Surgery in Bleeding Diathesis
DR.B.SELVARAJ,MS,Mch,FICS,
NEONATAL & PEDIATRIC
SURGEON
PONDICHERRY INSTITUTE OF
MEDICAL SCIENCES
PONDICHERRY-605014 INDIA
Surgery In Bleeding Diathesis
Plan
� Introduction
� Physiology Of Hemostasis
� Preop Evaluation
� Cases Managed
� Common Bleeding Disorders
� Surgery In Hemophiliacs
� Clinical Decision Making
Physiology Of
Hemostasis
FOUR COMPONENTS
� VESSEL WALL RESPONSE
� PLATELET ACTIVITIES
� COAGULATION CASCADE
� FIBRINOLYTIC SYSTEM
Physiology of Hemostasis
Platelet Activities
Vessel wall
Platelet
Fibrinogen
GP1b Receptor
Gpi ib -iii a Complex Receptor
VWBFEndothelium
Platelet membrane phospholipids
Arachiodonic Acid
Cyclic Endoperoxides:- PGG2 & PGH 2
Thromboxane-A2
C AMPThrombin
Collagen or ADP
Aspirin
Thromboxane
Synthetase
Phospholipase A2
Fatty acid Cyclooxygenase
inhibits Activates
inhibits
Coagulation factors
I. Fibrinogen
II. Prothrombin
III.Tissue factor
IV.Ionised calcium
V. Proaccelerin
VII.Proconvertin
VIII.Antihemophilic factor(AHF)
IX.Christmas factor
X. Stuart prower factor
XI.Plasma thrombo plastin antecedent
XII.Hageman factor
XIII.Fibrin stabilising factor
INTRINSIC SYSTEM
XII XII a
XI XI a
HMWK
IX IX a+VIII
X Xa +V
EXTRINSIC SYSTEM
VII
Ca
TF
Prothrombin Thrombin
XIII XIIa
Fibrinogen Fibrin
Stable fibrin
clot
Plasminogen
Stretokinase &
Plasminogen
Damaged cells
Tissue plasminogen Activator
Contact activation
Prourokinase Urokinase
Plasmin
Proactivator Activator
XII XIIa t-PA + Fibrin
t-PA Inhibitor
Rapid
Enhancement
slow
Fibrinogen
Fibrin
Factors V & VIII
Fibrinogen degradation products
Fibrin degradation products
Destruction by Proteolysis
EACA Alpha2-antiplasmin
PRE OP EVALUATION � Thorough personal medical history, family history& drug ingestion history
� PHYSICAL EXAM:
SKINPetechiae ����thrombocytopeniaEcchymoses &Hematomas���� platelet dysfunction
JOINTS Hemarthrosis ����severe coagulation defect
ORGANOMEGALY
Hepatomegaly ���� coagulopathy of cirrhosisSpleenomegaly ����possible thrombocytopenia
LAB SCREENIG TESTS
DIC,fibrinolysis10µgm/ml Fibrin Degradation
product assay
Hypofibrinogenemia,
heparin
12-20 secondsThrombin time
Intrinsic system,factors
VIII,IX,XI,XII
30-40 secondsPartial Thromboplastin
Time
Extrinsic system, factor
VII
12-14 secondsProthrombin Time
Thrombocytopenia
Thrombocytopathy
2- 8 minutesBleeding Time
Thrombocytopenia150-250,000/dlPlatelet Count
AbnormalitiesNormal rangeTest
CASE NO:1CASE NO:1
� 2 Yrs old 1st born male child
�Was brought with obstructed RIH
�H/O Epistaxis&easy bruisability
�Ear boring ceremony resulted in
prolonged bleeding
�Emergency�so no extensive workup
was done
CASE NO:1
Basic Screening Tests
� Hb-----11Gms
� Platelets----2 Lakhs/cmm
� Bleeding Time--- >15 mts
� Clotting Time----- 13 mts
� Prothrombin Time--- 12 sec
� PTT------------------- 39 Sec
� Blood group------B+ve
CASE NO:1 Contd
� Only B.T. was prolonged
� Provisional Diagnosis:Functional Platelet problem---------Thrombocytopathy
� Emergency Herniotomy with 200 ml of fresh whole blood
� Readmitted after 10 days for prolonged bleeding from a small cut to upper lip
� Managed by multiple WB transfusions
CASE NO:1 Contd
Hematological Workup
• Hb--------11.5Gms
• PCV------36%
• Platelets-----2.00.000/cmm
• TC------12.000/Cmm
• DC------N 33 L 43 E 18 M 4
• Bleeding Time---->15 mts
CASE NO:1 Contd
Hematological Workup
�Clotting Time--------13 mts
�Clot Retraction--------Nil
�Clot Lysis--------------Nil
