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BLEEDING DISORDERS

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									Diagnosis and Management of
 Hemorrhage in Oral Surgery
    What is meant by Hemorrhage ?


Prolonged or uncontrolled bleeding is often
referred to as hemorrhage.

The amount of blood lost as a result of
hemorrhage can range from minimal to
significant quantities.
          Hemorrhage in Surgery



Hemorrhage can occur to a greater or lesser
degree during all surgical procedures and it’s
management depends upon whether the patient is
hematologically normal or suffers from some
disturbance in the normal clotting mechanism.
Hemorrhage in Oral Surgery
            Hemorrhage in Oral Surgery


   The overwhelming majority of patients who
    undergo oral surgical procedures are those who
    have normal haemostatic mechanism.

   Therefore, significant or major hemorrhages are
    not that common in oral surgery except in patients
    who have a bleeding / clotting disorder or those
    who are on anticoagulants.
        Hemorrhage in Oral Surgery


However, uncontrolled and persistent bleeding
can occur in some healthy patients after dental
extraction.

Therefore, it is still important to achieve proper
hemostasis in all patients during oral surgical
procedures, so as to prevent excessive post-
operative blood loss.
     Normal Mechanism of Hemostasis



 Hemostasis   is a complicated process.

   It involves a number of events
       Hemostasis - Normal Mechanism


   1. VASCULAR PHASE

   2. PLATELET PHASE

   3. COAGULATION PHASE
         VASCULAR PHASE




When a blood vessel is damaged,
vasoconstriction results.
           PLATELET PHASE


Platelets adhere to the damaged surface
                  and
      form a temporary plug.
         COAGULATION PHASE



Through two separate pathways, the
Intrinsic and Extrinsic, the conversion of
fibrinogen to fibrin is complete. Fibrin
tightly binds the platelets to form a clot
      THE CLOTTING MECHANISM

 INTRINSIC             EXTRINSIC
  Collagen     Tissue Thromboplastin
  XII
    XI                   VII
      IX
        VIII
                   X

               V                       FIBRINOGEN
                                             (I)

PROTHROMBIN            THROMBIN
    (II)                  (III)        FIBRIN
                  HEMOSTASIS
DEPENDENT UPON:

 Vessel Wall Integrity

 Adequate Numbers of Platelets

 Proper Functioning Platelets

 Adequate Levels of Clotting Factors

 Proper Function of Fibrinolytic Pathway
           Hemorrhage in Oral Surgery


   Hemorrhage following Oral Surgical procedures
    can occur due to local or systemic causes.

   In healthy patients the postoperative bleeding is
    mainly due to local causes.
Local causes of hemorrhage in oral surgery




Local causes of hemorrhage originate in either
soft tissue or bone.
Local causes of hemorrhage in oral surgery –
                   Soft tissue bleeding



   Soft tissue bleeding is either arterial, venous, or
    capillary in nature.
Local causes - Soft tissue bleeding in oral surgery



   Arterial bleeding is bright red and spurting in nature.

   Arteries in the soft tissues at risk during oral surgical
    procedures are the lies posterior portion of hard palate)
    greater palatine artery and the buccal artery (lies lateral to
    the retromolar pad)
Local causes - Soft tissue bleeding in oral surgery



 Venous blood is dark red in color and flows
 steadily and heavily especially if the vein is large.

 Capillary bleeding is bright red in color and is
 more of a minimal ooze.
Local causes – Osseous (Bony) bleeding in oral
                    surgery



Troublesome bone bleeding originates either from
nutrient canals in the alveolar region, central
vessels, such as the inferior alveolar artery, or
from central vascular lesions (Hemangioma or
Vascular malformation)
Systemic causes of hemorrhage in oral surgery


   Some patients with heriditary conditions such as
    hemophilia, Von Willebrand’s disease are susceptible for
    hemorrhage following oral surgical procedures.

   Patients with thrombocytopenia (decreased platelet
    count) , Leukemia e.t.c., are also at risk of prolonged
    bleeding after surgery.

   Patients with uncontrolled hypertension.
Systemic causes of hemorrhage in oral surgery


   Patients with H/O prosthetic heart valve replacement,
    Stroke (Cerebrovascular accident) e.t.c., take oral
    anticoagulants like Aspirin or Warfarin to prevent the
    occurrence of a thromboembolic episode.

   These patients are also at risk of prolonged severe
    bleeding during and after an oral surgical procedure.
Types of Hemorrhage - Primary Hemorrhage

This occurs during the surgery, as a result of injury like
cutting or laceration of the artery or bleeding from
bone.

This also occurs when surgery is done in an infected
area with a lot of granulation tissue.

It can also occur after a very short period of time
immediately after surgery.

