6.hemostasis

what is hemostasis,mechanism,various hemostatic agents used

1. GOOD MORNING….. 1

2. Management of intraoral bleeding during surgery seminar on PRESENTER: PUNIT DEPARTMENT OF PERIODONTICS 2

3. CONTENTS INTRODUCTION HEMOSTATSIS ADVERSE EFFECTS OF SURGICAL BLEEDING FACTOR INFLUNCING SURGICAL BLEEDING WHY USE HEAMOSTATIC AGENTS CHARECTERISTICS OF IDEAL HEMOSTATIC AGENTS METHODS OF HEMOSTATIS CONCLUSION REFERENCE 3

4. Introduction 4

5. There are 3 mechanisms that work together to stop the flow of blood. They are :- Vasoconstriction Platelet plug formation Clotting of blood Hemostasis 5

6. Vasoconstriction 6

7. Platelet plug formation 7

8. Clotting of blood 8

9. COAGULATION CASCADE 9

10. 10

11. The best management of intraoperative hemorrhage is prevention. This includes a thorough preoperative patient history, necessary medical consults, familiarity with managing patients with possible bleeding diathesis, meticulous intraoperative technique, and appropriate postoperative instructions, care, and followup . 11

12. During oral surgical procedures, persistent minor oozing of blood is common, although occasionally a bleeding episode prevents the continuation of the procedure and requires immediate attention. The usual sources for this intraoperative complication are incision into an area of granulomatous tissue, vessels in the periosteum or mucosa, or encountering nutrient arteries in the alveolar bone. 12

13. The dentist should be familiar with the range of methods, techniques, materials, and their application during different types of bleeding episodes. Having a broad knowledge of the management approaches will allow the clinician to know when to apply a particular approach. One of the more common methods of intraoperative hemorrhage control involves the use of a topical hemostatic agent 13

14. Factors influencing Surgical bleeding 14

15. Visual obstruction of the surgical field Need for blood transfusions Reduction in core temperature Thrombocytopenia Hypovolemic shock Adverse effects of Surgical bleeding 15

16. 16

17. Factors in Choosing a Hemostatic Agent 17

18. Characteristics of an Ideal hemostatic agents for clinical use: (1) capability to stop large vessel arterial and venous bleeding within minutes of application when applied to an actively bleeding wound through a pool of blood; (2) no requirement for mixing or pre-application preparation; (3) simplicity of application (4) light weight and durable; (5) long shelf life in extreme environments; (6) safe to use with no risk of injury to tissues or transmission of infection; (7) cost-effective 18

19. The techniques for local hemostasis may be classified as Mechanical Thermal Chemical 19

20. Mechanical methods Pressure Use of hemostats Sutures and ligation Embolisaton of vessels 20

21. Application of pressure basically counteracts hydrostatic pressure within the bleeding vessel until such time that a clot can form and occlude the bleeding orifice. Pressure is usually able to control most of the hemorrhages . Pressure should be appied directly over the bleeding site firmly over a guaze packfor atleast five minutes. Pressure 21

22. Use of hemostats (also called a  hemostatic clamp, arterial forceps,) Haemostat ( mosquito,artery ) forces are specially designed to catch bleeding points in the surgical area.these can be straight or curved. Curved haemostats are used more frequently,because of their versatility and ease in tying the ligature around the tip of forceps. Hemostats 22

23. Transected blood vessel may need to be tied with the help of a ligature. When large artery needs to be ligated,nonabsorbable material like 3-0 black silk is preferred. Smaller vessels can be ligated with 3-0 catgut,or polyglactin . Large pulsatile artery ligated with double transfixation . Sutures and ligation 23

24. Embolization of the vessels With the help of angiography ,the exact bleeding point can be localized. Agents which can be used for embolization include steel coils, polyvinyl alcohol foam , gel foam, silicon spheres, methyl methacrylate. These particles are placed via a catheter superselectively into the bleeding vessel . 24

25. Thermal agents Cautery Electrosurgery Cryosurgery Argon-beam coagulator Lasers 25

26. Heat achieves haemostasis by denaturation of proteins which results in coagulation of large areas in the tissue. In cauterization, heat is transmitted from the instrument by conduction directly to the tissues. Cautery 26

27. In electrocautery,heating occurs by induction from an alternating current source.it is an effective and convenient way of controlling hemorrhage . Electrocautery can be applied directly to bleeding point or after catching the bleeding point with haemostat.then cautery pont is touched to the haemostat causing of the vessel through the action of heat. Electrosurgery 27

28. The argon beam coagulator (ABC) delivers radiofrequency electrical energy to tissue across a jet of argon gas, providing noncontact, monopolar , electrothermal hemostasis . In this ,coagulator monopolar current is transmitted to the tissues through the flow of argon gas which allows bleeding from vessels that are smaller than 3mm in diameter to be controlled without use of haemosats or ligatures. Argon-beam coagulator 28

29. Lasers usually result in bloodless surgery ,as these effectively coagulate the small blood vessels during cutting of tissues Argon laser provides excellent hemostasis and coagulation Lasers 29

