Surgeons are doing surgeries because of normal blood clotting and wound healing. Suppose if your patient’s blood doesn’t clot properly and you come to know this only on the table, it would be a nightmare to any surgeon irrespective of their subspecialty. In this PPT, I am discussing about how to handle a patient with bleeding diathesis during and after surgery. Indeed it is a challenging and fascinating problem. I hope you will enjoy the video. You can watch all my teaching videos in the following links: surgicaleducator.blogspot.com; youtube.com/c/surgicaleducator.

1. SURGERY IN BLEEDING
DIATHESIS
Dr.B.Selvaraj MS;Mch;FICS;
Professor of Surgery
Melaka Manipal Medical College
Melaka 75150 Malaysia

2. SURGERY IN BLEEDING
DIATHESIS
 Introduction
 Physiology Of Hemostasis
 Pre-op Evaluation
 Cases Managed
 Common Bleeding Disorders
 Surgery In Hemophiliacs
 Clinical vignettes
PLAN

3. SURGERY IN BLEEDING
DIATHESIS
 A challenging & fascinating problem
 Pre-existing hemostatic defects can be detected
with proper H&P and screening lab tests
 Occasionally the first sign of the defect would be
excessive intra-op bleeding
 Nightmare to any surgeon

4. SURGERY IN BLEEDING
DIATHESIS

5. PHYSIOLOGY OF
HEMOSTASIS
FOUR COMPONENTS:
 VESSEL WALL RESPONSE
 PLATELET ACTIVITIES
 COAGULATION CASCADE
 FIBRINOLYTIC SYSTEM

6. PHYSIOLOGY OF
HEMOSTASIS
 VESSEL WALL RESPONSE
- Intact endothelium maintain fluidity of blood
- Endothelial disruption initiates hemostasis
 PLATELET ACTIVITIES
- Adhesion to denuded endothelium by VWBF
- Aggregation into an unstable mass by
fibrinogen&Thromboxane A2

7. PHYSIOLOGY OF
HEMOSTASIS
PLATELET
ACTIVITIES

8. COAGULATION FACTORS

9. COAGULATION PATHWAY

10. FIBRINOLYTIC SYSTEM

11. PRE-OPERATIVE
EVALUATION
 Thorough personal medical history, family history& drug
ingestion history
 Physical Exam:
 Skin: Petechiae Thrombocytopenia
Ecchymosis & Hematomas Platelet dysfunction
 Joints: Hemarthrosis severe coagulation defect
 Organomegaly: Hepatomegaly Coagulopathy of Cirrhosis
Spleenomegaly Possible thrombocytopenia

12. PRE-OPERATIVE
EVALUATION

13. LAB SCREENING
TESTS

15. CASE NO: 1
 2 Yrs old 1st born male child was brought with obstructed RIH
 H/O Epistaxis & easy bruisability
 Ear boring ceremony resulted in prolonged bleeding
 Emergency, so extensive workup was not done
 Emergency herniotomy was done

16. CASE NO: 1
 Basic screening tests for bleeding diathesis:
 Hb  11Gms
 Bleeding time >15mts
 Prothrombin time 12 sec
 Partial thromboplastin time 39 sec
 Blood group B +ve

17. CASE NO: 1
 Only B.T. was prolonged
 Provisional Diagnosis: Functional Platelet problem
-Thrombocytopathy
 Emergency Herniotomy with 200 ml of fresh whole blood
 Readmitted after 10 days for prolonged bleeding from a small
cut to upper lip
 Managed by multiple WB transfusions

18. CASE NO: 1
 Hematological workup:
 Hb 11.5 GMs
 PCV 36%
 TC 12000/Cmm
 DC P33,L43,E18, M4
 Platlets200,000/
 Bleeding time > 15 mts
Clotting time13 mts
 Clot retraction Nil
 Clot lysis Nil
 PT 12 sec
 PTT 40 sec
 Plasma fibrinogen 280 mgms
 Factor xiii activity normal

