Surgery in Bleeding Diathesis

DR.B.SELVARAJ,MS,Mch,FICS,

NEONATAL & PEDIATRIC

SURGEON

PONDICHERRY INSTITUTE OF

MEDICAL SCIENCES

PONDICHERRY-605014 INDIA

Surgery In Bleeding Diathesis

Plan

� Introduction

� Physiology Of Hemostasis

� Preop Evaluation

� Cases Managed

� Common Bleeding Disorders

� Surgery In Hemophiliacs

� Clinical Decision Making

Physiology Of

Hemostasis

FOUR COMPONENTS

� VESSEL WALL RESPONSE

� PLATELET ACTIVITIES

� COAGULATION CASCADE

� FIBRINOLYTIC SYSTEM

Physiology of Hemostasis

Platelet Activities

Vessel wall

Platelet

Fibrinogen

GP1b Receptor

Gpi ib -iii a Complex Receptor

VWBFEndothelium

Platelet membrane phospholipids

Arachiodonic Acid

Cyclic Endoperoxides:- PGG2 & PGH 2

Thromboxane-A2

C AMPThrombin

Collagen or ADP

Aspirin

Thromboxane

Synthetase

Phospholipase A2

Fatty acid Cyclooxygenase

inhibits Activates

inhibits

Coagulation factors

I. Fibrinogen

II. Prothrombin

III.Tissue factor

IV.Ionised calcium

V. Proaccelerin

VII.Proconvertin

VIII.Antihemophilic factor(AHF)

IX.Christmas factor

X. Stuart prower factor

XI.Plasma thrombo plastin antecedent

XII.Hageman factor

XIII.Fibrin stabilising factor

INTRINSIC SYSTEM

XII XII a

XI XI a

HMWK

IX IX a+VIII

X Xa +V

EXTRINSIC SYSTEM

VII

Ca

TF

Prothrombin Thrombin

XIII XIIa

Fibrinogen Fibrin

Stable fibrin

clot

Plasminogen

Stretokinase &

Plasminogen

Damaged cells

Tissue plasminogen Activator

Contact activation

Prourokinase Urokinase

Plasmin

Proactivator Activator

XII XIIa t-PA + Fibrin

t-PA Inhibitor

Rapid

Enhancement

slow

Fibrinogen

Fibrin

Factors V & VIII

Fibrinogen degradation products

Fibrin degradation products

Destruction by Proteolysis

EACA Alpha2-antiplasmin

PRE OP EVALUATION � Thorough personal medical history, family history& drug ingestion history

� PHYSICAL EXAM:

SKINPetechiae ����thrombocytopeniaEcchymoses &Hematomas���� platelet dysfunction

JOINTS Hemarthrosis ����severe coagulation defect

ORGANOMEGALY

Hepatomegaly ���� coagulopathy of cirrhosisSpleenomegaly ����possible thrombocytopenia

