Diagnosis and Management of Hemorrhage in Oral Surgery

DR MOHAMMAD AKHEEL DR MOHAMMAD AKHEEL

OMFS PG OMFS PG

What is meant by Hemorrhage ?

Prolonged or uncontrolled bleeding is often Prolonged or uncontrolled bleeding is often referred to as hemorrhage.referred to as hemorrhage.

The amount of blood lost as a result of The amount of blood lost as a result of hemorrhage can range from hemorrhage can range from minimalminimal to to significant significant quantities.quantities.

Hemorrhage in Surgery

Hemorrhage can occur to a greater or lesser Hemorrhage can occur to a greater or lesser degree during all surgical procedures and it’s degree during all surgical procedures and it’s management depends upon whether the patient is management depends upon whether the patient is hematologically normalhematologically normal or suffers from or suffers from some some disturbance in the normal clotting mechanism.disturbance in the normal clotting mechanism.

Hemorrhage in Oral Surgery

Hemorrhage in Oral Surgery

The overwhelming majority of patients who The overwhelming majority of patients who undergo oral surgical procedures are those who undergo oral surgical procedures are those who have normal haemostatic mechanism.have normal haemostatic mechanism.

Therefore, significant or major hemorrhages are Therefore, significant or major hemorrhages are not that common in oral surgery except in patients not that common in oral surgery except in patients who have a who have a bleeding / clotting disorder or those bleeding / clotting disorder or those who are on anticoagulants.who are on anticoagulants.

Hemorrhage in Oral Surgery

However, uncontrolled and persistent bleeding However, uncontrolled and persistent bleeding can occur in some healthy patients after dental can occur in some healthy patients after dental extraction.extraction.

Therefore, it is still important to achieve proper Therefore, it is still important to achieve proper hemostasis in all patients during oral surgical hemostasis in all patients during oral surgical procedures, so as to prevent excessive post-procedures, so as to prevent excessive post-operative blood loss.operative blood loss.

Normal Mechanism of Hemostasis

Hemostasis is a complicated process. Hemostasis is a complicated process.

It involves a number of eventsIt involves a number of events

Hemostasis - Normal Mechanism

1. VASCULAR PHASE

2. PLATELET PHASE

3. COAGULATION PHASE

VASCULAR PHASE

When a blood vessel is damaged, When a blood vessel is damaged,

vasoconstriction results.vasoconstriction results.

PLATELET PHASE

Platelets adhere to the damaged surface Platelets adhere to the damaged surface andand

form a temporary plug.form a temporary plug.

Through two separate pathways, the Through two separate pathways, the Intrinsic and Extrinsic, the conversion of Intrinsic and Extrinsic, the conversion of fibrinogen to fibrin is complete. Fibrin fibrinogen to fibrin is complete. Fibrin tightly binds the platelets to form a clot tightly binds the platelets to form a clot

COAGULATION PHASE

THE CLOTTING MECHANISM

INTRINSIC EXTRINSIC

PROTHROMBIN THROMBIN

FIBRINOGEN

FIBRIN(II) (III)

(I)V

X

Tissue ThromboplastinCollagen

VII

XII

XI

IXVIII

HEMOSTASIS

DEPENDENT UPON:DEPENDENT UPON:

Vessel Wall IntegrityVessel Wall Integrity

Adequate Numbers of PlateletsAdequate Numbers of Platelets

Proper Functioning PlateletsProper Functioning Platelets

Adequate Levels of Clotting FactorsAdequate Levels of Clotting Factors

Proper Function of Fibrinolytic PathwayProper Function of Fibrinolytic Pathway

Hemorrhage in Oral Surgery

Hemorrhage following Oral Surgical procedures Hemorrhage following Oral Surgical procedures can occur due to can occur due to locallocal or or systemicsystemic causes. causes.

In healthy patients the postoperative bleeding is In healthy patients the postoperative bleeding is mainly due to local causes.mainly due to local causes.

Local causes of hemorrhage in oral surgery

Local causes of hemorrhage originate in either Local causes of hemorrhage originate in either soft tissuesoft tissue or or bone.bone.

Local causes of hemorrhage in oral surgery –Soft tissue bleeding

Soft tissue bleeding is either Soft tissue bleeding is either arterialarterial, , venousvenous, or , or capillarycapillary in nature. in nature.

Local causes - Soft tissue bleeding in oral surgery

Arterial bleeding is bright red and spurting in nature.Arterial bleeding is bright red and spurting in nature.

Arteries in the soft tissues at risk during oral surgical Arteries in the soft tissues at risk during oral surgical procedures are the lies posterior portion of hard palate) procedures are the lies posterior portion of hard palate) greater palatine arterygreater palatine artery and the and the buccal arterybuccal artery (lies lateral to (lies lateral to the retromolar pad)the retromolar pad)

Local causes - Soft tissue bleeding in oral surgery

Venous blood is dark red in color and flows Venous blood is dark red in color and flows steadily and heavily especially if the vein is largesteadily and heavily especially if the vein is large..

