Management of haemorrhage in OS

Question 1

What is primary haemorrhage?

Answer 1

Bleeding at the time of surgery - blood stained saliva 12-24 hours post surgery

Question 2

What is reactionary haemorrhage?

Answer 2

Bleeding usually occurs 2-3 hours post XLA as the LA vasoconstrictor wears off - call 111

Question 3

What is secondary haemorrhage?

Answer 3

Up to 14 days after the surgery - most likely cause of this is infection

Question 4

What are the stages of blood clotting?

Answer 4

Vasoconstriction - vascular spasm in smooth muscle in the walls of blood vessels

Platelet plug formation - adhesion, interaction and aggregations of platelets

Coagulation cascade - clotting factors in the extrinsic, intrinsic and common pathways leading to the formation of fibrin

Question 5

What is fibrinolysis?

Answer 5

Occurs when plasma enzyme plasminogen activates plasmin which digests the fibrin threads in the clot

Question 6

Where are the majority of clotting factors produced?

Answer 6

Liver

Question 7

Where are the platelets produced?

Answer 7

Red bone marrow

Question 8

Where do the intrinsic and extrinsic clotting factor pathways converge?

Answer 8

Clotting factor X

Question 9

What happens after the clotting pathways converge?

Answer 9

Factor V plus Ca convert prothrombin to thrombin which intern, converts fibrinogen to fibrin (network which stabilises a clot alongside platelets in a plug)

Question 10

What clotting factor deficiencies can cause post operative bleeds?

Answer 10

Haemophilia A - factor 8
Haemophilia B - Factor 9
vWF disease - affects platelet adhesion and causes factor 8 deficiencies
Vit K deficiencies - factor 2, 7, 9 and 10

Question 11

What acquired liver diseases can cause clotting issues?

Answer 11

Hepatitis/cirrhosis
History of alcohol XS

Question 12

Which thrombocytopenic diseases cause clotting issues?

Answer 12

Immune idiopathic thrombocytopenia ITP
Secondary disease - to leukaemia
Drug induced antiplatelet therapy

Question 13

Which vascular anomolies can cause post op bleeds?

Answer 13

Arterio-venous malformations
Hereditary haemorrhagic telangiectasia
Collagen disorders

Question 14

How to treat pts with haemophilia?

Answer 14

X linked disorder
Factor replacement
Fresh frozen plasma
Replacement factors and proteins

Question 15

How to treat vWF sufferers?

Answer 15

vWF - protein required for platelet aggregation
Protects factor 8 from rapid breakdown
Factor 8 deficiencies requiring replacement

Question 16

Which complications arise from having cirrhosis and hepatitis?

Answer 16

Varices which can lead to bleeds and anaemia

Question 17

What are the causes of thrombocytopenia?

Answer 17

150-400 x 10^9/L
Drug induced, e.g. NSAIDs/ alcohol, heparin
Aplastic anaemia
Immune driven (idiopathic)
EBV/HIV

Question 18

How to manage patients on vit K antagonists

Answer 18

Warfarin, acencoumarol, phenindione

Check INR no more than 24 hours before procedure (up to 72hrs if patient is stably coagulated)

If INR is below 4 - treat without interruption of meds
Stage Tx
Consider suture and packing

If above 4 - delay tx and refer

Question 19

How does warfarin work?

Answer 19

Inhibits vit k dependant synthesis of biologically active forms of the clotting factors 1,8,9 and 10 as well as the regulatory factor proteins

Blocking enzyme called vit k epoxide reductase

Question 20

How does aspirin work? (acetylsalicylic acid)

Answer 20

NSAID which suppresses platelet fn by blocking formation of thromboxane A2 in platelets producing an inhibitory affect on platelet aggregation during the 8-9 day lifespan of platelet.

Also inhibitors COX 1 and COX 2 which reduce the production of proinflammatory prostaglandins

Question 21

What local measure should be taken in aspirin alone users?

Answer 21

Pack and suture
Stage tx
Extensive or complex procedures

Question 22

How does clopidogrel work?

Answer 22

antiplatelet meds that reduce risk of MI and stroke
Can be prescribed with aspirin - dual antiplatelet therapy following coronary stent placement
Irreversibly inhibits adenosine diphosphate (ADP) receptor which is important for platelet activation and cross linking of fibrin

Question 23

Which other medications work similarly to clopidogrel?

Answer 23

Ticagrelor and prasugrel

Question 24

How do DOACs work?

Answer 24

Dabigatrin

Reversibly bind to active site on thrombin preventing thrombin mediated activation of coagulation factors and may enhance fibrinolysis

Question 25

How do apixaban and rivaroxaban work?

Answer 25

Direct inhibitors of factors Xa
Do not require INR monitoring

Question 26

What measures are taken for a low bleeding risk?

Answer 26

Treat without interruption to medss

Question 27

What steps are taken for higher bleeding risk patients?

Answer 27

Advise patients to delay/miss morning dose

Question 28

Which meds are taken 2x/day?

Answer 28

Apixaban and dabigatrin

Question 29

How long after XLA can rivaroxaban be taken?

Answer 29

4hrs post haemostats

Question 30

What are the subtle signs of leukaemia

Answer 30

Purpura of the palate
Bleeding gingival margins

Question 31

How to manage post op bleeds

Answer 31

Good light and assistance
Irrigation of socket with 0.9% saline
Suction and remove liver clot to visualise bleed

Apply pressure with damp gauze
Administer LA with adrenaline
Pack with surgicel/fibrin blocks
Silver nitrate/diathermy to bleeding points
Bone wax - possible foreign body reaction
Suture well - horizontal mattress suture/ X stitch
5% tranexamic acid soaked gauze - 1g IV

Discuss with haem/cardiology
Systemic signs and fluid resuscitation

Question 32

When would silver nitrate be used?

Answer 32

Difficult to apply finger pressure or suture

e.g. mucosal biopsy hard palate or retromolar pad

After a few mins, agent should be deactivated by swabbing area with saline to avoid damage to surrounding structures

Question 33

What are the alternatives to surgicel?

Answer 33

Haemocollagen, gelfoam, kaltostat

Question 34

How does tranexamic acid work?

Answer 34

5% mouthwash can be used in planned cases e.g. haemophilia or in cases with persistent bleeding.

Antifibrinolytic - binds to plasminogen and therefore reduces clot breakdown

Given orally pre/post op or IV