30. Chemical methods Astringent agents and styptics Bone wax Thrombin Gelfoam Oxycel Surgicel Fibrin glue Adrenaline others 30

31. Adrenaline or epinephrine,applied topicaly induces vasoconstriction and thus helps in acheiving hemostasis. Extensive application or undiluted preparation can cause systemic effects therefore ,care should be exercised while using adrenaline. It can also be injected along with local anesthetic in a concentration of 1:80,000 to 1:2,00,000 Adrenaline 31

32. Chemical agents vary in their hemostatic actions. Monsel’s solution contains Ferric sulphate and it acts by precipitating proteins.It is quite effective in arresting capillary bleeding. Tannic acid also helps in precipitating proteins. Mann hemostatic is a mixture of tannic acid,alum and chlorbutamol . Silver nitrate and ferric chloride are used in case of minimal capillary bleeding Astringent agents and styptics 32

33. Is a mixture of beeswax (70%) and Vaseline (30%). Used to help mechanically control bleeding from bone surfaces during surgical procedures. It is a non-absorbable material,becoming soft and malleable in the hand when warmed an is most commonly supplied in sterile sticks Bone wax 33

34. Topical use of thrombin acts by converting fibrinogen into.fibrin clot Topical thrombin indicated as an aid to hemostasis whenever oozing blood and minor bleeding from capillaries and small venules is accessible and control of bleeding by standard surgical techniques (such as suture, ligature or cautery ) is ineffective or impractical. Thrombin 34

35. Gelfoam sterile powder is a fine, dry, heat-sterilized light powder prepared by milling absorbable gelatin sponge. It is a water- insoluble,off -white, nonelastic , porous, pliable product While its mode of action is not fully understood, its effect appears to be more physical than the result of altering the blood clotting mechanism. Gelfoam 35

36. Gelfoam / Surgifoam Absorbable Gelatin SURGIFOAM Absorbable Gelatin Powder GELFOAM Absorbable Gelatin Sponge SURGIFOAM Absorbable Gelatin Sponge 36

37. 37 When not used in excessive amounts,Gelfoam is absorbed completely, with little tissue reaction When placed in soft tissues, Gelfoam is usually absorbed completely in from 4 to 6 weeks, without inducing excessive scar tissue. This absorption is dependent on several factors, including : The amount used Degree of saturation with blood or other fluids Site of use.

38. Usage 38 Gelfoam should be cut to the minimum size required to attain hemostasis. Gelfoam may be applied dry or saturated with a physiologic saline solution. When applied dry, Gelfoam should be manually compressed before application to the bleeding site. When used with saline, Gelfoam should be soaked in the solution, then withdrawn, squeezed between gloved fingers to expel air bubbles present in the interstices, replaced in saline, and kept there until needed. Gelfoam should be applied to the bleeding surface and held in place with moderate pressure until hemostasis is attained It is not necessary to apply suction to Gelfoam, since Gelfoam will draw up blood into its interstices by capillary action

39. Gelfoam should not be used in closure of skin incisions because it may interfere with healing of the skin edges. This is due to mechanical interposition of gelatin and is not secondary to intrinsic interference with wound healing. Gelfoam should not be placed in intravascular compartments, because of the risk of embolization. Contra-Indications: 39

40. Flowable Gelatin Composition( combination of two independent agents and consists of bovine-derived gelatin granules coated in human-derived thrombin that works in combination to form a stable clot at the bleeding site) Animal-derived gelatin mixed with thrombin (or saline) in a flowable consistency Mode of action Gelatin provides a matrix for platelet adhesion and aggregation Thrombin aids in fibrin clot formation Will not work if the area is not actively bleeding 40

41. Flowable Mechanism of Action A pplied to the tissue surface at the base of the lesion. Its granules fill the wound and conform to its shape. G ranules expand approximately 20% within about 10 min and restrict the flow of blood. Blood that percolates through the spaces is exposed to high concentrations of thrombin. A clot forms around the matrix provided by the granules and remains in place at the tissue surface. 41

42. Surgiflo 42

43. Oxidized regenerated cellulose is also known as Surgicel or Oxycel in its commercial forms is derived from alpha-cellulose that is actually plant-based. Oxycel is an absorbable haemostat that has been used to control bleeding safely, simply and effectively Oxycel or Surgicel 43

44. How Does SURGICEL Work? 44

45. Why is SURGICEL Bactericidal? 45

46. Conforms to wound site, minimal sticking to gloves or instruments Effective hemostasis for classic 6-8 minutes, Nu-knit 3-5 minutes, fibrillar 3-4 minutes No immunogenicity potential, bactericidal Absorption within 7-14 days (depending on amount used, degree of saturation with blood) 46

47. Fibrin glue(also called Fibrin sealant) is a formulation used to create a fibrin clot aiding in hemostasis It is made up of fibrinogen( lyophilised pooled human concentrate) and thrombin(bovine, which is reconstituted with calcium chloride) that are applied to the tissue sites to glue them together.it may also contain aprotinin,fibronectin and plasminogen Thrombin is an enzyme and converts fibrinogen into fibrin monomers between 10 and 60 seconds giving rise to a three-dimensional gel. Fibrin Glue 47

