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Hemostasis

Akhmad MustafaErwin WijatmikoDedy FarokaFarry

Department of Surgery - Hasan Sadikin Hospital - Medical Faculty Padjadjaran University

HEMOSTASIS Mechanism to stop spontaneous bleeding and maintain blood circulation in vessels

Including: - Coagulation system - Fibrinolysis system

Complex process

Hemostasis Pathofisiology

Bleeding and fibrinolysisCoagulationHemostasis Interaction: Blood vessel thrombocyte coagulation factors

Medical Bleeding Caused by Defects of:Blood vessel wall Inflammation

Thrombocyte Qualitative or quantitative

Coagulation factors Quantitative or inhibitor

Primary Hemostasis:Vascular (blood vessel)Thrombocyte

Secondary Hemostasis:Blood coagulation factorsHemostasis Pathofisiology

Schematic of processes initiated by vascular injuryVascular InjuryVasoconstrictionCoagulationHemostasisPlatelet adhesionAndaggregationExposure of SubendothelialCollagenRelease of tissue factorFibrinolysis

Blood VesselPermeability, Fragility, VasoconstrictionRelease:- Tissue Factor- von Willebrand factor (vWf)- Prostacyclin: Vasodilatation, Thrombocyte Aggregation inhibitor - Anti thrombin Coagulation inhibitor- ThrombomodulinPro - coagulation BalancingCoagulation Inhibition

THROMBOCYTEPerform and stabilized thrombocyte plug Adhesion - Aggregation - releasing

Protein S carrier (Protein S activate protein C)

COAGULATIONIntrinsic Pathway: XII, XI, IX, VIII, PF3, HMWK, Calcium ion HMWKXIIa Pre Kalikrein

Kalikrein VII

VIIaPlasminogenPlasmin

Extrinsic Pathway:- Tissue Thromboplastin- VII Factor - VIIa IX IXa X Xa

Common Pathway: FibrinogenProtrombin Thrombin

Fibrin

Coagulation Cascade

Blood cloth control mechanismBlood Circulation: dilutionClearance : Hepatocyte and RESINHIBITOR : AT III, Protein C, Protein S, 2 Macroglobulin, 1 Antitrypsin

FIBRINOLYSISFibrin destruction opening blood circulationFibrinolysis system : - Plasminogen - tissue-Plasminogen Activator (t-PA) - Plasmin Inhibitor

Plasminogen Activator: - Intrinsic (F XII a, Kalikrein) - Extrinsic : t-PA (Endothel)- Exogen : StreptokinasePlasmin Inhibitor: - 2 Plasmin Inhibitor - 2 Macroglobulin - 1 Antitripsin - AT III

Vasoconstriction

Primary Hemostasis

Thrombin

Fibrin Fibrinogen

Secondary Hemostasis

t-PA

ThrombomodulinFibrinolysis

Blocks coagulation

Anticoagulation counter-regulation

t-PA

ThrombomodulinFibrinolysis

Blocks coagulation

Anticoagulation counter-regulation

Clinical Difference of Vascular, thrombocyte and coagulation system defectClinical PresentationCoagulation DisorderThrombocyte/vascular Disorder- PetechiaeRarelyCharacteristic- HematomCharacteristic Rarely- EchimosisFrequent, big, soliterCharacteristic, small, multiple- HemarthrosisCharacteristicRarelyOccult bleedingFrequentRarely

Clinical Difference of Vascular, thrombocyte and coagulation system defectClinical PresentationCoagulation DisorderThrombocyte/vascular Disorder Bleeding from superficial lesionMinimal Persistent, severe bleeding is frequent- Sex80-90% MaleDominantly female- Family historyFrequentRarely

PetechiaeEchimosis

ThrombositopeniaDecreasing production: Hereditary, Bone marrow HypoplasiaIncreasing destruction: Immune : ITP, Secondary effect diseases Non immune : Microangiopathy, Vasculitis

Abnormal distribution: Splenomegali

Local HemostasisMechanical proceduresthe oldest method is digital pressure, than develop to hemostatgenerally ligature or a hemoclip replaces hemostat as permanent method on effecting hemostasis of a single disrupt vessel1st century Aulus Cornelius Celsus devise the use of ligature1552 Pare rediscovered the principle of ligature1800 Philip Sying Phsick employ absorbable suture1858 Simpson introduce fine wire suture, 1881 Lister used catgut1900 Halsted indicated the advantages of non absorbable silk1911 Cushing use silver clips to effect hemostasis in areas that are hard to reachRecently introduced Harmonic scalpel, an instrument that cuts and coagulates tissue via vibration at 55 kHz

Local HemostasisThermal AgentsHeat achieves hemostasis by denaturation of protein that result in coagulation of large are of tissueThe electrocautery can be AC or DCLocal cooling has been applied to control bleeding from the eroded mucosa of the eophagus and stomach, direct cooling with iced saline is effective but may provoke hypothermiaCryogenic procedure, at tempertures of -20 C, tissue, capillaries and arterioles undergo necrosis Chemical AgentsEpinephrine1911 Cushing use skeletal muscle, shortly thereafter hemostatic fibrin was introducedGelatin, oxydized cellulose, oxydized regenerated cellulose and micronized collagen are the most widely used

Evaluation of the Surgical Patient as a Hemostatic RiskPREOPERATIVEPatients historyProlonged bleeding or swelling after biting the li or tongueBruises without apparent injuryProlonged bleeding after dental extractionExcessive menstrual bleedingBleeding problems associated with major or minor operativesMedical problems receiving a physicians attention within the past 5 yearMedications including aspirin or remedies for headache taken within past 10 daysA relative wit a bleeding problemLaboratory findings (PT, aPTT, INR, Platelet count)

Evaluation of the Surgical Patient as a Hemostatic RiskEVALUATION OF EXCESSIVE INTRAOPERATIVE OR POST OPERATIVE BLEEDINGMaybe the result of the following factors:Ineffective local hemostasisComplications of blood transfusionA previously undetected hemostatic defectConsumptive coagulopathy Fibrinolysis