The document discusses surgical haemostasis, which is the process of preventing or stopping blood loss from injured blood vessels during or after surgery. It defines haemostasis and outlines its importance in surgery. The physiology of haemostasis is described, involving vasoconstriction, platelet plug formation, and coagulation/fibrin formation. Causes of bleeding during or after surgery are discussed, including defects in haemostasis or platelet function. Methods of achieving haemostasis are covered, such as mechanical techniques like pressure, sutures, and cauterization, as well as chemical agents, blood products, and thermal techniques. Management of haemostasis in the pre-operative, intra-operative, and post-operative periods

1. Surgical Haemostasis
By
Dr. Olofin K.E
Registrar
Accident And Emergency Dept.
UATH

2. OUTLIINE
 Introduction
• Definition
• Surgical importance
• Brief history
 Physiology of haemostasis
 Causes of bleeding during or after surgery
 Methods of hemostasis
 Management of haemostasis in a surgical patient
• Pre op evaluation
• Intra op management
• Post op management
• Haemostasis in trauma
 Conclusion
 References

3. INTRODUCTION
Definition
• Hemostasis is the process of forming clots in the walls of damaged
blood vessels and preventing blood loss while maintaining blood in
the fluid state within the vascular system.

4. INTRODUCTION
• The process of preventing or terminating blood loss from an injured
vessel
• Delicate balance between Pro and Anti coagulants
• Congenital and acquired defects result in clinically important
derangements
• Derangements in this process could cause uncontrollable hemorrhage
both spontaneously and on table
• The surgeon has a great role to play

5. INTRODUCTION
Surgical Importance
• Surgical haemostasis is one of the pillars of modern surgery (others
include anesthesia, antibiotics)
• Adequate surgical haemostasis reduces morbidity and mortality in
post. op patients by
– minimizing blood loss and anemia,
– attenuates the metabolic response to trauma,
– reducing infection and
– improving wound healing.

6. INTRODUCTION
Brief History
• The evolution of modern surgery has followed closely behind strides
in surgical hemostasis
• Ancient medicine men and barber surgeons developed maneuvers
based on intuition to control bleeding in their patients
• These intuitions informed scientific research and the elucidation of
the hemostatic process and modern interventions to achieve
hemostasis

8. Physiology Of Haemostasis
Natural inhibitors of coagulation cascade
• Smoothness of the endothelium
• Continuous blood flow
• Prostacyclin (secreted by the platelets)
• Heparin (secreted by the mast cells)
• Antithrombin III (secreted by the liver)
• Protein C & S (natural anticoagulants)

9. Physiology Of Haemostasis cont…
• Involves three (3) interdependent mechanisms
– Initial Vasoconstriction
– Platelet plug formation
– Coagulation/Fibrin formation and Fibrinolysis
• They are interrelated and occur as a continuum.
• Their products provide multiple reinforcements.

10. Physiology Of Haemostasis cont.…
Vaso-constriction
• The initial vascular response to injury.
• Dependent upon local contraction of smooth muscles.
• Occurs before platelet adhesion to site of injury.
• Effectiveness is dependent on type of vessel, calibre, perivascular
pressure, pattern of injury
• Vasoconstrictors: 5-HT, TXA2, bradykinins, fibrinopeptides,
Perivascular pressure

11. Physiology Of Haemostasis cont.…

12. Physiology Of Haemostasis cont.…
Platelet Plug Formation
• Platelets become “sticky” when
exposed to sub-endothelial
collagen to which they become
adherent.
• vWF is necessary for Platelet
collagen adherence
• The adherent platelets swell,
initiate a release reaction to
recruit other platelets which
aggregates to form a loose
platelet plug – primary
hemostatic plug

13. Physiology Of Haemostasis cont.…
Primary hemostasis
– Forms loose platelet plug
– Reversible and does not involve secretion
– ADP & 5-HT are principal mediators
– Heparin does not interfere with this process
– Aspirin & NSAIDS are both inhibitory (Aspirin causes irreversible blockade

