Surgical Bleeding

Presented by Nargess Tavakoli

Guilan University of Medical Sciences

Excessive Intraoperative or Postoperative Bleeding

may be the result of:

• ineffective local hemostasis

• complications of blood transfusion

• a previously undetected hemostatic defect

• consumptive coagulopathy, and/or fibrinolysis.

Ineffective Local Hemostasis Ineffective Local Hemostasis

• Excessive bleeding from the field of the procedure

• without bleeding from other sites

e.g. cvp line

intravenous line

tracheostomy

exception

• operations on the

Prostate

Pancreas

Liver

operative trauma =>

local plasminogen activation =>

increased fibrinolysis on the raw surface

• EACA: 24-48-hour interruption of plasminogen activation

• laboratory investigation must be confirmatory

• number of plt

• actual plt count: if the smear is equivocal

• aPTT

• PT

• TT

complications of blood transfusion

complications of blood transfusion

• thrombocytopenia due to massive blood transfusion

• hemolytic transfusion reaction

• Transfusion purpura

thrombocytopenia due to massive blood transfusion

massive transfusionmassive transfusion• a single transfusion greater than 2500 mL

• 5000 mL transfused over a period of 24 hours.

thrombocytopenia due to massive blood transfusion

• usually not associated with hemostatic failure

• prophylactic administration of plt: not indicated

if evidence of diffuse bleeding:

• empiric transfusion of 8_10 packs of fresh platelet concentrates

• no clear association between plt count,BT & the occurrence of profuse bleeding

hemolytic transfusion reaction

• Example:

anesthetized patient :

diffuse bleeding in an operative field that had previously been dry

Pathogenesis:

red blood cells lysis=>

release of ADP=>

diffuse plt aggregation=>

the plt clumps are swept out of the circulation

• Release of procoagulants =>

progression of the clotting mechanism =>

intravascular defibrination

• The fibrinolytic mechanism may be triggered.

Transfusion purpura

Transfusion purpura

• uncommon

• donor plt:uncommon PlA1 group

• Recipient makes Ab to the foreign plt Ag

• foreign plt antigen attach to the recipient's own plt

• sufficient titer of Ab to destroy recipent’s plt: within 6 or 7 days

• resultant thrombocytopenia & bleeding may continue for several weeks

• bleeding follows transfusion by 5 or 6 days:

Transfusion purpura as DDx.

Management:

• Platelet transfusions :

little help

damage from the Ab

• Corticosteroids:

some help

• self-limited

DIC and disseminated fibrinolysis

DIC and disseminated fibrinolysis

• control mechanisms fail to restrain the hemostatic process to the area of tissue damage

Caused by:

• trauma• incompatible transfused blood• Sepsis• necrotic tissue• fat emboli• retained products of conception• toxemia of pregnancy• large aneurysms• liver diseases

• distinguish between the two processes or the dominant element : important

• No single test can confirm or exclude the diagnosis or

distinguish between the two disorders

strong indications for DIC

The combination of

• Thrombocytopenia

• plasma protamine test for fibrin monomers:+

• fibrinogen level : LOW

• FDP: ELEVATED

• The euglobulin lysis time

detects diffusefibrinolysis

Biliary tract surgery in cirrhotic patients&Bleeding

• Related to:• portal hypertension

• coagulopathy associated with chronic liver disease

• The tests used to distinguish DIC from fibrinolysis pertain

• The therapeutic approach

IV vasopressin: temporary reduction in portal hypertension

EACA to correct the increased fibrinolysis

The therapeutic approach

• IV vasopressin: temporary reduction in portal hypertension

• EACA to correct the increased fibrinolysis.

Intra/Postoperative Bleeding &sepsis

• Endotoxin-induced thrombocytopeniaEndotoxin-induced thrombocytopenia

• DefibrinationDefibrination

Endotoxin-induced Endotoxin-induced thrombocytopeniathrombocytopenia

• Gram Neg. sepsis

a labile factor (possibly factor V)

DefibrinationDefibrination

• meningococcemia

• Clostridium perfringens sepsis

• staphylococcal sepsis

• Hemolysis leading to defibrination

• Evaluation:plt count, INR, aPTT,TT

Preoperative Evaluation of Hemostasis

Ask the patient8Qs

prolonged bleeding or swelling after biting the lip or tongue?

bruises without apparent injury?

prolonged bleeding after dental extraction?

excessive menstrual bleeding?

bleeding problems associated with major and minor operations?

medical problems receiving a physician's attention within the past 5 years?

• medical problems receiving a physician's attention within the past 5 years?

medications including aspirin or remedies for headache taken within the past 10 days?

• a relative with a bleeding problem?

Four levels

• Based on:

History

surgical procedure

level I

History: negative

procedure: relatively minor

e.g., breast biopsy

hernia repair

no screening tests are recommended

level II

• history:negative

• major operation but usually is not attended by significant bleeding

• platelet count

• PBS

• PTT

Level III

• history : suggestive of defective hemostasis • procedure :hemostasis may be impaired, e.g.,

operating using pump oxygenation or cell savers

• procedures : a large, raw surface is anticipated

• situations :minimal postoperative bleeding could be injurious(intracranial operations)

Level III

• plt count & bleeding time test : platelet function;

• aPTT & INR : coagulation

• the fibrin clot should be incubated to screen for abnormal fibrinolysis

Level IV

• history highly suggestive of a hemostatic defect

• consult with ahematologist

• tests prescribed for level III • BT test :4 hours after ingestion of 600

mg of aspirin operation is scheduled to take place 10 or more days after this study.

Level IV

• emergency procedure: platelet aggregation tests ADP, collagen,

epinephrine, and ristocetin

TT : detect any dysfibrinogenemia or a circulating, weak, heparin-like anticoagulant.

uremic patients

Qualitative platelet abnormality

most common deficit

best detected by the bleeding time test.

Thanks for your attention