Prolonged or uncontrolled bleeding is often referred to as
hemorrhage.
The amount of blood lost as a result of hemorrhage can range from minimal
to significant quantities.
Hemorrhage in Surgery
Hemorrhage can occur to a
greater or lesser degree during all surgical procedures and it’s management
depends upon whether the patient is hematologically normal or suffers from some
disturbance in the normal clotting mechanism.
The overwhelming majority of patients who undergo oral surgical
procedures are those who have normal haemostatic mechanism.
Therefore, significant or major hemorrhages are not that common in
oral surgery except in patients who have a bleeding / clotting disorder or
those who are on anticoagulants.
However, uncontrolled and persistent bleeding can occur in some
healthy patients after dental extraction.
Therefore, it is still important to achieve proper hemostasis in
all patients during oral surgical procedures, so as to prevent excessive
post-operative blood loss.
Normal Mechanism of Hemostasis
Hemostasis is a complicated process.
It 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, vasoconstriction results.
Platelet phase
Platelets adhere to the damaged surface an form a temporary plug.
Through two separate pathways, the Intrinsic and Extrinsic,
the conversion of fibrinogen to fibrin is complete. Fibrin tightly binds the
platelets to form a clot
Coagulation
phase
The clotting
mechanism
Hemostasis
Dependent upon:
- Vessel Wall Integrity
- Adequate Numbers of Platelets
- Proper Functioning Platelets
- Adequate Levels of Clotting Factors
- Proper Function of Fibrinolytic Pathway
Hemorrhage in Oral Surgery
Hemorrhage following Oral Surgical procedures can occur due
to local or systemic causes.
In healthy patients the postoperative bleeding is mainly due
to local causes.
Local causes of hemorrhage in oral surgery
Local causes of hemorrhage originate in either soft tissue
or bone.
Local causes of hemorrhage in oral surgery –Soft tissue bleeding
Soft tissue bleeding is either arterial, venous, or capillary
in nature.
Arterial bleeding is bright red and spurting in nature.
Arteries in the soft tissues at risk during oral surgical
procedures are the lies posterior portion of hard palate) greater palatine
artery and the buccal artery (lies lateral to the retromolar pad)
Venous blood is dark red in color and flows steadily and
heavily especially if the vein is large.
Capillary bleeding is bright red in color and is more of a
minimal ooze.
Local causes – Osseous (Bony) bleeding in oral surgery
Troublesome bone bleeding originates either from nutrient
canals in the alveolar region, central vessels, such as the inferior alveolar
artery, or from central vascular lesions (Hemangioma or Vascular malformation)
Systemic causes of hemorrhage in oral surgery
Some patients with heriditary conditions such as hemophilia,
Von Willebrand’s disease are susceptible for hemorrhage following oral surgical
procedures.
Patients with thrombocytopenia (decreased platelet count) ,
Leukemia e.t.c., are also at risk of prolonged bleeding after surgery.
Patients with uncontrolled hypertension.
Patients with H/O prosthetic heart valve replacement, Stroke
(Cerebrovascular accident) e.t.c., take oral anticoagulants like Aspirin or
Warfarin to prevent the occurrence of a thromboembolic episode.
These patients are also at risk of prolonged severe bleeding
during and after an oral surgical procedure.
Types of Hemorrhage - Primary Hemorrhage
This occurs during the surgery, as a result of injury like
cutting or laceration of the artery or
bleeding from bone.
This also occurs when surgery is done in an infected area
with a lot of granulation tissue.
It can also occur after a very short period of time immediately after surgery.
This type of bleeding is really normal and can be controlled
easily.
Types of Hemorrhage - Intermediate / Reactionary Hemorrhage
This type of bleeding occurs within a few hours after
surgery.
This type of bleeding occurs as a result of failure of
coagulation to occur (as in patients with systemic bleeding problems or those
on anticoagulants)
Patients who have unknowingly disturbed / dislodged the clot
are also prone for this type of bleeding.
Types of Hemorrhage - Secondary Hemorrhage
This occurs after 7 to 10 days after surgery. This is mainly
due to partial division of blood vessel in combination with infection of the
wound (Like patient’s who undergo radical neck dissection e.t.c.,).
This type of bleeding is not very frequently encountered
after oral surgery procedures.
Management of Primary Hemorrhage in Normal patients
The management of bleeding during surgery (Primary bleeding)
can be achieved by the following means,
- Securing / ligation of blood vessels with silk sutures.
- Use of pressure swab to achieve hemostasis.
- Use of electrocautery to achieve hemostasis.
- Use of hemostatic agents like bone wax, surgicel,e.t.c.,
- Hypotensive anaesthesia (G.A) and use of vasoconstrictors in L.A.
Local Measures ( Synthetic
Materials)
There are several materials that are commercially available
that are used locally for achieving
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 after
surgery (Reactionary bleeding) involves proper examination of the surgical
wound to identify the site of bleeding (i.e ) from bone or soft tissue.
If bleeding is from bone then the hemostatic agents like
bone wax or gelfoam is usually used.
If bleeding is from soft tissues then, ligation /
cauterization of blood vessels along with the use of hemostatic agents like
surgicel and suturing of the wound is carried out.
Management of Secondary Hemorrhage in Normal patients
The management of this type of bleeding that occurs a few
days after surgery involves the removal of any debris from the wound surface
that promotes the infection of the wound.
Identify the source of bleeding and treat as would be done
in a patient with secondary bleeding.
Surgical stents can be placed over extraction sockets for
stabilization of clot and prevention of
wound contamination.
Management of Hemorrhage in patients with bleeding disorders / and those on
anticoagulant therapy
The usual protocol involved in the treatment of this group
of patients consists of pre-operative blood investigations and preoperative
correction of the underlying deficiency (Replacement of Clotting factors /
platelets) if any in these patients.
Subsequently, after
this appropriate local measures are used to decrease the chances of
post-operative bleeding.
Laboratory evaluation
- Platelet count
- Bleeding time (bt)
- Prothrombin time (pt)
- Partial thromboplastin time (ptt)
- Thrombin time (tt)
Platelet count
Normal 100,000 - 400,000 cells/mm3
< 100,000 Thrombocytopenia
50,000 - 100,000 Mild
Thrombocytopenia
< 50,000 Severe
Thrombocytopenia
Provides assessment of platelet count
and function
Normal value
2-8 MINUTES
Prothrombin
time
Measures Effectiveness
of the Extrinsic Pathway
Normal value
10-15 SECS
Partial thromboplastin time
Measures
Effectiveness of the Intrinsic Pathway
Normal value
25-40 SECS
Thrombin time
Time for
Thrombin To Convert Fibrinogen to Fibrin
A Measure of Fibrinolytic Pathway
Normal value
9-13 SECS
Management of Hemorrhage in patients with uncontrolled
hypertension.
This group of patients need appropriate medical consultation
for initiation of medical treatment to decrease their Blood Pressure.
Thus once their B.P is controlled, then the bleeding
decreases and with local measures the hemorrhage is controlled.
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