14. Physiology Of Haemostasis cont…
• Release reaction
– Platelets degranulates releasing powerful mediators
– The Platelet plug becomes compacted to form an irreversible amorphous
plug.
– Mitigated by ADP, platelet factor 4, trace thrombin, in the presence of Ca2+,
Mg2+
– Products include: platelet factor 3 & 4, thromboglobulin, PDGF, ADP, 5-HT,
Ca2+
– Process is inhibited by cAMP

15. Physiology Of Haemostasis cont…
Coagulation/Fibrin Formation
• Aims to convert prothrombin into the proteolytic enzyme thrombin.
• Thrombin cleaves fibrinogen molecules to insoluble fibrin
• fibrin provides stability to the platelet plug.
• Involves two pathways:
– Intrinsic Pathways (factors VII, X, II)
– Extrinsic Pathways (factors XII, XI, IX, X and II)

16. Fibrin Formation

17. Physiology Of Haemostasis cont.…
Fibrinolysis
• Aim is to maintain patency of blood vessels by lysis of fibrin deposits
• Initiated from start by circulating kinases, tissue activators, and
kallikrein.
• Dependent on Plasmin which lyses fibrin to produce fibrin
degradation end products
• Smaller products interfere with platelet aggregation while the larger
products incorporates into the clot resulting in unstable clots

18. Causes of excessive bleeding during or after
surgery
• Defects of hemostasis
• Mismatched blood transfusion
• Transfusion with plasma expanders especially dextran
• Shock
• Septicemia
• Liver disease

19. Surgical procedures associated with excessive bleeding
1. Prostatic surgery
2. Transplant surgery
3. Portacaval shunts
4. Extracorporeal circulation

20. Causes of bleeding during or after surgery
cont…
Defects of hemostasis
1. Defective Vasoconstriction
• Idiopathic Hemorrhagic Telengiectasia/ Osler Weber Rendu syndrome
• low perivascular pressure in muscular dystrophy, Ehlers-Danlos syndrome,
elderly, prolonged steroid therapy

21. Causes of bleeding during or after surgery
cont…
Defective Platelet Function
• Congenital:
• Bernard Soulier syndrome (GP 1b/IX/V receptor for vWF),
• Glanzman Thrombastenia (GP IIb/IIIA)
• Storage pool disease: Dense and α granules (occur with partial albinism in
Hermansky-Pudlak syndrome)
• Treatment: DDAVP(Desmopressin), platelet concentrate

22. Causes of bleeding during or after surgery
cont…
Acquired platelet disorders.
A. Quantitative Disorders:
1. Failure of production: (related to impairment in bone marrow function):
• Leukemia.
• Myeloproliferative disorders.
• B12 or folate deficiencies.
• Chemotherapy or radiation therapy.
• Acute alcohol intoxication
• Viral infections

23. Causes of bleeding during or after surgery
cont…
2. Decreased survival
• Immune-mediated
– Idiopathic thrombocytopenia (ITP)
– Heparin-induced thrombocytopenia
– Autoimmune disorders or B-cell malignancies
– Secondary thrombocytopenia.
• Disseminated intravascular coagulation (DIC)
• Related to platelet thrombi
– Thrombocytopenic purpura (TTP)
– Hemolytic uremic syndrome (HS)

24. Causes of bleeding during or after surgery
cont…
3. Sequestration.
• Portal hypertension.
• Sarcoid.
• Lymphoma.
• Gaucher’s Disease.
B. Qualitative Disorders
• Massive transfusion
• Therapeutic platelet inhibitors (aspirin, clopidogrel, prasugrel dipyridamole, GPIIb/IIIa
inhibitors)
• Disease states
• Myeloproliferative disorders
• Monoclonal gammopathies
• Liver disease, ureamia

