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HEMOSTASI

S
Akhmad Mustafa
Erwin Wijatmiko
Dedy Faroka
Farry
Department of Surgery - Hasan
Sadikin Hospital - Medical Faculty
Padjadjaran University

HEMOSTASIS
Mechanism to stop spontaneous
bleeding and maintain blood
circulation in vessels

Including: - Coagulation system


- Fibrinolysis system

Complex process

Hemostasis Pathofisiology
Bleeding
and
fibrinolysis

Coagulatio
n

Hemostasi
s
Interaction: Blood vessel thrombocyte

Medical Bleeding Caused by


Defects of:
1. Blood vessel wall
Inflammation

2. Thrombocyte
Qualitative or quantitative

3. Coagulation factors
Quantitative or inhibitor

Hemostasis Pathofisiology
Primary Hemostasis:
Vascular (blood vessel)
Thrombocyte

Secondary Hemostasis:
Blood coagulation factors

Schem atic ofprocesses initiated by vascular injury

Exposure of
Subendothelial
Collagen

Vasoconstriction

Vascular Injury

Platelet adhesion
And
aggregation

Hemostasis

Fibrinolysis

Release of
tissue factor

Coagulation

Blood Vessel
Permeability, Fragility, Vasoconstriction
Release:

- Tissue Factor
- von Willebrand factor (vWf)
- Prostacyclin: Vasodilatation, Thrombocyte
Aggregation
inhibitor
- Anti thrombin
Coagulation inhibitor
- Thrombomodulin
Pro - coagulation
Balancing
Coagulation Inhibition

THROMBOCYTE
Perform and stabilized thrombocyte

plug
Adhesion - Aggregation - releasing
Protein S carrier

(Protein S activate protein C)

COAGULATION
Intrinsic Pathway: XII, XI, IX, VIII,

PF3, HMWK,

Calcium ion
HMWK

XIIa

Pre Kalikrein

Kalikrein

Plasminogen

VII

VIIa
Plasmin

Extrinsic Pathway:

- Tissue

Thromboplastin
- VII Factor
- VIIa
IX
X
Xa

Common Pathway:

Protrombin

Fibrinogen
Thrombin
Fibrin

IXa

Coagulation Cascade

Blood cloth control


mechanism
Blood Circulation : dilution
Clearance
: Hepatocyte and

RES
INHIBITOR
: AT III, Protein C,
Protein S,
2 Macroglobulin,
1 Antitrypsin

FIBRINOLYSIS
Fibrin destruction opening blood circulation
Fibrinolysis system : - Plasminogen

- tissue-Plasminogen Activator (t-PA)


- Plasmin Inhibitor
Plasminogen Activator: - Intrinsic (F XII a, Kalikrein)

- Extrinsic : t-PA (Endothel)


- Exogen : Streptokinase
Plasmin Inhibitor: - 2 Plasmin Inhibitor
- 2 Macroglobulin
- 1 Antitripsin
- AT III

Vasoconstricti

Primary Hemostasis

Secondary Hemostasis

Fibrin

Thrombin
Fibrinogen

Anticoagulation counter-regulation

Fibrinolys
is
t-PA

Blocks coagulation

Thrombomodulin

Anticoagulation counter-regulation

Fibrinolys
is
t-PA

Blocks coagulation

Thrombomodulin

Clinical Difference of Vascular, thrombocyte and


coagulation system defect

- Petechiae
- Hematom
- Echimosis

Rarely
Characteristic
Frequent, big,
soliter

Hemarthrosis
-Occult
bleeding

Characteristic

Thrombocyte/
vascular Disorder
Characteristic
Rarely
Characteristic,
small,
multiple
Rarely

Frequent

Rarely

Clinical
Presentation

Coagulation
Disorder

Clinical Difference of Vascular, thrombocyte


and coagulation system defect
Clinical
Presentation

Coagulation
Disorder

- Bleeding from

Minimal

superficial
lesion
- Sex
- Family history

80-90% Male
Frequent

Thrombocyte/
vascular Disorder
Persistent, severe
bleeding is
frequent
Dominantly
female
Rarely

Echimosis

Petechiae

Thrombositopenia
Decreasing production: Hereditary,

Bone marrow
Hypoplasia
Increasing destruction:
Immune
: ITP, Secondary effect
diseases
Non immune : Microangiopathy, Vasculitis
Abnormal distribution: Splenomegali

LocalH em ostasis
Mechanical procedures
the oldest method is digital pressure, than develop to

hemostat
generally ligature or a hemoclip replaces hemostat as
permanent method on effecting hemostasis of a single
disrupt vessel
1st century Aulus Cornelius Celsus devise the use of
ligature
1552 Pare rediscovered the principle of ligature
1800 Philip Sying Phsick employ absorbable suture
1858 Simpson introduce fine wire suture, 1881 Lister used
catgut
1900 Halsted indicated the advantages of non absorbable
silk
1911 Cushing use silver clips to effect hemostasis in

LocalH em ostasis
Thermal Agents
Heat achieves hemostasis by denaturation of protein that

result in coagulation of large are of tissue


The electrocautery can be AC or DC
Local cooling has been applied to control bleeding from the
eroded mucosa of the eophagus and stomach, direct cooling
with iced saline is effective but may provoke hypothermia
Cryogenic procedure, at tempertures of -20 C, tissue,
capillaries and arterioles undergo necrosis

Chemical Agents
Epinephrine
1911 Cushing use skeletal muscle, shortly thereafter

hemostatic fibrin was introduced


Gelatin, oxydized cellulose, oxydized regenerated cellulose
and micronized collagen are the most widely used

Evaluation ofthe SurgicalPatient as a


H em ostatic Risk
PREOPERATIVE

Patients history
1. Prolonged bleeding or swelling after biting
the li or tongue
2. Bruises without apparent injury
3. Prolonged bleeding after dental extraction
4. Excessive menstrual bleeding
5. Bleeding problems associated with major or
minor operatives
6. Medical problems receiving a physicians
attention within the past 5 year
7. Medications including aspirin or remedies for
headache taken within past 10 days
8. A relative wit a bleeding problem
. Laboratory findings (PT, aPTT, INR, Platelet

Evaluation ofthe SurgicalPatient as a


H em ostatic Risk
EVALUATION OF EXCESSIVE
INTRAOPERATIVE OR POST OPERATIVE
BLEEDING
Maybe the result of the following
factors:
1. Ineffective local hemostasis
2. Complications of blood transfusion
3. A previously undetected hemostatic
defect
4. Consumptive coagulopathy
5. Fibrinolysis