Capillary bleeding is bright red in color and is Capillary bleeding is bright red in color and is more of a minimal ooze.more of a minimal ooze.

Local causes – Osseous (Bony) bleeding in oral surgery

Troublesome bone bleeding originates either from Troublesome bone bleeding originates either from nutrient canals in the alveolar region, central nutrient canals in the alveolar region, central vessels, such as the vessels, such as the inferior alveolar arteryinferior alveolar artery, or , or from central vascular lesions from central vascular lesions (Hemangioma or (Hemangioma or Vascular malformation)Vascular malformation)

Systemic causes of hemorrhage in oral surgery

Some patients with heriditary conditions such as Some patients with heriditary conditions such as hemophilia, Von Willebrand’s disease are susceptible for hemophilia, Von Willebrand’s disease are susceptible for hemorrhage following oral surgical procedures.hemorrhage following oral surgical procedures.

Patients with thrombocytopenia (decreased platelet Patients with thrombocytopenia (decreased platelet count) , Leukemia e.t.c., are also at risk of prolonged count) , Leukemia e.t.c., are also at risk of prolonged bleeding after surgery.bleeding after surgery.

Patients with uncontrolled hypertension.Patients with uncontrolled hypertension.

Systemic causes of hemorrhage in oral surgery

Patients with H/O prosthetic heart valve replacement, Patients with H/O prosthetic heart valve replacement, Stroke (Cerebrovascular accidentStroke (Cerebrovascular accident) e.t.c., take oral ) e.t.c., take oral anticoagulants like Aspirin or Warfarinanticoagulants like Aspirin or Warfarin to prevent the to prevent the occurrence of a thromboembolic episode. occurrence of a thromboembolic episode.

These patients are also at risk of prolonged severe These patients are also at risk of prolonged severe bleeding during and after an oral surgical procedure.bleeding during and after an oral surgical procedure.

Types of Hemorrhage - Primary Hemorrhage

This occurs during the surgery, as a result of injury like This occurs during the surgery, as a result of injury like cutting or laceration of the artery or bleeding from cutting or laceration of the artery or bleeding from bone.bone.

This also occurs when surgery is done in an infected This also occurs when surgery is done in an infected area with a lot of granulation tissue.area with a lot of granulation tissue.

It can also occur after a very short period of time It can also occur after a very short period of time immediately after surgery. immediately after surgery.

This type of bleeding is really normal and can be This type of bleeding is really normal and can be

controlled easily.controlled easily.

Types of Hemorrhage - Intermediate / Reactionary Hemorrhage

This type of bleeding occurs within a few hours after This type of bleeding occurs within a few hours after surgerysurgery..

This type of bleeding occurs as a result of failure of This type of bleeding occurs as a result of failure of coagulation to occur (as in patients with systemic coagulation to occur (as in patients with systemic bleeding problems or those on anticoagulants)bleeding problems or those on anticoagulants)

Patients who have unknowingly disturbed / dislodged the Patients who have unknowingly disturbed / dislodged the clot are also prone for this type of bleeding.clot are also prone for this type of bleeding.

Types of Hemorrhage - Secondary Hemorrhage

This occurs after This occurs after 7 to 10 days7 to 10 days after surgery. This is after surgery. This is mainly due to partial division of blood vessel in mainly due to partial division of blood vessel in combination with infection of the wound (Like patient’s combination with infection of the wound (Like patient’s who undergo radical neck dissection e.t.c.,).who undergo radical neck dissection e.t.c.,).

This type of bleeding is not very frequently encountered This type of bleeding is not very frequently encountered after oral surgery procedures.after oral surgery procedures.

Management of Primary Hemorrhage in Normal patients

The management of bleeding during surgery The management of bleeding during surgery (Primary (Primary bleeding)bleeding) can be achieved by the following means, can be achieved by the following means,

(i)(i) Securing / ligation of blood vessels with silk sutures.Securing / ligation of blood vessels with silk sutures.

(ii)(ii) Use of pressure swab to achieve hemostasis.Use of pressure swab to achieve hemostasis.

(iii)(iii) Use of electrocautery to achieve hemostasis.Use of electrocautery to achieve hemostasis.

(iv)(iv) Use of hemostatic agents like bone wax, surgicel,e.t.c.,Use of hemostatic agents like bone wax, surgicel,e.t.c.,

(v)(v) Hypotensive anaesthesia (G.A) and use of Hypotensive anaesthesia (G.A) and use of vasoconstrictors in L.A.vasoconstrictors in L.A.

Local Measures ( Synthetic Materials)

There are several materials that are commercially There are several materials that are commercially available that are used locally for achieving available that are used locally for achieving adequate hemostasis.adequate hemostasis.

