surgical hemostasis
TRANSCRIPT
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Case ConferenceCase Conference
Vincent Chen
5/26/2005
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58 yo male, history of two previous
septorhinoplasties. He has a persistent nasal
septal perforation. Presents for septal
perforation repair.
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During the course of the procedure, patient
loses 700ml of blood. There is diffuse
bleeding during elevation of the septal flaps.
The procedure is terminated, the nose is
packed and the patient is observed in the
hospital overnight.
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History
History
Bleeding from multiple sites or occasions
Spontaneous bleeding or after trauma
Easy bruising
Hematomas
Heavy periods
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Med
icat
ions
Med
icat
ions
Aspirin
NSAIDS
Supplements
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Past
Med
ical
History
Past
Med
ical
History
Liver disorders
Prior transfusions?
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Past surg
ical h
istory
Past surg
ical h
istory
Difficulty with bleeding during procedures.
Bleeding after dental work, labor,
lacerations
Prior transfusions.
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Fam
ily
History
Fam
ily
History
Familial syndromes
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Phys
ical Exam
Phys
ical Exam
Petechiae
Telangiectasias
Ecchymoses
Hemarthroses
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Different
ial d
iagnos
is
Different
ial d
iagnos
is
V
I
T
A
M
I N
C
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Platelet
Funct
ion Assay
Platelet
Funct
ion Assay
The PFA test result is dependent on plateletfunction, plasma von Willebrand Factor level,
platelet number. Anticoagulated whole blood is passed
through membranes coated with eithercollagen /epinephrine or collagen / ADP to
si
mulate thein vivo
hemodynami
csi
n thesmall capillaries. Platelets adhere to themembranes and gradually occlude a smallaperture in the center of each membrane.
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Platelet Aggregat
ion
Platelet Aggregat
ion
Adhesion
Release Reaction
Aggregation
Pro-Coagulant Activity
Platelet Fusion Growth Factors
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Platelet Aggregat
ion
Platelet Aggregat
ion
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Coagulation CascadeCoagulation Cascade
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Extrinsic SystemExtrinsic System
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Common PathwayCommon Pathway
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Coagulation CascadeCoagulation Cascade
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Hemostasis reactionsHemostasis reactions
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Von W
illebrand
Disease
Von W
illebrand
Disease
Heterogeneous disease. >20 subtypes
Abnormality or deficiency of vWF
Carrier for factor VIII, prevents its
degradation
Synthesized from endothelial wall.
0.8-1.6% of general population
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Von W
illebrand
Disease
Von W
illebrand
Disease
Bleeding times
Factor VIII activity
vWF antigen levels
vWF activity (ristocetan)
vWF multimer analysis
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Hemoph
ilia A
Hemoph
ilia A
Genetic deficiency ofFactor VIII
X linked gene product. Males only
1:10,000 males
Degrees of severity: mild to severe
Severe: spontaneous bleeding, severe bleed after
trauma Prolonged PTT, low factor VIII
Bleeding time normal
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Hemoph
ilia A
Hemoph
ilia A
Treatment:
DDAVP: releases VIII stores.
Cryoprecipitate
Factor VIII concentrates
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Hemoph
ilia B
Hemoph
ilia B
Deficiency ofFactorIX
X linked recessive
1:30,000 males
Acquired: vit K deficiency, liver disease,
coumadin
Prolonged PTT, deficient factorIX,
RX: FFP, FactorIX concentrates
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Vitam
in K
Deficiency
Vitam
in K
Deficiency
Activation ofFactors II, VII, IX, X
Sources: diet, intestinal bacteria
Coumadin is a vitamin K antagonist
RX: vitamin K, FFP
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Liver
Failure
Liver
Failure
Decrease coagulation factor synthesis
Biliary obstruction causes impaired Vit K
absorption Portal Hypertension: hypersplenism and
thrombocytopenia
Fibrinogen dysfunction DIC
RX: factor replacement
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Renal
Failure
Renal
Failure
Platelet dysfunction due to uremia
Abnormal platelet aggregation and
prolonged bleeding time
Anemia of chronic renal failure
RX: DDAVP, packed red blood cells
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Transfus
ion Syndrome
Transfus
ion Syndrome
>10 units blood over 24 hr period
Platelets and coagulation factors lose
activity over time
RX: platelet transfusion and FFP
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Platelet Abnormal
ities
Platelet Abnormal
ities
Quantitative: Thrombocytopenia
Qualitative Disorders
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Thrombocytopen
ia
Thrombocytopen
ia
Drug induced
Platelet underproduction
Hypersplenism Autoimmune: ITP
Pregnancy
HIV
Transfusion
TTP
RX platelet transfusion
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Platelet Qual
itat
iveDi
sordersP
latelet Qualitat
iveDi
sorders Drugs
Congenital Platelet Disorders
Uremia
Liver disease
RX treat underlying disease, platelets,DDAVP