25. Causes of bleeding during or after surgery
cont.…
Coagulation Factor Deficiencies
• Congenital
– Haemophilia A (Factor VIII deficiency) Von willibrands Disease (treatment:
desmopressin & vWF concentrate)
– Haemophilia B (Factor IX deficiency/Christmas disease)
– Haemophilia C (Factor XI deficiency) (treatment: FFP)
• Acquired
– Vit. K Deficiency (Factor II, VII, IX & X; III, VIII, XI, Protein C, fibrinogen)
– Ureamia
– Massive Blood Transfusion
– DIC

26. Methods of haemostasis
• Mechanical
• Direct pressure
• Gauze pack
• Suture and ligation
• staples
• Chemical/biological
• Local
• systemic
• Thermal

27. Methods of haemostasis cont…
Mechanical methods
• PRESSURE
• Immediate measure for capillary or venous
bleeding.
• Firm pressure should be applied over the
bleeding site using either fingers or gauze for at
least 5 minutes.
• This controls hemorrhages by counteracting
the hydrostatic pressure of the bleeding vessel.
• HAEMOSTAT
• Application of haemostat at the bleeding point
helps in direct occlusion of the bleeding vessel

28. Methods of haemostasis cont.…
SUTURES AND LIGATION
• Severed blood vessels may be tied
with ligatures. A ligature replaces
the hemostat as a permanent
method of effective hemostasis.
• For large pulsatile artery, a trans –
fixation suture to prevent slipping is
indicated.
• Non – resorbable sutures such as
silk and polyethylene are used as
they evoke less tissue reaction.

29. Methods of haemostasis cont.…
Chemical methods
Local Agents:
• Adrenaline
• Topical application of adrenaline brings about vasoconstriction of bleeding
capillaries.
• Available in ampoule, which is applied with the help of gauze.
• Concentration of 1 in 1000 is used for hemostasis over the oozing site.
• Thrombin
• Helps in converting fibrinogen into fibrous clot.

30. Methods of haemostasis cont…
• Surgicel
• Oxidized cellulose polymer obtained by dissolving pure alphacellulose in an
alkaline solution.
• Acts by forming acid products from partial dissolution that coagulates the
plasma proteins to form a black or brown sticky gelatinous clot.
• Applied surgicel resorbs from the site in 4 to 8 weeks.
• Disadvantage is that the surgicel clot is not formed by normal physiological
mechanism.

31. Methods of haemostasis cont.…
• Surgicel fibrillar:
• Modified surgicel or oxidized regenerated cellulose in
layers that can be adapted to irregular surfaces and
inaccessible areas.
• Complete resorption occurs in 2 weeks.
• Gelatine sponge or gelfoam or surgifoam:
• Formed from purified pork skin gelatin.
• Completely absorbable material.
• Has the capacity to absorb 45 times its weight in blood.
• Resorbs completely in 4 to 6 weeks.

32. Methods of haemostasis cont.…
• OXYCEL
• Oxidized cellulose polymer product.
• This absorbable hemostatic material is
manufactured by controlled oxidation of cellulose
using nitrous dioxide.
• Cellulosic acid present in it has affinity for
hemoglobin which leads to the formation of
artificial clot.
• Should be applied on the dry surface as the acid
formed during the wetting process inactivates the
thrombin.
• The platelets plug into its meshwork like surface
& helps in clot formation.

33. Methods of haemostasis cont.…
Microfibrillar collagen (avitene)
• Collagen derived from bovine skin cause
contact activation in addition to direct platelet
aggregation.
• Absorption time is 3 months.
• Fibrin glue
• Biological adhesive which contains thrombin,
fibrinogen, factor XIII, aprotinin.
• Thrombin converts fibrinogen to unstable fibrin
clot, factor XIII stabilizes the clot and aprotinin
prevents its degradation.

