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SURGERY
Factor 1 Fibrinogen
Factor Prothrombin
Factor 3 Tissue thromboplastin
Factor 4 Calcium ions
Factor 5 Labile factor
Factor 7 Stable factor
Factor 8 Antihemophillic Factor
Factor 9 Christmas Factor
Factor 10 Stuart-Prower Factor
Factor 11 Plasma thromboplastin antecedent
Factor 12 Hageman Factor
Factor 13 Fibrin stabilising Factor
HEMOSTASIS
1.Vascular phase
2.Platelet phase
3.Coagulation phase
4.Fibrinolytic phase
Hemostasis
Primary Hemostasis
•Blood vessel contraction
•Platelet Plug Formation
Secondary Hemostasis
•Activation and clotting cascade
•Depostion and Stabilization of Fibrin
Tertiary Hemostasis
•Dissolution of Fibrin clot
•Dependent on Plasminogen Activation
So What Causes Bleeding
Disorders?
VESSEL DEFECTS
PLATELET DISORDERS
FACTOR DEFICIENCIES
OTHER DISORDERS
Classification:
•Disorders of coagulation
•Extrinsic.intrinsic,combined
•Disorders of Platelets
•Thrombocytopenia ITP,HUS,DIC
•Aspirin therapy,Thrombasthenia
•Other disorders
•Post transfusion purpura
VASCULAR DISORDERS
General aspects
•Hereditary haemorrhagic
telangiectasia is an autosomal
dominant condition with a high
penetrance,as 97% of people
affected exhibit symptoms
•There is vascular dysplasia
leading to telangiectasia and
arteriovenous malformation in
the skin,mucosa and viscera
Clinical features
•Interestingly,HHT usually presents in adolescence.
•Telangiectasia on the skin or any part of the
oral,nasal,conjuctival,respiratory,gastrointestinal or
urogenital mucosa,or brain and liver,leads to bleeding
•Associated features include:
•Heamorrhage of the gastrointestinal tract,which
can result in iron deficiency anemia
•Respiratory arteriovenous malformations,which
can present as dyspnoea,cyanosis or finger –
clubbing.
•Liver arteriovenous malformations that can cause
cirrhosis,which can further exacerbate the bleeding
tendency,and high output cardiac failure
.
General management
•Investigations include capillary microscopy,
computed tomography,magnetic resonance imaging
and angiography,
•Treatment is by cryosurgery or by argon laser
treatmet.
Dental aspects
•Telangiectasias may be seen in any part of the mouth
and may be conspicious on the lips and tongue.
•Regional local anesthesia should be avoided because
of the risk of deep bleeding.
•Concious sedation can be given if required.
SURGICAL MANAGEMENT
General aspects
•Haemophillia a is an X-linked disorder resulting
from a deficiency in blood clotting factor 8, a key
component of the coagulation cascade.
•Haemophillia mainly affects males
•All daughters of an affected male are carriers but
sons are normal.
•The female carriers will transmit the disorder to
half of her sons and the carrier state to half of her
daughters.
Hemophillia A
Symptoms and diagnosis
•Bruising
•Spontaneous bleeding
•Bleeding into joints and
associated pain and swelling
•Gastrointestinal tract and urinary
tract hemorrhage
•Blood in the urine or stool
•Prolonged bleeding from cuts,
tooth extraction and surgery
General management
•The diagnosis of heamophillias is based on the clinical
presentation, a positive family history ,coagulation studies
and clotting factors assays.
Laboratory findings in haemophillia
•Normal prothrombin time
•Prolonged activated partial thromboplastin time
•Reduced factor 8
•Reduced factor 9
•Haemophilliacs should be under the care of recognised
hemophilliac centres,where the primary aim is to prevent
and treat bleeding with the missing clotting factor,using a
specific factor concentrate.
•Factor 8 must be replaced to adequate levels during
episodes of bleeding.
•Patients usually recognise early symptoms of bleeding
even before the manifestations of physical signs.
•This is often described as tingling sensation or aura
•Acute bleeds should be treated as quickly as
possible,preferably within 2 hours.
•Desmopressin can raise factor 8 level adequately to
control bleeding in patients with mild and possibly
moderate,hemophillia A
Surgical considerations
Symptoms include:
•Nose bleeds,Bruising
•Spontaneous bleeding
•Bleeding into joints and associated pain and swelling
•Gastrointestinal tract and urinary tract hemorrhage
•Blood in the urine or stool.
General management
•The activated partial thromboplastin time is
prolonged with a normal prothrombin time
•Treatment is with factor 9 concentrate
• A dose of 20 units of factor 9 per kilogram body
weight is given intravenously 1 hour
preoperatively
VON WILLEBRAND DISEASE