19. CASE NO: 1
 PLATELET FUNCTION TESTS:
-Invivo Platelet Adhesion10.8%
-ADP Aggregation Absent
Aggregometer Studies
-ADP No Aggregation
-Collagen No Aggregation
 Thrombin Time 8sec
 Blood group B+ve

20. CASE NO: 1
 Normal Platelet count&morphology
 Normal Clotting tests
 Prolonged Bleeding Time
 Absent Platelet Aggregation with ADP and Collagen
 Absent Clot Retraction
 GLANZMAN`S THROMBASTHENIA

21. CASE NO: 2
 11 yrs old boy with no known H/O any bleeding diathesis
underwent emergency appendicectomy
 He started oozing from the operated site in immediate post-
operative period
 In subsequent interrogation parents came out with the H/O
ingestion of aspirin tablet by the boy
 Labs: BT- prolonged; PT, PTT- Normal; Platelet count- Normal
 Since this is a functional disorder of Platelets(Thrombocytopathy)
the boy was treated with Platelet concentrate

22. CASE NO: 3
 4 yrs old boy was brought with pain abdomen and fever for 1 day
 O/E: Abdomen- diffuse tenderness with rigidity
 AXR- erect revealed free gas under diaphragm
 Boy is a known Hemophiliac
 Laparotomy and ileal perforation closure was done with Anti
hemophilic factor
 On 2nd POD boy was oozing from the surgical site. So factor8
assay was done in hematology lab and dose of AHF was adjusted.

23. CASE NO: 4
 5 yrs old boy with a H/O fall over cycle bar presented with
retention of urine
 O/E: Drop of blood at uretheral meatus, perineal hematoma and
extravasation of urine were present
 Emergency SPC was done after confirming rupture urethra with
Retrograde urethrogram
 The next day the boy started bleeding from SPC site
 On subsequent interrogation parents told the boy is a known
Hemophiliac
 He was managed with AHF

24. Hematological Disorders Commonly
Encounter by surgeons
 Thrombocytopenia
 Thrombocytopathy
 Hemophilia- A
 Hemophilia- B- Christmas disease
 Von Willebrand Disease
 Disseminated Intravascular Coagulation
 Liver Disease– Factor vii & x deficiency

25. THROMBOCYTOPENIA
 Low Platelet Count
 Acquired or Inherited
 Purpura & Ecchymosis superficial bleeding
 Labs: BT- prolonged, PC- decreased, PT, PTT- Normal
 Treatment: Platelet concentrates

26. THROMBOCYTOPATHY
 Functional Platelet Abnormality
 Acquired due to drugs like Aspirin and Uremia
 Inherited Defective Platelet adhesion Bernard Soulier
Syndrome
Defective Platelet aggregation Glanzman’s
Thrombasthenia
 Labs: BT- Prolonged; PC,PT,PTT Normal
 Ecchymosis & Epistaxis Superficial hemorrhage
 Treatment: Platelet concentrates

27. HEMOPHILIA- A
 Factor viii procoagulant deficiency
 Sex linked recessive inheritance
 Deep tissue bleed & hemarthrosis
 LABS: PTT- Prolonged; PC,PT,BT- Normal
Individual factor assay
 Treatment: AHF- 1U/Kg raises the level by 2%
For 5 Kg baby 250U for 100% raise
Cryoprecipitate & FFP

28. HEMOPHILIA- B
 Factor ix deficiency Christmas disease
 Sex linked recessive inheritance
 Deep tissue bleed&Hemarthrosis
 LABS: PTT- Prolonged; BT,PC,PT- Normal
Individual factor assay
 Treatment: Factor 9 concentrates or FFP

29. VON WILLEBRAND’S
DISEASE
 Factor viii vwf deficiency
 Autosomal Dominant Inheritance
 Epistaxis, easy bruising and prolonged bleeding from
dental extraction
 LABS: BT & PTT- Prolonged; PC,PT- Normal
Individual factor assay
 Treatment: Cryoprecipitate or FFP or DDAVP

