SURGICAL BLEEDING

& HEMOSTASIS

Dr Mungatana
March 2013
Hemostasis
 Objective of hemostasis:

 To prevent or terminate blood loss from a site of

vascular disruption

 Mechanism

 Formation of a stable clot

The Hemostatic Events
 Transient Vasospasm

 Platelet Plug

 Fibrin Deposition

 Fibrinolysis
Hemostasis:
BV Injury

Tissue
Neural Factor

Blood Vessel Platelet Coagulation

Vasospasm Activation Activation
Primary hemostatic plug

Reduced
Plt-Fusion Thrombin,
Blood flow
Fibrin

Stable Hemostatic Plug

Transient Vasospasm
 The initial response to vascular injury
 May be enough by itself to stop bleeding
 Stimuli for vasoconstriction
 TXA2 mostly from platelet AA
 5-HT
 Bradykinin and fibrinopeptides

 Stimuli for vasodilation

 Prostacyclin (PGI2)

 Factors affecting effectiveness of vasospasm

 Tangent of injury
 Linear bleeds more than cross sectional
 Perivascular pressure
 Steroids, weight loss, ageing
 Vascular abnormalities
 Ehlers Danlos
The Role of Platelets
 Are 200,000-400,000 with a lifespan 9 days

 Mediates primary hemostasis: reversible clot formed immediately after injury .

vW factor dependent

 Upon exposure to subendothelial collagen platelets undergo a release reaction

that recruits more platelets hence the primary hemostasis

 From platelet AA
 TXA mediates vasoconstriction and platelet aggregation
 Prostacyclin (PGI2) the reverse

 In the presence of Ca thrombin and with fibrin the platelet plug is stabilised by
the coagulation cascade becoming irreversible
Coagulation:

Intrinsic 12,11,9,8 Extrinsic-7

(aPTT-) (PT)

Common Path (TT)

FX  FXa

Prothrombin Thrombin

Fibrinogen  Fibrin
 Clot formation & retraction

Fibrinogen
Thrombin

Fibrin Mononer

Fibrin Polymer
F-XIIIa
Cross Linked
Fibrin
Coagulation Cascade

 How is luminal patency maintained and systemic

fibrin deposition prevented

 What are the Vit K dependent factors and which are

synthesized in the liver
 Prothrombin

Xa
Va

Thrombin
Fibrinogen Fibrin
 Extrinsic Pathway/
Tissue Factor Pathway
TF
Prothrombin
VIIa

Xa
Va

Thrombin
Fibrinogen Fibrin
Intrinsic pathway/
Contact Activation Pathway

XIIa

Extrinsic Pathway
XIa
TF
Prothrombin
IXa VIIa
VIIIa Xa
Va

Thrombin
Fibrinogen Fibrin
Intrinsic pathway

XIIa

Extrinsic Pathway
XIa
TF
Prothrombin
IXa VIIa
VIIIa Xa
Va

Thrombin Soft clot

Fibrinogen Fibrin
XIIIa Hard clot
Fibrin
Fibrinolysis
 Maintains luminal patency by lysing fibrin deposits

 Mediated by plasmin activated from plasminogen

at the same time of coagulation
Hematological disorders
 Platelet disorders
 Congenital:
 von Willebrand disease, hereditary thrombocytopenia
 Acquired :
 Thrombocytopenia
 Transfusion; heparin

 Coagulapathies
 Classical hemophilia
DIC
 Defribination syndrome; consumptive
coagulopathy

 Results in Systemic bleeding really rather than

clotting

 Cause:
 thromboplastic material entering into the circulation
 Examples : Endotoxinemia; malignancies; snake bite;
transfusions; abruptio placenta; retained fetus
Natural Anticoagulation
 Antithrombin
 Inhibits fibrinogen cleavage
 Inhibits V & VIII
 Inhibits platelet aggregation

 Activated protein C
 Inhibits Va and VIIIa

 Thrombin inactivated by incorporation into clot

Tests of Hemostasis: Coag Profile
 Screening tests:
 Bleeding.T - To test Platelet & BV function
 Prothrombin.T – Extrinsic, aPTT – Instrinsic
 Thrombin.T – Both paths. (DIC)

 Specific tests:
 Factor assays –
 Tests of thrombosis – TT, FDP,
 Platelet function studies:
 Adhesion, Aggregation, Release & PG pathway tests.
 Bone Marrow Analysis
Taking a History
 Recent intake of aspirin?
 Bruising without any apparent injury
 Bleeding into joints
 Prolonged bleeding after tooth extraction
 Heavy menses
 Excessive postop bleeding
 Family History
Hemostatic Techniques
 Goal: Prevent flow into an incised vessel
 Local
 Mechanical
 Digital pressure
 Hemostat forceps
 Suture ligature
 Pressure packing
 Torniquets
 Chemical
 Epinephrine
 Gelfoam : has a pressure and surface area effect
 Surgicel : reacts t form an artificial clot
 Thermal
 Electrocoagualation
 Direct current
 Cryogenic surgery

 Systemic
Excessive Peri-operative Bleeding
 Inadequate hemostatic technique

 Predating hemostatic anomaly

 DIC

 Transfusion reaction