Hemostatic Control

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  1. 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
  2. Patient Dependent Factors of Bleeding:
    –Decreases post-operative complications


    •Systemic. 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
  3. Complete Blood test Square
    ☓..what goes in each corner?
    Image Upload 1
  4. Normal Range Hemoglobin:
    Hgb = ~12-18 g/dl

    Physically how many RBC. weight
  5. Normal Hematocrit (Hct)

    What percentage of the blood is made of RBC
  6. What is normal Hct compared to Hgb?
    Hct is 3x the Hgb
  7. What is too low for Hemoglobin?
    ~8 g/dl
  8. What is too low for Hematocrit?
  9. How do you fix a low hemoglobin?
    • Give the patient PRBC
    • 1 unit PRBC= ↑ Hbg by ~ 1g/dl

                         ↑ Hct by ~ 3%
  10. If Hbg 6, how many units of PRBC do you give a patient?
    2 or 3
  11. Normal Platelet count:
    150,000-450,000 cells/ul
  12. What is too low for platelet count? (Plt)
    • <100,000 canoot get epidurla
    • <50,00 hold surgery
  13. How do you fix low platelet count?
    transfuse 1 unit of platelets: ↑ by ~20,000
  14. Life span of platelet:
    5-9 days

  15. Normal bleeding time (this regulates platelet function):
    ~2-9 mins

    • (<10 mins)
    • -hold aspirin a week before surgery
  16. Coagulation Study T (or Y)
    What goes in the sections?  I---
    • Image Upload 2
    • PTT=partial thromboplastin time
    • PT= Prothrombin Time
    • INR= International normalized ratio
  17. Coagulation studies: WEPT
    • Warfarin (Coumadin)
    • Extrinsic Pathway
    •       •Factor VII (also I, II, V, X)
    • PT and INR
  18. PTT:
    • Intrinsic Pathway
    •       Factors VIII, IX, XI, XII
    • Heparin
  19. PT/INR normal:
    10-13 seconds/1.0
  20. PTT normal
    24-38 seconds
  21. INR too high?
    • >1.5
    • Will take longer to stop bleeding
  22. 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
  23. What is the day of surgery comes and the PT is too high?
    CANNOT do surgery!
  24. 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
  25. Medication that will affect bleeding (increase)
    • –Aspirin: affects plts
    •       •↑ Bleeding time
    • –Plavix: stent or bypass
    •       •↑ Bleeding time
    • –Warfarin/Coumadin
    •       •↑ PT/INR
    • –Heparin
    •       •↑ PTT
    • –Lovenox
    •       •No change
    • –NSAIDs and Steroids
  26. Coagulopathies:
    • –Previous DVT/PE
    •       •Very common in legs
    • –Sickle Cell Disease
    •       •Have to specifically ask
    • –HIV/AIDS

    • Immobilization
    • Afib/CHF/MI
    • Malignancy
    • Coagulopathy
    • Longevity
    • Obesity
    • Trauma
    • Tobacco
    • Estrogen/BCP/HRT
    • DVT/PE history
  27. What is the protocol for SCA?
    • almost NEVER use a tourniquet
    • give them something to decrease chance of clotting
  28. Patients with peripheral arterial disease:
    –Any lower extremity bypass patient

    –ABI < 0.9

    –Absolute ankle pressure < 40mmHg

    –Absolute digital pressure <  20mmHg

    –TcPO2 < 20mmHg
  29. Surgical Layers of Dissection:

    • •Superficial Fascia
    •      –1st Dissection Interval

    • •Deep Fascia
    •       –2nd Dissection Interval

    • •Periosteum
    •       –3rd Dissection Interval

  30. Why does skin bleed so much?
    •Several horizontal plexi of artery/vein run through the dermis and superficial fascia
  31. Superficial Fascia and Bleeding:
    • Contains large veins
    • •Large, named cutaneous veins

    •Still no named or identifiable arteries
  32. Deep Fascia and Bleeding
    • relatively vascular
    • * neurovascualr found in the 2nd dissection interval
  33. Periosteum and Bleeding
    does NOT directly bleed
  34. Nutrient arteries and metatarsals
  35. What parts of bone bleed?
    Cancellous portion

    NOT cortex
  36. How to control bleeding:
    •Anatomic Dissection Technique-- Ex: with gas green, transmit amputation= 



  37. Anatomical Dissection Technique:
    Image Upload 3
  38. Why is a 90 degree incision better for bleeding?
    Less surface area compared to an oblique incision
  39. Anatomic Dissection Technique:

    Superficial Fascia AND
    Second Dissection Interval
    •Blunt dissection/Retraction

    • •Bovie
    • *Usual settings? 
    • *Contraindications?

    • •Suture ligation/Hand tie
    • -  Usually something like a 3-0 or 4-0 Vicryl      
    • General rule of thumb?
  40. Special products to control bleeding
    -  Thrombin spray  

    -  Gelfoam  

    -  Surgicel

  41. 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
  42. Drains:
    • Penrose
    • TLS
    • Jackson-Pratt
  43. Most Common tourniquets:
    • Digital
    • Thigh
    • Proximal CAlf
    • Ankle
  44. Digital tourniquet
    • cannot vary the pressure
    • Escmarch similarity
    •    pressure between 200- 500 mmHg
  45. Calf Tourniquet
    • - supramalleola 
    • proximal calf
  46. What is the pressure of a calf tourniquet?
    • Approx 250 mmHg
    • 100mmHg> Systolic Blood Pressure
  47. How long can you keep a calf tourniquet on?
    90-120 mins
  48. What is the most common tourniquet used in podiatry?
  49. Thigh tourniquet
    Located on proximal thigh
  50. What is the pressure for a thigh tourniquet?
    • up to 350mmHg
    • Consider 100mmHg> Systolic Blood Pressure
  51. How long can a thigh tourniquet stay on?
    Up to 120 mins
  52. 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
  53. For every 30 mins the tourniquet was inflated, how many minutes must you wait deflated before you inflate again?
    5 minutes
  54. 1 unit PRBC
    250 ml or cc
  55. Estimate blood loss?
    put it in your report but not actuate AT ALL
Card Set
Hemostatic Control
Dr. Meyer Intro to surg
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