34. Methods of haemostasis cont.…
• Typtics & astringents
• Precipitates protein & arrests bleeding.
• Commonly used styptics & astringents are Monsel’s solution containing ferric
subsulfate & tannic acid.
• Thrombin & gelatin sponge are now widely used.
• Alginic acid
• Placed over the bleeding sites, a protective film is formed over the bleeding site, this
film compresses the capillaries & stabilizes the blood clot.
• Natural collagen sponge
• White sponge material, fully absorbable. It stimulates the platelet aggregation
thereby enhancing hemostasis.
• Activates coagulation factors XI & XIII.
• Preferred in patients who are susceptible for hemorrhage after dental surgical
procedures.

35. Methods of haemostasis cont.…
• Fibrin sponge
• Obtained from bovine material.
• Chemically treated to avoid allergic reactions.
• Applied on the bleeding site especially in post extraction socket.
• Fully absorbed by the tissues within 4-6 weeks.
• OSTENE (a new water soluble bone hemostatic agent)
• New bone hemostatic agent, made of water-soluble alkylene oxide copolymers.
• Showed no incidence of adverse response in the cortical defect site, medullary cavity
or the surrounding tissue.

36. Methods of haemostasis cont.…
• Bone wax
• Sterilized, non – absorbable mix of waxes.
• Consists of seven parts by weight of wax (white bees wax, paraffin wax & an
isopropyl ester of palmitic acid), two parts of olive oil and one part of phenol.
• Indicated in cases of bleeding from the bone or from chipped edges of bone.
• Bone wax is softened with the fingers to desired consistency & then applied
over the bleeding site.
• Its hemostatic mechanism is through mechanical obstruction of the osseous
cavity containing the bleeding vessels.

37. Methods of haemostasis cont.…
Systemic Agents:
• Whole Blood:
• Fresh whole blood refers to blood that is administered within 24 hours of its
donation.
• Whole blood transfusion indicated when there is excessive blood loss.
• Contains all factors for coagulation.
• Must be checked for HIV, hepatitis B, C viruses.
• Platelet Rich Plasma:
• Platelets can be collected from donated whole blood.
• Platelet concentrates are viable for 3 days when stored at room temperature.
• Must be infused quickly via short i.v. transfusion set.
• One unit raises platelet count by approx 7,000 to 10,000 cells per cu mm.

38. Methods of haemostasis cont.…
• Fresh Frozen Plasma:
• Unit of fresh frozen plasma is collected from one donor and contains all
coagulation factors.
• Stored at -30°C, should be infused within 2 hours once defrosted.
• Cryoprecipitate:
• Stored at -30°C.
• Each bag is derived from single donor and is not treated to inactivate viruses.
• Associated with a substantial risk of viral transmission.

39. Methods of haemostasis cont.…
Thermal agents
• Heat achieves hemostasis by
denaturation of proteins.
• Cautery:
• Heat is transmitted from instrument by
conduction directly to the tissues.
• Electro – cautery has replaced direct
heat application.

40. Methods of haemostasis cont.…
• Electrocautery:
• Most widely used.
• Electrocautery can be applied directly to bleeding point.
• Cautery point is touched to the hemostat, causing sealing of vessel through
action of heat.
• Causes tissue destruction producing burning smell and smoke during
application.
• Effective and convenient way of controlling hemorrhage.

41. Methods of haemostasis cont.…
• Advantages of electrocautery:
• Permits any degree of hemorrhage
control.
• Provides clear and improved view.
• Increases efficiency.
• Reduces chair side time.
• Gives pressure – less cutting.

42. Methods of haemostasis cont.…
• Cryosurgery:
• Extreme cooling has been used for hemostasis.
• Temperature ranging from -20°C to -180°C are used.
• Tissues, capillaries, small arterioles and venules
undergo cryogenic necrosis.
• Caused by dehydration and denaturation of lipid
molecules.
• Specially used to treat superficial hemangiomas.
• Lasers:
• Lasers usually result in bloodless surgery.
• Effectively coagulate the small blood vessels during
cutting of tissues.