This type of bleeding is really normal and can be
controlled easily.
    Types of Hemorrhage - Intermediate /
             Reactionary Hemorrhage


This type of bleeding occurs within a few hours after
surgery.

This type of bleeding occurs as a result of failure of
coagulation to occur (as in patients with systemic
bleeding problems or those on anticoagulants)

Patients who have unknowingly disturbed / dislodged the
clot are also prone for this type of bleeding.
Types of Hemorrhage - Secondary Hemorrhage



 This occurs after 7 to 10 days after surgery. This is
 mainly due to partial division of blood vessel in
 combination with infection of the wound (Like patient’s
 who undergo radical neck dissection e.t.c.,).

 This type of bleeding is not very frequently encountered
 after oral surgery procedures.
        Management of Primary Hemorrhage in Normal
                          patients

        The management of bleeding during surgery (Primary
         bleeding) can be achieved by the following means,

(i)     Securing / ligation of blood vessels with silk sutures.
(ii)    Use of pressure swab to achieve hemostasis.
(iii)   Use of electrocautery to achieve hemostasis.
(iv)    Use of hemostatic agents like bone wax, surgicel,e.t.c.,
(v)     Hypotensive anaesthesia (G.A) and use of
        vasoconstrictors in L.A.
       Local Measures ( Synthetic Materials)



   There are several materials that are commercially
    available that are used locally for achieving
    adequate hemostasis.
Local Measures: Surgicel (Oxidised Regenerated
                  Cellulose)
Local measures: Gelfoam with activated thrombin
Local Measures: Avitene (Microfibrillar
               Collagen)
      Local Measures:
Etik Collagen (Packed collagen)
Local Measures: Tranexamic acid 5%
Local Measures: Tranexamic acid 5% in Syringe
Local Measures: Irrigation of wound with
            Tranexamic acid
Local Measures: Suturing the wound
Local Measures: Pressure with oral packs
       Management of Intermediate Hemorrhage in
                   Normal patients

      The management of bleeding that occurs immediately
       after surgery (Reactionary bleeding) involves proper
       examination of the surgical wound to identify the site
       of bleeding (i.e ) from bone or soft tissue.

(i)    If bleeding is from bone then the hemostatic agents like
       bone wax or gelfoam is usually used.

(ii)   If bleeding is from soft tissues then, ligation /
       cauterization of blood vessels along with the use of
       hemostatic agents like surgicel and suturing of the
       wound is carried out.
Management of Secondary Hemorrhage in Normal
                  patients

    The management of this type of bleeding that occurs a
     few days after surgery involves the removal of any debris
     from the wound surface that promotes the infection of the
     wound.


    Identify the source of bleeding and treat as would be
     done in a patient with secondary bleeding.


    Surgical stents can be placed over extraction sockets for
     stabilization of clot and prevention of wound
     contamination.
     Management of Hemorrhage in patients with
    bleeding disorders / and those on anticoagulant
                        therapy


   The usual protocol involved in the treatment of this
    group of patients consists of pre-operative blood
    investigations and preoperative correction of the
    underlying deficiency (Replacement of Clotting factors /
    platelets) if any in these patients.

   Subsequently, after this appropriate local measures are
    used to decrease the chances of post-operative bleeding.
LABORATORY EVALUATION


PLATELET COUNT
BLEEDING TIME (BT)
PROTHROMBIN TIME (PT)
PARTIAL THROMBOPLASTIN TIME (PTT)
THROMBIN TIME (TT)
             PLATELET COUNT

 NORMAL            100,000 - 400,000 CELLS/MM3

 < 100,000          Thrombocytopenia

 50,000 - 100,000   Mild Thrombocytopenia

 < 50,000           Severe Thrombocytopenia
        BLEEDING TIME


 PROVIDES ASSESSMENT OF PLATELET
        COUNT AND FUNCTION



NORMAL VALUE
 2-8 MINUTES
          PROTHROMBIN TIME

Measures Effectiveness of the Extrinsic Pathway

NORMAL VALUE
 10-15 SECS
PARTIAL THROMBOPLASTIN TIME

   Measures Effectiveness of the Intrinsic
    Pathway




NORMAL VALUE
  25-40 SECS
            THROMBIN TIME

 Time for Thrombin To Convert
  Fibrinogen          Fibrin
 A Measure of Fibrinolytic Pathway


 NORMAL VALUE
    9-13 SECS
Management of Hemorrhage in patients with
uncontrolled hypertension.

   This group of patients need appropriate medical
    consultation for initiation of medical treatment to
    decrease their Blood Pressure.

   Thus once their B.P is controlled, then the bleeding
    decreases and with local measures the hemorrhage is
    controlled.

								
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