surgical hemostasis

8/7/2019 surgical hemostasis

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Case ConferenceCase Conference

Vincent Chen

5/26/2005


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58 yo male, history of two previous

septorhinoplasties. He has a persistent nasal

septal perforation. Presents for septal

perforation repair.


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During the course of the procedure, patient

loses 700ml of blood. There is diffuse

bleeding during elevation of the septal flaps.

The procedure is terminated, the nose is

packed and the patient is observed in the

hospital overnight.


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History

History

Bleeding from multiple sites or occasions

Spontaneous bleeding or after trauma

Easy bruising

Hematomas

Heavy periods


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Med

icat

ions

Med

icat

ions

Aspirin

NSAIDS

Supplements


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Past

Med

ical

History

Past

Med

ical

History

Liver disorders

Prior transfusions?


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Past surg

ical h

istory

Past surg

ical h

istory

Difficulty with bleeding during procedures.

Bleeding after dental work, labor,

lacerations

Prior transfusions.


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Fam

ily

History

Fam

ily

History

Familial syndromes


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Phys

ical Exam

Phys

ical Exam

Petechiae

Telangiectasias

Ecchymoses

Hemarthroses


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Different

ial d

iagnos

is

Different

ial d

iagnos

is

V

I

T

A

M

I N

C


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Platelet

Funct

ion Assay

Platelet

Funct

ion Assay

The PFA test result is dependent on plateletfunction, plasma von Willebrand Factor level,

platelet number. Anticoagulated whole blood is passed

through membranes coated with eithercollagen /epinephrine or collagen / ADP to

si

mulate thein vivo

hemodynami

csi

n thesmall capillaries. Platelets adhere to themembranes and gradually occlude a smallaperture in the center of each membrane.


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Platelet Aggregat

ion

Platelet Aggregat

ion

Adhesion

Release Reaction

Aggregation

Pro-Coagulant Activity

Platelet Fusion Growth Factors


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Platelet Aggregat

ion

Platelet Aggregat

ion


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Coagulation CascadeCoagulation Cascade


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Extrinsic SystemExtrinsic System


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Common PathwayCommon Pathway


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Coagulation CascadeCoagulation Cascade


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Hemostasis reactionsHemostasis reactions


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Von W

illebrand

Disease

Von W

illebrand

Disease

Heterogeneous disease. >20 subtypes

Abnormality or deficiency of vWF

Carrier for factor VIII, prevents its

degradation

Synthesized from endothelial wall.

0.8-1.6% of general population


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Von W

illebrand

Disease

Von W

illebrand

Disease

Bleeding times

Factor VIII activity

vWF antigen levels

vWF activity (ristocetan)

vWF multimer analysis


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Hemoph

ilia A

Hemoph

ilia A

Genetic deficiency ofFactor VIII

X linked gene product. Males only

1:10,000 males

Degrees of severity: mild to severe

Severe: spontaneous bleeding, severe bleed after

trauma Prolonged PTT, low factor VIII

Bleeding time normal


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Hemoph

ilia A

Hemoph

ilia A

Treatment:

DDAVP: releases VIII stores.

Cryoprecipitate

Factor VIII concentrates


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Hemoph

ilia B

Hemoph

ilia B

Deficiency ofFactorIX

X linked recessive

1:30,000 males

Acquired: vit K deficiency, liver disease,

coumadin

Prolonged PTT, deficient factorIX,

RX: FFP, FactorIX concentrates


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Vitam

in K

Deficiency

Vitam

in K

Deficiency

Activation ofFactors II, VII, IX, X

Sources: diet, intestinal bacteria

Coumadin is a vitamin K antagonist

RX: vitamin K, FFP


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Liver

Failure

Liver

Failure

Decrease coagulation factor synthesis

Biliary obstruction causes impaired Vit K

absorption Portal Hypertension: hypersplenism and

thrombocytopenia

Fibrinogen dysfunction DIC

RX: factor replacement


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Renal

Failure

Renal

Failure

Platelet dysfunction due to uremia

Abnormal platelet aggregation and

prolonged bleeding time

Anemia of chronic renal failure

RX: DDAVP, packed red blood cells


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Transfus

ion Syndrome

Transfus

ion Syndrome

>10 units blood over 24 hr period

Platelets and coagulation factors lose

activity over time

RX: platelet transfusion and FFP


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Platelet Abnormal

ities

Platelet Abnormal

ities

Quantitative: Thrombocytopenia

Qualitative Disorders


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Thrombocytopen

ia

Thrombocytopen

ia

Drug induced

Platelet underproduction

Hypersplenism Autoimmune: ITP

Pregnancy

HIV

Transfusion

TTP

RX platelet transfusion


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Platelet Qual

itat

iveDi

sordersP

latelet Qualitat

iveDi

sorders Drugs

Congenital Platelet Disorders

Uremia

Liver disease

RX treat underlying disease, platelets,DDAVP

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