43. Management
Pre Op Evaluation
• History
– Hx of abnormal bleeding, prolonged bleeding, easy bruising, mucosal bleeds,
menorrhagia
– Hx of coagulation disorder in relatives
– Hx of use of anticoagulant.
– Hx of chronic diseases such as CKD, CVDs, CLD, HTN
– Hx of use of drugs e.g. cytotoxic, anticoagulants.
Aspirin 7-10days, clopidogrel 7days, ticlopidine 10days, OCPs 6wks, monoamine
oxidase 2-3wks, warfarin 5days in patients with INR between 2-3, 6 days for INR 3-4.5,
LMWH 24 hours before surgery
• Examination
– General examination (anemia, jaundice, asterixis, anasarca)
– Skin: ecchymosis, stigmata of cld
– Abd: Hepatomegaly, splenomegaly, ballotable kidneys
– Bed side bleeding time (1-9min, up to 13min in children)

44. Management cont.…
• Investigations
– General: CBC, LFT, E/U/Cr, Abd USS
– Specific -tests of hemostasis
• CT (8-15min)
• PT (VII, X, II) (9.6-11.8sec)
• PTT (XII, XI, IX, X & II) (20-36sec)
• INR, Fx assays, fibrinogen level, Clot elastography and elastometry,

45. Management cont…
Intra operative Management
• Anesthetic Techniques
– Posture/Position
– Permissive hypotension
– Intermittent positive pressure ventilation
– Normothermia
– Anaesthetic agent: Regional anesthesia,
• L/A+adrenaline, GA: propofol

46. Management cont…
• Pharmacologic methods
– Traxenamic acid
– Σ- Aminocaproic acid
– Aprotinin: serine protease inhibitor directly inhibits free plasmin
– Recombinant factor VIIa (rFVIIa)
– Vit K
• Surgical techniques
– Appropriate dissection
– Compression/Pressure and maneuvers
– Vascular clamps and forceps
– Intraluminal balloons
– Arterial ligation
– Diathermy
– Minimal access surgery

47. Management cont…
• Topical agents
– Surgicel (oxidized cellulose)
– Gelfoam (gelatin foam)– Avitene (microfibrillar collagens)
– Topical thrombin
– Fibrin sealant
– Platelet sealant
– Human recombinant thrombin derivatives

48. Management cont…
• Mechanical Factors
– Digital pressure
– Pringle maneuver
– Pressure packing
– Limb elevation
– Limb exsanguination
– Tourniquets
• Blood products
– FFP
– Platelet concentrates
– Factor concentrates

49. Post Op Management
– Antibiotics
– Wound care
– Elevation

50. Hemostasis in trauma
• Pre hospital use of tranexamic acid
• Prothrombin complex concentrate
• Damage control resuscitation
– Prompt mechanical or surgical hemorrhage control
– Permissive hypotension
– Minimalistic crystalloid/ synthetic colloid based resuscitation
– Early use of blood products in the ration of 1:1:1 of PRBC:FFP:Platelets

51. Conclusion
• Understanding the concept of haemostasis is important in achieving a
good surgical outcome
• It is the responsibility of the surgeon to preempt surgically important
haemorrhage, employ multiple modalities to prevent it, and arrest it
when it does occur.
• All bleeding (eventually) stops

52. REFRENCES
• Schwartz: Principles of Surgery, 7/e © 1999 by The McGraw-Hill
Companies, Inc.
• Baja’s Principles and Practice of Surgery, Including Pathology in the
Tropics: 5th Ed
• Farquharson’s textbook of operative general surgery 10th edition
Margaret Farquharson, James Hollingshead and Brendan Moran
• Vival in surgical and principles and operative surgery 1st edition by
Emeka kesieme

53. Thank you for your attention