30. Disseminated Intravascular
Coagulation
 Thrombohemorrhagic disorder
 Acquired: Abruptio placenta, septic abortion, toxemia,
Gram-ve sepsis, massive tissue injury, snake bite Etc
 Activation of coagulation cascade Microthrombi
throughout the micro circulation
 Consumption of coagulation factors, platelets and
fibrin
 Activation of fibrinolytic system

31. Disseminated Intravascular
Coagulation
 Mucosal bleeding, oozing from wound sites and
ecchymosis
 LABS: BT,PC,PT,PTT,TT- all prolonged; FDP- increased
 Treat the underlying causes
 FFP & Platelete concentrates

32. Advanced Liver Disease
 Acquired
 Factor vii & x deficiency
 Epistaxis, Menorrhagia and Hemarthrosis
 LABS: BT,PC- normal; Factor x  PT,PTT both elevated
Factor vii PT- Prolonged; PTT- Normal;
Specific factor assays
 Treatment: FFP & Vitk

33. Treatment Algorithm

34. Surgery in Hemophiliacs
 Give Factor viii, dose calculated to bring patient’s plasma level to
100% 1 hour prior to surgery(50 units/kg q12h); Assay daily prior to
dose
 For Minor Surgery: Maintain plasma level > 60% for 1st 4days
Maintain plasma level > 20% for next 4days
 For Major Surgery: Maintain plasma level > 60% for 1st 4days
Maintain plasma level > 40% for next 4 days
 For Orthopedic Surgery: Maintain plasma level > 80% for 1st 4days
Maintain plasma level > 40% for next 4 days

35. Case Vignette 1
 40yrs old man c/o bleeding PR
 Colonoscopy revealed single polyp in descending colon
 Colonoscopic snare polypectomy was done
 Postop profuse bleeding+
 Labs: only B.T is prolonged; PC,PT,PTT- Normal
 Diagnosis& Treatment ?
 Answer: Diagnosis Thrombocytopathy due to aspirin ingestion
Treatment Platelet concentrates

36. Case Vignette 2
 3 months old congenital Biliary Atresia baby
 Was brought with purpuric skin lesions&oozing from gums
 Labs: PT&PTT- prolonged; BT,PC- Normal
 Diagnosis & Treatment ?
 Answer: Diagnosis Advanced liver disease
Treatment FFP & individual factors x & vii

37. Case Vignette 3
 3 days old baby was brought with H/O Hemetemesis & Melena
 O/E Well baby
 Labs: Hb –N; B.T,P.C,PT,PTT -Normal
 Diagnosis ?
 Answer: Normal baby- No pathology
Baby swallowed maternal blood during labour
and subsequently vomiting the same.
No need for any treatment

38. Case Vignette 4
 60 yrs old man a case of ESRD on chronic hemodialysis
 Called to see him for profuse oozing from puncture site @ AV fistula
 LABS: BT,PC,PT- normal; PTT, TT- prolonged
 Diagnosis and Treatment?
 Answer: Diagnosis: Heparin overdosage
Treatment: Protamine 1mgm counter 1 unit of heparin

39. Case Vignette 5
 12 yrs old girl on chronic hemodialysis for ESRD
 Uremia developed because of temporary interruption of dialysis
 Developed brisk epistaxis
 Labs:BUN-164 mgms, BT>20mts
 Diagnosis & Treatment?
 Answer: Diagnosis: Thrombocytopathy due to uremia
Treatment: Platelet concentrates

40. Case Vignette 6
 50 yrs old lady with severe burns injury became febrile & toxic
 Epistaxis, Hemetemesis & melena
 Wound Swab Gram –ve sepsis
 Labs: BT,PC,PT&PTT,TT- all are prolonged
 Diagnosis & Treatment?
 Answer: Diagnosis: DIC
Treatment: FFP

41. THANK
YOU
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