Hemostasis, Surgical Bleeding

and
Transfusion

Hemostasis
Hemostasis = to stop bleeding
4 Basic mechanism / phase
Vascular constriction
Platelet plug formation
Fibrin formation
Fibrinolysis

Vascular Constriction
Injury to vessel contraction smooth muscle
Mediators :
Thromboxane A2 at site of injury via release
arachidonic acid from platelet
membranpotent constrictor smooth muscle
Endothelin endhothelium+serotonin during
platelet agregation potent vasoconstictors
Tromboxane A2 (TXA2),
Bradykinin, Fibrinopeptides

Platelet Phase
Source megakaryocyt marrow
Anucleated, normaly remove by splen,average life

span 7-10 day

Integral role hemostasis : forming hemostasis
plug and contributing in thrombin formation
Injury intimal layerexposes colagen sub
endhotelial+vW factorplatelet adhere (release
ADP+serotonin)recruits other platelet from
circulating blood disrupt vessel sealed (platelet
agregationfibrinogen binding the platelet
surface & strengthens platelet interactions

PLATELET IS EXTREMELY IMPORTANT

Coagulations
Interaction endothelium + platelet +

circulating coagulations factor

Intrinsic no need for surface exposure
Extrinsic begin once vessel is disrupted
Intrinsic+extrinsic cascade merge into
common pathway on factor X
Prothrombinthrombinchange fibrinogen to
fibrin
Measurement aPTTintrinsic factor, PTT
extrinsic factor

Prothrombin circulating plasma proteins

Vit K is required for normal formation of
prothrombin in liver

Fibrinolysis
Prevent propagation of clot formation
1. feedback inhibition on the coagulation cacscade
2. fibrinolysis
Aims on reconstitution of blood flow
Initiated as the same time clotting mechanism
Main enzyme plasmincleaves fibrin + degrade

fibrinogen
tPA activates plasminogen more efficientlybound to
fibrinplasmin is formed selectively on the clot
Product : E-nodule and D-dimer
marker of thrombosis or other conditions in activation of
fibrinolysis is present

Congenital Factor
Deficiencies
Coagulation factor deficiency
Factor VIII hemofilia A
Factor IX hemofilia B
Recessive autosomal disorders affect in male
Clinical severity depend on measurable factor
VIII or IX in plasma
A. Plasma factor level < 1% : severe
B.
-1 5 % : moderate
C.
-5 30 % : mild
Platelet function still normal

Von Willebrands disease

Common congenital bleeding disorders

Autosomal dominant disorders, and primary
defect is low vWF
platelet disorders mucosal bleeding,easy
bruising.

Acquired hemostatic
defect
Platelet abnormalities could be

Quantitative or Quantitative

Acquired
hypofibrinogenemia
DIC acquired syndrome characterized by

intravascular activation of coagulation

Clotting mechanism excessive thrombin
microthrombus formation
Vasculature damage depletion and consumption
of coagulation factor and platelet diffuse
bleeding
Causative Sepsis, trauma, vascular disorder,
obstetric complications, malignancy, imunologic
disorder, drugs, snake/insect, liver disease,
shock, massive transfusion

Anticoagulation and Bleeding

Spontaneous bleeding can be complication of
anticoagulant therapi ex hematuria,soft tissue
bleeding, intracerebral bleeding, skin necrosis and
abdominal bleeding.
!!!one of the fisrt symptoms of an underlying tumor
may be bleeding in patient with nticoagulation
therapy
Rapid reversal of anticoagulation can be
accomplished with FFP in an emergent situation.

Local Hemostasis
Mechanical prosedurs

digital pressure in proximal or over

bleeding site is effective
Thermal agent
achieves hemostasis by denaturation of
protein result in coagulation
negative grounding plate should be place
beneath the patient ti avoid severe skin burn
Topical hemostasis
thrombin derivate product direct te
conversion of fibrinogen to fibrin

Transfusion
1. Human red cell membrane : least 300

different antigen
2. fortunately, only the ABO and the Rh
systems are important in the majority of
blood transfusion
3. History
Infection : Hepatitis B,C syphillis HIV-1,2
HTLV-I,II

Due to surgery or trauma not necessarily

require transfusion
Improvement in Oxygen-Carrying Capacity
Treatment of Anemia
Volume replacement
Below 7 g/dL widely accepted

Whole Blood

Banked
Reduce of intracelluler ADP & 2,3
disphosphoglycerate decrease oxygen transport
Clotting factor relatively stable advantage
Elevated lactate, potassium and amonium
Volume replacement
Fresh
Administered within 24 hours of its donation

Packed Red Cells

Choice for most clinical situation

Concentrate suspensions of red blood cells can
prepared by removing most of supernatant
plasma after centrifuge reduce reaction by
plasma component

Red Blood Cells

Ideal for patients requiring red cells but not

volume replacement

Only one Increase O2 carrying

capacity
AGE
Neonates
Premature
Full-term
Infants
Adults
Men
Women

BLOOD VOLUME
95 ml/kg
85 ml/kg
80 ml/kg
75 ml/kg
65 ml/kg

By Centrifugation removing supernatant

plasmareduce reaction caused by plasma
comp
One unit increse approximately 1 g/dL
PRC Formula:
PRC volume = 3.3 x ( Hb) x BW

The indications thrombocytopenia qualitative and

quantitative c.b massive bloods loss and replacement with

Platelet
platelet-poor products,inadequate platelet production
* prophylactic : plt.counts below 10,000-20,000
* prophylactic preoperative : plt.counts below 50,000
*Microvascular bleeding in surgical patient with platelets
< 50,000
*Neuro/ ocular surgery > 75,000
One unit = 50 mL
Targeted therapy to 50,000 - 100,000/L
Increasing 10.000 60.000
Recently platelets tranfussion tresholds can safely
lowered in patients who have no signs of hemostatic
deficiency and no history of poor tolerance to low
platelets count

FFP
Resuscitation trauma-associated

coagulopathy
Source of the vitamin K-dependent factor and
is the only source factor V

Indications for Replacement

1. improvement in oxygen-carrying capacity
2. treatment of anemia
3. volume replacement

and

Preoperative Evaluation of hemostasis

Hb level < 7 gr/dl associated more

complications
Consider factor : presence cardiopulmonary
disease, type of surgery, likelihood of surgical
blood loss
IMPORTANT directed bleeding history and
phisical examination occult bleeding disorder
If (+) performed measurement PT,aPTT,
and platelet count

Evaluation of Excessive Intraoperative

Bleeding during or post operative

innefecctive hemostasis,blood transfusion,

undetected hemostasis defect, consumptive
coagulopaty, and or fibrinolysis.
Massive blood tranfusion trombocytopenia
dilutional coagulopaty

THANK
YOU