48. Fibrin glue is "Fibrin Fibronectin Sealing System (FFSS)" It is available as two component system: first component contains highly concentrated fibrinogen, factor XIII, fibronectin , and traces of other plasma proteins. The second component contains thrombin, calcium chloride, and antifibrinolytic agents such as aprotinin . Mixing of two components promotes clotting with the formation and cross-linking of fibrin. 48

49. When periodontal plastic surgical procedures done or implants placed in esthetic zone, fibrin sealants may be variable alternative to closing flaps with sutures and with histologic benefits In periodontal plastic surgeries of esthetically important areas it gives better results than sutures. 49

50. Fibrin Sealants EVICEL Uses human thrombin (all human components) Low risk of immune reaction No aprotinin or tansexamanic acid Prep time <1 minute Clear clot Spray or drip TISSEEL Uses bovine thrombin Higher risk of immune reaction Contains aprotinin Prep time 15 minutes Cloudy white clot Spray (syringe or pressure delivery) or drip 50

51. Precautions and limitations

1. Fibrin sealant cannot be used in individuals who are known to be hypersensitive to bovine protein . 2. Fibrin sealant cannot be indicated for the treatment of massive and brisk arterial or venous bleeding 3. To avoid risk of allergic anaphylactic reaction and/or thromboembolic events, which may be life threatening, fibrin sealant should not be applied intravascularly or into the tissues. 51

52. Tisseel 52

53. Evicel 53

54. Co-Seal and BioGlue most commonly used Creates a shell over the area applied Caution not to cover things that will be removed Synthetic Sealants BioGlue Composed of Glutaraldehyde and purified bovine serum albumin (BSA) Binds covalently to tissue surface proteins (won’t work if place on non-protein surface) Supplied with multiple syringe tips as they clot off as soon as there is no active injection. 54

55. CoSeal Composed of two synthetic polyethylene glycols (PEGs) in hydrogen chloride and sodium phosphate When mixed the PEGS form a hydrogel that adheres to tissue and covalently bonds to itself Completely synthetic, no gluteraldehyde Swells up to 4 times its volume in 24 hrs and additional swelling may occur as the gel resorbs 55

56. Chitosan-based dressing Chitosan is a biodegradable,nontoxic,complex carbohydrate derived from chitin(a naturally occuring substance from zeolites ): when the deacetylation of chitin is above 70% the generic name” Chitosan ” is applied In the form of an acid salt it has a mucoadhesive activity It has a positive charge and it attracts RBCs and Platelets which have negative charge. The freeze-dried Dressing augments its sealing action Also offers an antibacterial barrier 56

57. Hemostatic mechanism is due to activation of thromboplastin formation on damaged vessel walls and decrease prostacyclin 2 synthesis and facilitates platelet aggregation. Ethamsylate reduces capillary bleeding in the presence of normal number of platelets. It acts by correcting abnormal platelet adhesion. It exerts antihyaluronidase action,improves capillary wall.stability,not stabilize fibrin(not an antifibrinolytic ). Ethamsylate 57

58. Indications: used in prevention and.treatment of capillary bleeding in * menorrhagia *epistaxis *hematuria *after tooth extraction Efficacy is unsubstantiated adverse effects like rash are common and blood pressure falls only after IV injection. Dose: 250-500 mg TDS oral /IV 58

59. Tranexamic acid Tranexamic acid 4.8% oral rinse is an antifibrinolytic agent that stabilizes clots and facilitates clot formation by competitively inhibiting plasminogen , the enzyme responsible for activating plasmin. It can also be useful as a prophylactic mouthwash in patients who are on anticoagulant medications which require oral surgery. It can be used preoperatively, intraoperatively , or postoperatively to manage bleeding . It is very popular as a post-operative hemostatic mouthwash. 59

60. Botroclot Haemocoagulase :- A proteolytic enzyme from venom of South American viper,Bothrops atorox , A plasma clotting agent for fibrinogen(a haemostatic) INDICATIONS: •     Topical capillary bleeding & tissue oozing •     Hastens coagulation through multiple actions •     Promotes cosmetically elegant, scarless wound healing •     Arrests bleeding in cuts and wounds •     Surgical incisions •     Post Hysterectomy •     Plastic Surgeries, Skin Grafting (Donor & Receptor areas) •     Dental Extractions 60

61. Dosage: Apply 5 to 10 drops or sufficient quantity to cover the wound completely.   61

62. Conclusion Control of bleeding is the most important integral part of any surgical treatment procedure. Proper prior evaluation of the patient & complete medical and family history are very much essential to overcome intra operative & post operative bleeding arising from undetected bleeding disorders 62

63. References Contemporary Oral and Maxillofacial Surgery – Peterson Textbook of Pathology – Harshmohan . Textbook of Oral Surgery – Vinod Kapoor Review of hemostatic agents used in dentistry. McBee WL ,  Koerner KR . 63

64. “All Bleeding Stops” THANK YOU 64