Hemorrage Oral Surgery

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POST EXTRACTION

BLEEDING

MARYAM ASAAD

200710172


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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 rangefrom minimal to significant

quantities.


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Hemorrhage in Surgery

Hemorrhage can occur to agreater or lesser degree duringall surgical procedures and its

management depends uponwhether the patient ishematologically normal orsuffers from some disturbance

in the normal clottingmechanism.


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Hemorrhage in Oral Surgery


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The overwhelming majority ofpatients who undergo oralsurgical procedures are thosewho have normal haemostatic

mechanism.

Therefore, significant or majorhemorrhages are not that

common in oral surgery exceptin patients who have a bleeding

/ clotting disorder or those whoare on anticoagulants.


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However, uncontrolled andpersistent bleeding can occur insome healthy patients afterdental extraction.

Therefore, it is still important toachieve proper hemostasis in allpatients during oral surgical

procedures, so as to preventexcessive post-operative bloodloss.


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Normal Mechanism of

Hemostasis

Hemostasis is a complicated

process.

It involves a number of

events


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Hemostasis -NormalMechanism

VASCULAR PHASE

2. PLATELET PHASE

3. COAGULATION PHASE


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VASCULAR PHASE

When a blood vessel isdamaged,

vasoconstriction results.


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PLATELET PHASE

Platelets adhere to the

damaged surface and

form a temporary plug.


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Through two separatepathways, the Intrinsic and

Extrinsic, the conversionof fibrinogen to fibrin is

complete. Fibrin tightly

binds the platelets to forma clot

COAGULATION

PHASE


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THE CLOTTING

MECHANISM

INTRIN

SIC EXTRINSIC

PROTHROMBINTHROMBIN

FIBRINOGEN

FIBRIN

Tissue

Thromboplastin


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HEMOSTASIS

DEPENDENT UPON:

Vessel Wall Integrity

Adequate Numbers of Platelets

Proper Functioning Platelets

Adequate Levels of Clotting Factors

Proper Function of FibrinolyticPathway


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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.


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Local causes of hemorrhage in

oral surgery

Local causes of hemorrhage

originate in either soft tissue orbone.


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Local causes of hemorrhage in

oral surgerySoft tissuebleeding

Soft tissue bleeding is either

arterial, venous, or capillary innature.


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Local causes -Soft tissuebleeding 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 thebuccal artery (lies lateral to the

retromolar pad)


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Local causes -Soft tissuebleeding 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.


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Local causesOsseous (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 Vascularmalformation)


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Systemic causes of

hemorrhage in oral surgery

Some patients with heriditaryconditions such as hemophilia, VonWillebrands disease are susceptiblefor hemorrhage following oralsurgical procedures.

Patients with thrombocytopenia(decreased platelet count) ,Leukemia e.t.c., are also at risk of

prolonged bleeding after surgery.

Patients with uncontrolledhypertension.


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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 thromboembolicepisode.

These patients are also at risk ofprolonged severe bleeding during

and after an oral surgical procedure.


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Types of Hemorrhage -Primary

Hemorrhage

This occurs during the surgery, as aresult of injury like cutting orlaceration of the artery or bleedingfrom bone.

This also occurs when surgery isdone in an infected area with a lot

of granulation tissue.

It can also occur after a very shortperiod of time immediately aftersurgery.

This type of bleeding is reallynormal and can be controlled easily.


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Types of Hemorrhage -Intermediate / Reactionary

Hemorrhage

This type of bleeding occurs within afew hours after surgery.

This type of bleeding occurs as a

result of failure of coagulation tooccur (as in patients with systemicbleeding problems or those onanticoagulants)

Patients who have unknowinglydisturbed / dislodged the clot arealso prone for this type of bleeding.


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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 thewound (Like patients who undergo

radical neck dissection e.t.c.,).

This type of bleeding is not veryfrequently encountered after oral

surgery procedures.


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Management ofPrimary

Hemorrhagein Normal patients

The management of bleeding

during surgery (Primary bleeding)

can be achieved by the followingmeans,

(i) Securing / ligation of bloodvessels with silk sutures.

(ii) Use of pressure swab to achieve

hemostasis.

(iii) Use of electrocautery to achievehemostasis.

(iv) Use of hemostatic agents like bone

wax, surgicel,e.t.c.,

(v) Hypotensive anaesthesia (G.A)

and use of vasoconstrictors in L.A.


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Local Measures ( Synthetic

Materials)

There are several materials that

are commercially available that

are used locally for achieving

adequate hemostasis.


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Local Measures:Surgicel(Oxidised Regenerated Cellulose)


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Local measures:Gelfoam withactivated thrombin


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Local Measures:Avitene

(Microfibrillar Collagen)


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Local Measures:Etik Collagen (Packed collagen)


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Local Measures:Tranexamicacid 5%


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Local Measures:Tranexamic

acid 5% in Syringe


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Local Measures:Irrigation of

wound with Tranexamic acid


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Local Measures:Suturing thewound


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Local Measures:Pressure with

oral packs


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Management ofIntermediate


The management of bleeding thatoccurs immediately after surgery

(Reactionary bleeding) involvesproper examination of the surgicalwound to identify the site ofbleeding (i.e ) from bone or softtissue.

(i) If bleeding is from bone then thehemostatic agents like bone waxor gelfoam is usually used.

(ii) If bleeding is from soft tissuesthen, ligation / cauterization ofblood vessels along with the use ofhemostatic agents like surgicel and

suturing of the wound is carriedout.


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Management ofSecondary


The management of this type ofbleeding that occurs a few days aftersurgery involves the removal of any

debris from the wound surface thatpromotes the infection of the wound.

Identify the source of bleeding and

treat as would be done in a patientwith secondary bleeding.

Surgical stents can be placed overextraction sockets for stabilization ofclot and prevention of woundcontamination.


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Management ofHemorrhagein

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 preoperativecorrection 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-operativebleeding.


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LABORATORY EVALUATION

PLATELET COUNTBLEEDING TIME (BT)

PROTHROMBIN TIME (PT)

PARTIALTHROMBOPLASTIN TIME

(PTT)

THROMBIN TIME (TT)


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PLATELET COUNT

NORMAL 100,000 -

400,000 CELLS/MM3

< 100,000

Thrombocytopenia

50,000 - 100,000 Mild

Thrombocytopenia

< 50,000 Severe

Thrombocytopenia


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BLEEDING TIME

PROVIDES ASSESSMENT OF

PLATELET COUNT AND

FUNCTION

NORMAL VALUE

2-8 MINUTES


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PROTHROMBIN TIME

Measures Effectiveness of theExtrinsic Pathway

NORMAL VALUE10-15 SECS


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PARTIAL

THROMBOPLASTIN

TIME

Measures Effectiveness of thIntrinsic

Pathway

NORMAL VALUE

25-40 SECS


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THROMBIN TIME

Time for Thrombin To Convert

Fibrinogen Fibrin

A Measure of Fibrinolytic

Pathway

NORMAL VALUE

9-13 SECS


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Hemorrage Oral Surgery

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