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Bleeding Disorders Shalu Rai et al

AGENT DESCRIPTION COMMON INDICATIONS
Platelets 1 unit = 50 mL; may raise count by 6,000 Platelet count < 10,000 in nonbleeding individuals, < 50,000
presurgical level, < 50,000 in actively bleeding individuals,
Nondestructive thrombocytopenia
Fresh frozen plasma 1 unit = 150–250 mL, 1 hour to thaw, Undiagnosed bleeding disorder with active bleeding, Severe liver
Contains factors II, VII, IX, X, XI, XII, XIII disease, When transfusing > 10 units of blood, Immune globulin
and heat-labile V and VII deficiency
Cryoprecipitate 1 unit = 10–15 mL Hemophilia A, von Willebrand’s disease, when factor
concentrates and DDAVP are unavailable, Fibrinogen deficiency
Factor VIII concentrate 1 unit raises factor VIII level 2%, Heat- Hemophilia A with active bleeding or presurgery; some cases of
treated contains von Willebrand’s factor, von Willebrand’s disease
Recombinant and monoclonal technologies
are pure factor VIII
Factor IX concentrate 1 unit raises factor IX level 1–1.5% , Hemophilia B, with active bleeding or presurgery, Prothrombin
Contains factors II, VII, IX and X complex concentrates used for hemophilia A with inhibitor
,Monoclonal formulation contains only
Factor IX
Desmopressin Synthetic analogue of antidiuretic hormone Active bleeding or presurgery for some patients with von
0.3µg/kg IV or SC, Intranasal application Willebrand’s disease, uremic bleeding of liver disease, bleeding
esophageal varices
Epsilon-aminocaproic acid Antifibrinolytic: 25% oral solution (250 Adjunct to support clot formation for any bleeding disorder
mg/mL)Systemic: 75 mg/kg every 6 hours
Tranexamic acid Antifibrinolytic: 4.8% mouth rinse (not Adjunct to support clot formation for anybleeding disorder
available in the United States) Systemic:
25mg/kg every 8 hours

Table 1: Principal agents for systemic management of patients with bleeding disorders 1

in the treatment of these coagulopathies. 1 analgesia, can be employed to reduce or eliminate the
need for anesthesia. Patients undergoing extensive
Disease related coagulopathies treatment requiring factor replacement may be treated
Deficient vitamin K related clotting factors (II, VII, IX, X) in under general anesthesia in a hospital operating
liver diseases is treated with Vitamin K injections for 3 days. room. 1,6,7
Infusion of FFP and DDAVP therapy is also been used.
Bleeding in renal disorders can be managed by Dialysis, Oral Surgery Procedures
Hemodialysis, Cryoprecipitate, DDAVP, Conjugated estrogen Local hemostatic measures (TABLE 2)
preparation or Recombinant erythropoietin . During any surgical procedure complete hemostasis
1
must be achieved before closure of the wound and the
DIC best method to achieve it is by applying direct control
Disseminated intravascular coagulopathy can be treated with of bleeding at the site of injury. 7
intravenous unfractionated heparin, infusion of activated
protein C, antithrombin III, FFP and Platelet transfusion. 1 Mechanical methods 1,3,6
Pressure- It’s application counteracts the hydrostatic
ORAL HEALTH CONSIDERATIONS pressure within the bleeding vessel until clot formation
occurs which occludes the bleeding orifice. Pressure
Pain control: must be applied directly over the bleeding site firmly
In patients with coagulopathies, nerve-block anesthetic over a gauze pack for atleast five minutes. In fractures
injections are contraindicated unless there is no better of mandible bleeding from inferior dental artery
alternative and prophylaxis is provided, as the anesthetic usually stops immediately or with the help of pressure
solution is deposited in a highly vascularized area, which packs.
carries a risk of hematoma formation. The commonly used Use of hemostats-Bleeding points are caught using a
blocks require minimum clotting factor levels of 20% to 30%. Hemostat (mosquito foreceps) in the surgical area.
Extravasation of blood in the oropharyngeal area by an inferior Embolisation of vessels- Agents used are steel coils,
alveolar block or in the pterygoid plexus can produce gross polyvinyl alcohol foam, gel foam, silicon spheres and
swelling, pain, dysphasia, respiratory obstruction and risk of methyl methacrylate.
death from asphyxia. Anesthetic infiltration and
intraligamentary anesthesia are potential alternatives to nerve Thermal agents 1,3,6 -
block in many cases. An anesthetic with a vasoconstrictor Cauterization-Here heat is transmitted from the
should be used when possible. Alternative techniques, instrument directly onto the tissues though conduction

including sedation with diazepam or nitrous oxide–oxygen which results in coagulation of these areas.

Journal of Oral Sign 2011, Vol 3, No 2 (May-Aug)