Local Measures: Surgicel (Oxidised Regenerated Cellulose)

Local measures: Gelfoam with activated thrombin

Local Measures: Avitene (Microfibrillar Collagen)

Local Measures: Etik Collagen (Packed collagen)

Local Measures: Tranexamic acid 5%

Local Measures: Tranexamic acid 5% in Syringe

Local Measures: Irrigation of wound with Tranexamic acid

Local Measures: Suturing the wound

Local Measures: Pressure with oral packs

Management of Intermediate Hemorrhage in Normal patients

The management of bleeding that occurs immediately The management of bleeding that occurs immediately after surgery (Reactionary bleeding) involves proper after surgery (Reactionary bleeding) involves proper examination of the surgical wound to identify the site examination of the surgical wound to identify the site of bleeding (i.e ) from bone or soft tissue.of bleeding (i.e ) from bone or soft tissue.

(i)(i) If bleeding is from bone then the hemostatic agents If bleeding is from bone then the hemostatic agents like bone wax or gelfoam is usually used.like bone wax or gelfoam is usually used.

(ii)(ii) If bleeding is from soft tissues then, ligation / If bleeding is from soft tissues then, ligation / cauterization of blood vessels along with the use of cauterization of blood vessels along with the use of hemostatic agents like surgicel and suturing of the hemostatic agents like surgicel and suturing of the wound is carried out.wound is carried out.

Management of Secondary Hemorrhage in Normal patients

The management of this type of bleeding that occurs a The management of this type of bleeding that occurs a few days after surgery involves the removal of any debris few days after surgery involves the removal of any debris from the wound surface that promotes the infection of the from the wound surface that promotes the infection of the woundwound..

Identify the source of bleeding and treat as would be Identify the source of bleeding and treat as would be done in a patient with secondary bleeding.done in a patient with secondary bleeding.

Surgical stents can be placed over extraction sockets for Surgical stents can be placed over extraction sockets for stabilization of clot and prevention of wound stabilization of clot and prevention of wound contamination.contamination.

Management of Hemorrhage in patients with bleeding disorders / and those on anticoagulant

therapy

The usual protocol involved in the treatment of this The usual protocol involved in the treatment of this group of patients consists of pre-operative blood group of patients consists of pre-operative blood investigations and preoperative correction of the investigations and preoperative correction of the underlying deficiency (Replacement of Clotting factors / underlying deficiency (Replacement of Clotting factors / platelets) if any in these patients.platelets) if any in these patients.

Subsequently, after this appropriate local measures are Subsequently, after this appropriate local measures are used to decrease the chances of post-operative bleeding.used to decrease the chances of post-operative bleeding.

LABORATORY EVALUATION

PLATELET COUNTPLATELET COUNT BLEEDING TIME (BT)BLEEDING TIME (BT) PROTHROMBIN TIME (PT)PROTHROMBIN TIME (PT) PARTIAL THROMBOPLASTIN TIME (PTT)PARTIAL THROMBOPLASTIN TIME (PTT) THROMBIN TIME (TT)THROMBIN TIME (TT)

PLATELET COUNT

NORMAL 100,000 - 400,000NORMAL 100,000 - 400,000 CELLS/MM CELLS/MM33

< < 100,000100,000 ThrombocytopeniaThrombocytopenia

50,000 - 100,00050,000 - 100,000 Mild ThrombocytopeniaMild Thrombocytopenia

< < 50,00050,000 Severe ThrombocytopeniaSevere Thrombocytopenia

BLEEDING TIME

PROVIDES ASSESSMENT OF PLATELET COUNT AND FUNCTION

NORMAL VALUENORMAL VALUE

2-8 MINUTES2-8 MINUTES

PROTHROMBIN TIME

Measures Effectiveness of the Extrinsic PathwayMeasures Effectiveness of the Extrinsic Pathway

NORMAL VALUENORMAL VALUE

10-15 SECS10-15 SECS

PARTIAL THROMBOPLASTIN TIME

Measures Effectiveness of the IntrinsicMeasures Effectiveness of the Intrinsic

PathwayPathway

NORMAL VALUENORMAL VALUE

25-40 SECS25-40 SECS

THROMBIN TIME

Time for Thrombin To Convert

Fibrinogen Fibrin A Measure of Fibrinolytic Pathway

NORMAL VALUENORMAL VALUE

9-13 SECS9-13 SECS

Management of Hemorrhage in patients with uncontrolled hypertension.

This group of patients need appropriate medical This group of patients need appropriate medical consultation for initiation of medical treatment to consultation for initiation of medical treatment to decrease their Blood Pressure.decrease their Blood Pressure.

Thus once their B.P is controlled, then the bleeding Thus once their B.P is controlled, then the bleeding decreases and with local measures the hemorrhage is decreases and with local measures the hemorrhage is controlled.controlled.

THANK YOU THANK YOU