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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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Hemorrhage in Oral Surgery
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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Hemorrhage in Oral Surgery
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 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.
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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
Hemorrhagein Normal patients
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
Hemorrhagein Normal patients
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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