HEMOSTASIS

Dr. Imran Aslam

Assistant Professor
North Surgical Ward
INTRODUCTION
 Hemostasis is the process of forming clots
in
the walls of damaged blood vessels and
preventing blood loss while maintaining
blood
in the fluid state within the
vascular system.
VIRCHOW’S TRIAD
 Coagulation is combination of

1. Stasis of blood
2. Endothelial injury
3. Hypercoagulability
EVENTS IN HEMOSTASIS
 Hemostasis means prevention of ‘Blood Loss’. Hemostasis is achieved by
several mechanism:-
 Vascular constriction
 Formation of platelet plug
 Formation of blood clot
 Growth of fibrous tissue into the clot.
1.VASCULAR CONSTRICTION
 The contraction results from:-
 Local myogenic spasms
 Local autacoid factors
 Nervous reflexes

 Platelets release, Thromboxane-A2

which is responsible for
vasoconstriction of smaller vessels.
 The more severely a vessel is
traumatized, the greater the degree of
vascular spasm.
2.FORMATION OF PLATELET
PLUG
 MECHANISM OF PLATELET
PLUG
 Platelet adhesion
 Platelet activation
 Platelet aggregation
 Formation of temporary
hemostatic plug
3.BLOOD COAGULATION IN
RUPTURED VESSEL
 Third mechanism for hemostasis is formation of blood clot
 Clot begins to develop-
 severe trauma-15 to 20 sec
 minor trauma-1 to 2 min
COAGULATION PATHWAYS
 These mechanisms are set into play by:-
 Trauma to the vascular wall and the adjacent tissues
 Contact of the blood with damaged endothelial cells

 a) Extrinsic pathway for initiating blood clotting

 b) Intrinsic pathway for initiating blood clotting
EXTRINSIC PATHWAY FOR
INITIATING BLOOD CLOTTING
INTRINSIC PATHWAY
FORMATION OF FIBRIN
NETWORK
 In response to rupture of the vessel or damage to the
blood itself-formation of prothrombin activator
 Prothrombin activator catalyzes conversion of
prothrombin to thrombin
 Thrombin catalyzes fibrinogen into fibrin fibers.
CONVERSION OF PROTHROMBIN TO
THROMBIN AND THEN FIBRINOGEN INTO
FIBRIN
BLOOD CLOT
 The clot is a meshwork
 Fibrin fibers also adhere to damaged surfaces of blood vessels.
 As the clot contracts, the edges are further pulled together, contributing
ultimate state of Hemostasis.
CONVERSION OF
FIBRINOGEN TO FIBRIN-
FORMATION OF THE CLOT
FIBRINOGEN

ACTION OF THROMBIN ON FIBRINOGEN TO FORM

FIBRIN

BLOOD CLOT

CLOT RETRACTION-SERUM
CLOTTING PROCESS IN A TRAUMATIZED BLOOD
VESSEL
METHODS OF
HAEMOSTASIS
METHODS OF
HAEMOSTASIS
MECHANICAL HEMOSTASIS
Direct pressure

Gauze pack

Suture and ligation

Staples
DIRECT PRESSURE
 First choice to control bleeding
 Fast and simplest
 Small Arterial bleeding
 Venous bleeding
 15-20 sec
 Not recommended in major artery and veins.
FABRIC
PADS/GAUZE/SPONGE
 Used with direct pressure
 It is used in
 - only pressure is not an
option
 -systemic bleeding due
to infection, trauma, massive
blood loss, and platelet
dysfunction.

SUTURE/STAPLES/LIGATING
CLIPS
 Suture – used in major arteries and veins
 Ligation of facial artery, lingual artery, and external carotid artery
TYPES OF LIGATION
 Stick Tie:
 Also called as transfixation.
 Used for High Blood pressure
 Proximal part of the vessels

 Regular Tie
 Used for Distal part of the vessels
 Also used for tubectomy .
 Staples- sterile and disposable
 titanium staples

 Ligating clips-
 quick and easy
 decrease foreign body reaction
 various size
USE OF HEMOSTATS
 Hemostats (Mosquito and Artery) are designed to catch bleeders.
 Can be straight or curved.
BONE WAX
 Is a mixture of Beeswax (70%) and Vaseline (30%).
 It is a non-absorbable material , becoming soft and malleable in the hand
when warmed
 Its Hemostatic effect is based on physical rather than biochemical
properties.
 It has been used in bone surgeries
TRANS CATHETER ARTERIAL
EMBOLIZATION
 -Restricts tumors blood supply .
 -Arterial embolization preferentially interrupts tumors blood supply and
stalls growth until neovascularization
 - Used to control bleeding in Hemangiomas
THERMAL
ENERGY
METHOD
METHODS:
 Heat (Cautery)
 Electro cautery: it is the use of high frequency alternating current for
cutting, coagulating, dessication or fulgurating tissue in both open and
laparoscopic procedure
 monopolar electro surgery
 bipolar electro surgery
 bipolar electrosurgery vessel sealing technology
 argon enhanced coagulation technology
 Ultrasonic device
 Lasers
MONOPOLAR ELECTRO
CAUTRY
 Most frequently used
 Two electodes- active (the pencil)
 - dispersive
 Modes - coagulation mode
 - cutting mode
 - blend mode
 Current flows through the patient from electrode (active) to electrode
(dispersive)
BIPOLAR ELECTRO SURGERY
 Current does not flow through the patient’s body
 Lower voltage
 Indicated in limited thermal spread
 Delicate tissue, small anatomical tissue
 Safe for implanted medical devices such as pacemaker, internal
cardioconverter fibrillator etc.
CHEMICAL
METHODS
 Pharmacological agents
 Topical haemostatic agent
 Passive
 active
PHARMACOLOGICAL
AGENTS
 Sterile haemocoagulase solution
 Epinephrine
 Vitamin k
 Protamine
 Desmopressin
 Lysin analogs
 Etamsylate
EPINEPHRINE
 Causes direct vasoconstriction
 Can be applied topically and can be injected with LA
 Prolong analgesic effect
 Reduces bleeding during surgery
 Topical - The drug is applied with the help of gauze pack in concentration of
1:1000 over a oozing
 It is also injected along with local anesthetics in concentration of 1:80,000
and 1:2,00,000.
VITAMIN K
 Plays important role in coagulation process
 Helps in production of fibrinogen and prothrombin in liver
 Route- orally and IV(slow)
 IM and subcutaneous is not recommended because irratic absorption
 Dose- Males: 120 mcg/day PO
 Females: 90 mcg/day PO
  5-10 mg IV (dilute in 50 mL IV fluid and infuse over 20 min
PROTAMINE
 Reverse heparin anticoagulation activity
 Adverse effect- anaphylaxis, acute pulmonary vasoconstriction, right
ventricular failure
 Contraindication
 -diabetic
 -pt undergone vasectomy
 -drug allergy
 -previous protamine exposure
 Dose -1.0 -to- 1.5 mg protamine sulfate IV for every 100 IU of active
heparin
LYSINE ANALOGUES
 Tranexamic acid- loading dose 2-7gm
 Follwed by 20-250 mg hourly
 Total dose of 3-10gm
 Oral dose; 500 mg 6-8 hrly
 Children; 1.25g/5 ml of syrup
 Inj- 0.5-1g slow i.v infusion TID
TOPICAL HAEMOSTATIC
AGENTS
 Passive- collagen based product
 - oxidised regenerated cellulose
 - gelatine


 Active haemostat
 - thrombin product
 - pooled human plasma thrombin
 - recombinant thrombin