LAB SCREENIG TESTS

DIC,fibrinolysis10µgm/ml Fibrin Degradation

product assay

Hypofibrinogenemia,

heparin

12-20 secondsThrombin time

Intrinsic system,factors

VIII,IX,XI,XII

30-40 secondsPartial Thromboplastin

Time

Extrinsic system, factor

VII

12-14 secondsProthrombin Time

Thrombocytopenia

Thrombocytopathy

2- 8 minutesBleeding Time

Thrombocytopenia150-250,000/dlPlatelet Count

AbnormalitiesNormal rangeTest

CASE NO:1CASE NO:1

� 2 Yrs old 1st born male child

�Was brought with obstructed RIH

�H/O Epistaxis&easy bruisability

�Ear boring ceremony resulted in

prolonged bleeding

�Emergency�so no extensive workup

was done

CASE NO:1

Basic Screening Tests

� Hb-----11Gms

� Platelets----2 Lakhs/cmm

� Bleeding Time--- >15 mts

� Clotting Time----- 13 mts

� Prothrombin Time--- 12 sec

� PTT------------------- 39 Sec

� Blood group------B+ve

CASE NO:1 Contd

� Only B.T. was prolonged

� Provisional Diagnosis:Functional Platelet problem---------Thrombocytopathy

� Emergency Herniotomy with 200 ml of fresh whole blood

� Readmitted after 10 days for prolonged bleeding from a small cut to upper lip

� Managed by multiple WB transfusions

CASE NO:1 Contd

Hematological Workup

• Hb--------11.5Gms

• PCV------36%

• Platelets-----2.00.000/cmm

• TC------12.000/Cmm

• DC------N 33 L 43 E 18 M 4

• Bleeding Time---->15 mts

CASE NO:1 Contd

Hematological Workup

�Clotting Time--------13 mts

�Clot Retraction--------Nil

�Clot Lysis--------------Nil

�Plasma Fibrinogen---280 mgms

�Factor xiii activity----normal

�PT---------12 Sec

�PTT-------40Sec

CASE NO:1 Contd

• PLATELET FUNCTION TESTS

-Invivo Platelet Adhesion—10.8%

-ADP Aggregation------Absent

-Aggregometer Studies

-ADP-------No Aggregation

-Collagen-----No Aggregation

• Thrombin Time---------8sec

• Blood group-----------B+ve

CASE NO:1 CASE NO:1 ContdContd

•• Normal Platelet count&morphologyNormal Platelet count&morphology

•• Normal Clotting testsNormal Clotting tests

•• Prolonged Bleeding TimeProlonged Bleeding Time

•• Absent Platelet Aggregation with Absent Platelet Aggregation with

ADP and CollagenADP and Collagen

•• Absent Clot RetractionAbsent Clot Retraction

•• GLANZMAN`S THROMBASTHENIAGLANZMAN`S THROMBASTHENIA

CASE NO:2

11Yrs old boy , no previous H/O bleeding underwent Interval Appendicectomy

Excessive bleeding from OP site immediate postop

B.T.---prolonged,C.T.----Normal, Platelet count--------Normal

Since no Platelet concentrate was available,was treated with multiple WB transfusions

CASE NO:3

• 4Yrs old boy came with fever&pain abdomen

• O/E Abdomen---Generalised tenderness and rigidity

• AXR-Erect---Gas under diaphragm +

• Patient known Hemophiliac

• Laparotomy&ileal perforation closure was done with 1 unit of AHF

• On 2nd POD –oozing from the wound,one more unit of AHF Was given

CASE NO:4

5Yrs old boy with H/O fall over cycle bar reported with retention of urine

Perineal Hematoma&Extravasation of urine +

With difficulty catheter was passed into the bladder

Multiple Perineal incisions were made

CASE NO:4 Contd

Next day –profuse bleeding from the perineal incision sites

On subsequent interrogation parents came out with H/O previous bleeding episodes

Child was a Hemophiliac

He was treated with AHF& repeated fresh WB transfusions

Bleeding Disorders Commonly

Encounter By Surgeons

Thrombocytopenia

Thrombocytopathy

Hemophilia- A

Hemophilia- B- Christmas disease

Von Willebrand Disease

Disseminated Intravascular Coagulation

Liver Disease– Factor vii & x deficiency

THROMBOCYTOPENIA

Low Platelet Count

Acquired or Inherited

Purpura & Ecchymosis----- superficial bleeding

Labs:B.T P.C PT/PTT- N

Treatment--- Platelet Concentrates

THROMBOCYTOPATHY

� Functional Platelet Abnormality

� Acquired due to drugs like Aspirin and

Uremia

� Inherited-----Bernard Soulier Syndrome

due to defective Platelet adhesion,

Glanzman`s Thrombasthenia due to

defective Platelet aggregation

THROMBOCYTOPATHY

♦ Ecchymosis&Epistaxis------ Superficial

Hemorrhage

♦ Labs:B.T P.C—N, PT/PTT---N

♦ Treatment---Platelet Concentrates

HEMOPHILIA----A

� Factor viii procoagulant deficiency

� Sex linked recessive inheritance

� Deep tissue bleed&hemarthrosis

� Labs:B.T,P.C,P.T---N;PTT--Specific Factor Assays

� Treatment:AHF 1U/Kg raise the level by 2%.For 5Kg child 250u for 100% raise

Hemophilia-B—Christmas Disease

� Factor ix deficiency

� Sex linked recessive inheritance

� Deep tissue bleed&Hemarthrosis

� Labs:B.T,P.C,P.T—N,PTT--

Specific Factor Assays

� Treatment:Factor ix Concentrates or FFP

Von Willebrand`s Disease

� Factor viii vwf deficiency

� Autosomal Dominant Inheritance

� Epistaxis,easy bruising& prolonged

bleeding from dental extraction

� Labs:B.T P.C—N,P.T—N,PTT--

Specific Factor Assays

� Treatment: FFP or Cryoprecipitate

Disseminated Intravascular Coagulation—(D.I.C)

