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Surgeon dependent factors on bleeding:
–Better visualization of anatomy
–Reduced OR time; Happier staff
- •Less OR time the better. OR time is extremely expensive. Every minute costs
- something like $200-300. adds up quickly. The more you get in and out of the
- OR, the more money you make, the less money it costs the system. Less mess
–Makes you look like a better surgeon
Patient Dependent Factors of Bleeding:
–Decreases post-operative complications
Not always operating on healthy people.
The more fluid the patient loses, will effect the CV supply. The heart will have to pump faster and harder to get the fluid. Increase the Cardiac demand and increases chance of cardiac event like an MI
- –Reduced OR time: direct relationship to how long the patients is under anesthesia (not normal phenomenon!) they will have more
- complications the longer the surgery. Taking them out of a homeostatic state so less time under anesthesia the better
Complete Blood test Square
☓..what goes in each corner?
Normal Range Hemoglobin:
Hgb = ~12-18 g/dl
Physically how many RBC. weight
Normal Hematocrit (Hct)
What percentage of the blood is made of RBC
What is normal Hct compared to Hgb?
Hct is 3x the Hgb
What is too low for Hemoglobin?
What is too low for Hematocrit?
How do you fix a low hemoglobin?
- Give the patient PRBC
- 1 unit PRBC= ↑ Hbg by ~ 1g/dl
↑ Hct by ~ 3%
If Hbg 6, how many units of PRBC do you give a patient?
2 or 3
Normal Platelet count:
What is too low for platelet count? (Plt)
- <100,000 canoot get epidurla
- <50,00 hold surgery
How do you fix low platelet count?
transfuse 1 unit of platelets: ↑ by ~20,000
Life span of platelet:
Normal bleeding time (this regulates platelet function):
-hold aspirin a week before surgery
Coagulation Study T (or Y)
What goes in the sections? I---
- PTT=partial thromboplastin time
- PT= Prothrombin Time
- INR= International normalized ratio
Coagulation studies: WEPT
- –Warfarin (Coumadin)
- –Extrinsic Pathway
- •Factor VII (also I, II, V, X)
- –PT and INR
- Intrinsic Pathway
- Factors VIII, IX, XI, XII
INR too high?
- Will take longer to stop bleeding
How can you improve INR?
- Hold medication: platelets regenerate in 5-9 days
- Warfarin or PT
- Heparin held for PTT (heparin 1/2 is short)
- Vitamin K replacement (PO, SC, IV)
- Transfues fresh frozen plasma (FFP)
- directly replaces affected factors
What is the day of surgery comes and the PT is too high?
CANNOT do surgery!
Past medical History relating to bleeding:
- –Hemophilia: intrinsic pathway!
- •↑ PTT
- –Von Willebrand’s Disease
- •↑ PTT and Bleeding time
- –Vit K Deficiency:
- affect both Intrinsic and EXtrinsic
- •↑ PTT and PT
- –Alcoholics: intrin ad extrin factors are made in the liver
- –Bleeders, Bruisers, etc
Medication that will affect bleeding (increase)
- –Aspirin: affects plts
- •↑ Bleeding time
- –Plavix: stent or bypass
- •↑ Bleeding time
- •↑ PT/INR
- •↑ PTT
- •No change
- –NSAIDs and Steroids
- –Previous DVT/PE
- •Very common in legs
- –Sickle Cell Disease
- •Have to specifically ask
- –I AM CLOTTED
- DVT/PE history
What is the protocol for SCA?
- almost NEVER use a tourniquet
- give them something to decrease chance of clotting
Patients with peripheral arterial disease:
–Any lower extremity bypass patient
–ABI < 0.9
–Absolute ankle pressure < 40mmHg
–Absolute digital pressure < 20mmHg
–TcPO2 < 20mmHg
Surgical Layers of Dissection:
- •Superficial Fascia
- –1st Dissection Interval
- •Deep Fascia
- –2nd Dissection Interval
- –3rd Dissection Interval
Why does skin bleed so much?
•Several horizontal plexi of artery/vein run through the dermis and superficial fascia
Superficial Fascia and Bleeding:
- Contains large veins
- •Large, named cutaneous veins
•Still no named or identifiable arteries
Deep Fascia and Bleeding
- relatively vascular
- * neurovascualr found in the 2nd dissection interval
Periosteum and Bleeding
does NOT directly bleed
Nutrient arteries and metatarsals
What parts of bone bleed?
How to control bleeding:
•Anatomic Dissection Technique-- Ex: with gas green, transmit amputation=
Anatomical Dissection Technique:
Why is a 90 degree incision better for bleeding?
Less surface area compared to an oblique incision
Anatomic Dissection Technique:
Superficial Fascia AND
Second Dissection Interval
- *Usual settings?
- •Suture ligation/Hand tie
- - Usually something like a 3-0 or 4-0 Vicryl
- General rule of thumb?
Special products to control bleeding
- Thrombin spray
-TIME and PRESSURE
Anatomical Dissection Technique: Bone
- Fusion: take out cartilage
- cancellous bone next to each other
- exposed cancellous bone will bleed!
–Nature abhors dead space. Blood/hematoma will fill any dead space.--> infection!!!
–This applies to all the surgical layers/dissection interveals
•Another specialized product: Bone wax
Most Common tourniquets:
- Proximal CAlf
- cannot vary the pressure
- Escmarch similarity
- pressure between 200- 500 mmHg
- - supramalleola
- proximal calf
What is the pressure of a calf tourniquet?
- Approx 250 mmHg
- 100mmHg> Systolic Blood Pressure
How long can you keep a calf tourniquet on?
What is the most common tourniquet used in podiatry?
Located on proximal thigh
What is the pressure for a thigh tourniquet?
- up to 350mmHg
- Consider 100mmHg> Systolic Blood Pressure
How long can a thigh tourniquet stay on?
Up to 120 mins
Why are there max tourniquet times? What do you do if your case is taking longer than 120 mins?
•Drop the tourniquet to allow for tissue reperfusion prior to re-inflation:
- –General rule of thumb: 5 minutes/30 minutes
- - finish the procedure wet (you probably near the end time and have good hemostatic control
- - Or you can deflate the tourniquet for 5
- minutes every 30 mins it was inflated. Then you can reflate it
For every 30 mins the tourniquet was inflated, how many minutes must you wait deflated before you inflate again?
Estimate blood loss?
put it in your report but not actuate AT ALL