count & bleeding time test : platelet function; aPTT & INR : coagulation the fibrin clot should be incubated to screen for abnormal fibrinolysis

59. Level IV history highly suggestive of a hemostatic defect consult with ahematologist tests prescribed for level III BT test :4 hours after ingestion of 600 mg of aspirin operation is scheduled to take place 10 or more days after this study.

60. Level IV emergency procedure: platelet aggregation tests ADP, collagen, epinephrine, and ristocetin TT : detect any dysfibrinogenemia or a circulating, weak, heparin-like anticoagulant.

61. uremic patients Qualitative platelet abnormality most common deficit best detected by the bleeding time test .

62. Thanks for your attention