� Thrombohemorrhagic disorder

� Acquired:Abruptio placenta,Septic abortion,Toxemia,Gram-ve sepsis,snake bite,Massive tissue injury etc

� Activation of Coagulation Cascade—Microthrombi throughout microcirculation

� Consumption of Coagulation factors,Platelets and Fibrin

� Activation of Fibrinolytic System

Disseminated Intravascular

Coagulation--------contd

� Mucosal bleed,Ecchymosis,oozing from

wound sites

� Labs:B.T P.C PT/PTT

� T.T F.S.P Fragmented RBCs +

� Treat the underlying cause

� FFP&Platelet Concentrates

� Role of Heparin is controversial

LIVER DISEASELIVER DISEASE

� Acquired

� Factor vii& x deficiency

� Epistaxis,Menorrhagia&Hemarthrosis

� Labs:B.T—N,P.C—N, Factor x—PT/PTT

Factor vii----P.T P.T.T----N.,Specific Factors

Assay

� Treatment-------FFP

Surgery In HemophiliacsMinor Surgery

� Give dose calculated to bring patient’s plasma level to 100% 1 hour prior to surgery(50 units/kg q12h)

� Maintain plasma level above 60% for 4 days

� Maintain plasma level above 20% for subsequent 4 days

� Assay daily prior to dose

Surgery In Hemophiliacs

Major Surgery

�Give dose calculated to bring patient’s plasma level to 100% 1 hour prior to surgery(50 units/kg q12h)

�Maintain plasma level above 60% for 4 days

�Maintain plasma level above 40% for subsequent 4 days or until all drains & sutures are removed

�Assay daily prior to dose

Surgery In HemophiliacsSurgery In HemophiliacsOrthopedic Surgical ProceduresOrthopedic Surgical Procedures

•• Give dose calculated to bring Give dose calculated to bring

patient’s plasma level to 100% 1 hour patient’s plasma level to 100% 1 hour

prior to procedure (50 units/kg q12h)prior to procedure (50 units/kg q12h)

•• Maintain plasma level >80% for 4 Maintain plasma level >80% for 4

daysdays

•• Assay daily prior to doseAssay daily prior to dose

•• Maintain plasma level >40% for 4 Maintain plasma level >40% for 4

daysdays

Surgery In Hemophiliacs

Orthopedic Surgical Procedures

If patient is casted, discontinue replacement

until rehabilitation program is begun

If not casted, maintain above 20 % for

ambulation

For rehabilitation program ,maintain > 10%

for three weeks

Clinical Decision MakingClinical Decision Making

Case No:1Case No:1

� 40yrs old man c/o bleeding PR

� Colonoscopy revealed single polyp in descending colon

� Colonoscopic snare polypectomy was done

� Postop profuse bleeding+

� Labs:only B.T

� Diagnosis& Treatment ?

Clinical Decision Making

Case No:2

�3 months old congenital Biliary

Atresia baby

�Was brought with purpuric skin

lesions&oozing from gums

�Labs:PT&PTT

�Diagnosis & Treatment ?

Clinical Decision MakingCase No:3Clinical Decision MakingCase No:3

� 3 days old baby was brought with

H/O hemetemesis& melena

� O/E Well baby

� Labs: Hb –N;B.T,P.C,PT,PTT----N.

� Diagnosis--?

Clinical Decision Making

Case No:4

• 60 yrs old man a case of ESRD on

chronic hemodialysis

• Called to see him for profuse oozing

from puncture site @ AV fistula

• Labs:B.T,P.C,P.T---N,PTT&TT

• Diagnosis and Treatment?

Jump to first page

Clinical Decision Making Case No:5

� 12 yrs old girl on chronic

hemodialysis for ESRD

� Uremia developed because of

temporary interruption of

dialysis

� Developed brisk epistaxis

� Labs:BUN-164 mgms, BT>20mts

� Diagnosis & Treatment?

Clinical Decision Making

Case No:6

� 50 yrs old lady with severe burns injury became febrile & toxic

� Epistaxis, Hemetemesis & melena

�Wound Swab--Gram –ve sepsis

� Labs:BT PC PT&PTT TT

� Diagnosis & Treatment?

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