�Plasma Fibrinogen---280 mgms
�Factor xiii activity----normal
�PT---------12 Sec
�PTT-------40Sec
CASE NO:1 Contd
• PLATELET FUNCTION TESTS
-Invivo Platelet Adhesion—10.8%
-ADP Aggregation------Absent
-Aggregometer Studies
-ADP-------No Aggregation
-Collagen-----No Aggregation
• Thrombin Time---------8sec
• Blood group-----------B+ve
CASE NO:1 CASE NO:1 ContdContd
•• Normal Platelet count&morphologyNormal Platelet count&morphology
•• Normal Clotting testsNormal Clotting tests
•• Prolonged Bleeding TimeProlonged Bleeding Time
•• Absent Platelet Aggregation with Absent Platelet Aggregation with
ADP and CollagenADP and Collagen
•• Absent Clot RetractionAbsent Clot Retraction
•• GLANZMAN`S THROMBASTHENIAGLANZMAN`S THROMBASTHENIA
CASE NO:2
11Yrs old boy , no previous H/O bleeding underwent Interval Appendicectomy
Excessive bleeding from OP site immediate postop
B.T.---prolonged,C.T.----Normal, Platelet count--------Normal
Since no Platelet concentrate was available,was treated with multiple WB transfusions
CASE NO:3
• 4Yrs old boy came with fever&pain abdomen
• O/E Abdomen---Generalised tenderness and rigidity
• AXR-Erect---Gas under diaphragm +
• Patient known Hemophiliac
• Laparotomy&ileal perforation closure was done with 1 unit of AHF
• On 2nd POD –oozing from the wound,one more unit of AHF Was given
CASE NO:4
5Yrs old boy with H/O fall over cycle bar reported with retention of urine
Perineal Hematoma&Extravasation of urine +
With difficulty catheter was passed into the bladder
Multiple Perineal incisions were made
CASE NO:4 Contd
Next day –profuse bleeding from the perineal incision sites
On subsequent interrogation parents came out with H/O previous bleeding episodes
Child was a Hemophiliac
He was treated with AHF& repeated fresh WB transfusions
Bleeding Disorders Commonly
Encounter By Surgeons
Thrombocytopenia
Thrombocytopathy
Hemophilia- A
Hemophilia- B- Christmas disease
Von Willebrand Disease
Disseminated Intravascular Coagulation
Liver Disease– Factor vii & x deficiency
THROMBOCYTOPENIA
Low Platelet Count
Acquired or Inherited
Purpura & Ecchymosis----- superficial bleeding
Labs:B.T P.C PT/PTT- N
Treatment--- Platelet Concentrates
THROMBOCYTOPATHY
� Functional Platelet Abnormality
� Acquired due to drugs like Aspirin and
Uremia
� Inherited-----Bernard Soulier Syndrome
due to defective Platelet adhesion,
Glanzman`s Thrombasthenia due to
defective Platelet aggregation
THROMBOCYTOPATHY
♦ Ecchymosis&Epistaxis------ Superficial
Hemorrhage
♦ Labs:B.T P.C—N, PT/PTT---N
♦ Treatment---Platelet Concentrates
HEMOPHILIA----A
� Factor viii procoagulant deficiency
� Sex linked recessive inheritance
� Deep tissue bleed&hemarthrosis
� Labs:B.T,P.C,P.T---N;PTT--Specific Factor Assays
� Treatment:AHF 1U/Kg raise the level by 2%.For 5Kg child 250u for 100% raise
Hemophilia-B—Christmas Disease
� Factor ix deficiency
� Sex linked recessive inheritance
� Deep tissue bleed&Hemarthrosis
� Labs:B.T,P.C,P.T—N,PTT--
Specific Factor Assays
� Treatment:Factor ix Concentrates or FFP
Von Willebrand`s Disease
� Factor viii vwf deficiency
� Autosomal Dominant Inheritance
� Epistaxis,easy bruising& prolonged
bleeding from dental extraction
� Labs:B.T P.C—N,P.T—N,PTT--
Specific Factor Assays
� Treatment: FFP or Cryoprecipitate
Disseminated Intravascular Coagulation—(D.I.C)
� Thrombohemorrhagic disorder
� Acquired:Abruptio placenta,Septic abortion,Toxemia,Gram-ve sepsis,snake bite,Massive tissue injury etc
