Curriculum Vitae

Nama : Samsul Maarif

Tgl Lahir : Gresik 06 Mei 1972
Status : Menikah, 1 orang Istri, 2 anak
Alamat : Jl Sampurna 74 Malang
Email : samsulmaarifmlg@yahoo.com

Pekerjaan : Staf Perawat IBS RS Islam Aisyiyah Malang

Ketua Komite Keperawatan RS Islam Aisyiyah Malang
Dosen Tamu pada FIKES Universitas Muhammadiyah Malang
Dosen Tamu pada D IV Kep Periop POLTEKKES Negeri Malang

Organisasi : Ketua Cabang HIPKABI Malang Raya

Anggota Bid Diklat & Pengembangan SDM PD HIPKABI JATIM
 Perioperative
Bleeding Management

Samsul Maarif
Excess perioperative bleeding remains a major
complication following surgery, resulting in
increased morbidity and mortality
There are two main causes of perioperative
bleeding.

surgical bleeding which is directly attributable to a

failure to surgically control bleeding vessels at the
operative site.
Haemostatic bleeding is due to a failure of the
haemostatic pathways. This is often manifest as
generalized oozing.
Normal Coagulation Process

Vasoconstriction
Platelet plug formation, after vasoconstriction, platelets are
activated by thrombin and aggregate at the site of injury to form
a temporary platelet plug.
Fibrin clot formation, To stabilize the initially platelet plug
Coagulation Cascade
Management in perioperative bleeding :

Pre operative identification for whom at Risk

Maintaining adequate tissue perfusion
Intraoperative Bleeding Control
1. Pre operative identification for whom at risk

1.a. Preoperative Nursing Assessment

1.b. Specific Laboratory Test of Coagilation
1.a. Preoperative Nursing Assessment

Does the patient

use anticoagulants or antiplatelet medications?
use supplements or herbs that might contribute to
increased bleeding?
have a personal or family history of bleeding disorders?
report bleeding gums or severe nosebleeds?
have anemia?
have a history of renal or hepatic disease?
1.b. Specific Laboratory Test of Coagulation

Platelet count, a first test in evaluating primary

haemostasis
Bleeding time, is a test used to determine how
quickly your blood clots to stop you from bleeding
Clotting Time, is the time required for a sample of
blood to coagulate in vitro under standard
conditions.
2. Maintaining Adequate Tissue Perfussion
2.a. Airway Support
2.b. Blood Transfussion

Potential benefits should be weighed against the risks.

The decision of blood transfusion should be
based mainly on the patients individual ability to
tolerate and compensate for anemia

Global signs of inadequate oxygenation ec.

blood lose are hemodynamic instability,
tachycardia and hypotension, increase serum
lactate
The alternative strategies that aim at decreasing
perioperative allogeneic RBCs transfusion:

Preoperative autologous donation (PAD)

Preoperative use of erythropoietin
Acute normovolemic hemodilution
Pharmacologic prevention of massive bleeding
Donor Recipient Blood Type
3. Intra Operative Bleeding Control

Mechanical methods
Direct pressure
Sutures/ ligating clips
Thermal/energy-based methods
Electrosurgery
Laser
Chemical methods
Topical hemostatic products
Pharmacological agents
Key Considerations in the Selection of
Hemostatic Product / Methood

Rapidly and effectively control bleeding

Be compatible with the patients physiology,
Be safely used
Be cost effective.
ELECTROSURGICAL UNIT

Monopolar ESU
Bipolar ESU
 Monopolar ESU

Electrical current flows from the

generator
through an active electrode to the
patient

Patient is included in circuit

The energy then returns to the generator to

complete the circuit
Placement of Passive Electrode
Patient return electrode safety precautions
Bipolar ESU

In bipolar electrosurgery, two electrodes

serve as the
equivalent of the active and return
electrodes

Bipolar electrosurgery works well for procedures in which the surgeon

needs to limit thermal spread
Bipolar electrosurgery uses lower voltage to deliver the current, making it
a safer option
Bipolar Advantage

It is much safer than monopolar

Current flow only through well defined area, while in monopolar current
flow back through large section of patient body
Less interference for other instrumens
No patient plate or return electrode is required
Topical Hemostatic Agent

Passive Hemostatic Agents, the first generation of hemostatic

agents, effective for areas of minimal bleeding, and do not
affect or interrupt the clotting cascade (gelatin, collagen,
oxydized regenerated cellulose)

Active Hemostatic Agents, provide hemostasis within 10

minutes and control bleeding better than passive agents
(human thrombin, bovine thrombin, recombinant thrombin)
 Flowable Hemostatic Agents, have both an active and a
passive component

Tissue Sealants, Generally contain both thrombin and

fibrinogen
 Referrence

American Society of Anesthesiologists, Practice guidelines for perioperative

blood transfusion and adjuvant therapies, 2006
European Society of Anesthesiology, Management of Severe Perioperative
Bleeding, 2013
American Operating Room Nurses Association, Management of Surgical
Hemostasis, 2013
Margaret A, MSN, BSN, RN, Hemostatic Agent, a gide to safe practice for
perioperative nurses, 2014
Beverley J Hunt, The Management of Perioperative Bleeding, 2003