� Activation of Coagulation Cascade—Microthrombi throughout microcirculation
� Consumption of Coagulation factors,Platelets and Fibrin
� Activation of Fibrinolytic System
Disseminated Intravascular
Coagulation--------contd
� Mucosal bleed,Ecchymosis,oozing from
wound sites
� Labs:B.T P.C PT/PTT
� T.T F.S.P Fragmented RBCs +
� Treat the underlying cause
� FFP&Platelet Concentrates
� Role of Heparin is controversial
LIVER DISEASELIVER DISEASE
� Acquired
� Factor vii& x deficiency
� Epistaxis,Menorrhagia&Hemarthrosis
� Labs:B.T—N,P.C—N, Factor x—PT/PTT
Factor vii----P.T P.T.T----N.,Specific Factors
Assay
� Treatment-------FFP
Surgery In HemophiliacsMinor Surgery
� Give dose calculated to bring patient’s plasma level to 100% 1 hour prior to surgery(50 units/kg q12h)
� Maintain plasma level above 60% for 4 days
� Maintain plasma level above 20% for subsequent 4 days
� Assay daily prior to dose
Surgery In Hemophiliacs
Major Surgery
�Give dose calculated to bring patient’s plasma level to 100% 1 hour prior to surgery(50 units/kg q12h)
�Maintain plasma level above 60% for 4 days
�Maintain plasma level above 40% for subsequent 4 days or until all drains & sutures are removed
�Assay daily prior to dose
Surgery In HemophiliacsSurgery In HemophiliacsOrthopedic Surgical ProceduresOrthopedic Surgical Procedures
•• Give dose calculated to bring Give dose calculated to bring
patient’s plasma level to 100% 1 hour patient’s plasma level to 100% 1 hour
prior to procedure (50 units/kg q12h)prior to procedure (50 units/kg q12h)
•• Maintain plasma level >80% for 4 Maintain plasma level >80% for 4
daysdays
•• Assay daily prior to doseAssay daily prior to dose
•• Maintain plasma level >40% for 4 Maintain plasma level >40% for 4
daysdays
Surgery In Hemophiliacs
Orthopedic Surgical Procedures
If patient is casted, discontinue replacement
until rehabilitation program is begun
If not casted, maintain above 20 % for
ambulation
For rehabilitation program ,maintain > 10%
for three weeks
Clinical Decision MakingClinical Decision Making
Case No:1Case No:1
� 40yrs old man c/o bleeding PR
� Colonoscopy revealed single polyp in descending colon
� Colonoscopic snare polypectomy was done
� Postop profuse bleeding+
� Labs:only B.T
� Diagnosis& Treatment ?
Clinical Decision Making
Case No:2
�3 months old congenital Biliary
Atresia baby
�Was brought with purpuric skin
lesions&oozing from gums
�Labs:PT&PTT
�Diagnosis & Treatment ?
Clinical Decision MakingCase No:3Clinical Decision MakingCase No:3
� 3 days old baby was brought with
H/O hemetemesis& melena
� O/E Well baby
� Labs: Hb –N;B.T,P.C,PT,PTT----N.
� Diagnosis--?
Clinical Decision Making
Case No:4
• 60 yrs old man a case of ESRD on
chronic hemodialysis
• Called to see him for profuse oozing
from puncture site @ AV fistula
• Labs:B.T,P.C,P.T---N,PTT&TT
• Diagnosis and Treatment?
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Clinical Decision Making Case No:5
� 12 yrs old girl on chronic
hemodialysis for ESRD
� Uremia developed because of
temporary interruption of
dialysis
� Developed brisk epistaxis
� Labs:BUN-164 mgms, BT>20mts
� Diagnosis & Treatment?
Clinical Decision Making
Case No:6
� 50 yrs old lady with severe burns injury became febrile & toxic
� Epistaxis, Hemetemesis & melena
�Wound Swab--Gram –ve sepsis
� Labs:BT PC PT&PTT TT
� Diagnosis & Treatment?
THANK YOUTHANK YOUTHANK YOUTHANK YOU
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