S214: Hemostasis: A Clinical Review of Pathophysiology, Pharmacotherapy, and Perioperative Management

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Paramount to surgical success is hemostasis and wound healing. The practice of oral and maxillofacial surgery challenges our patients’ hemostatic mechanisms daily. Because of this, oral and maxillofacial surgeons have always been well-versed in managing the patient with defects in hemostasis—whether congenital or acquired. Presently, there is an ever increasing aging population, increasing medical indications for patients to be placed on medications affecting portions of the hemostatic mechanisms (antiplatelet medications, anti-thrombotic medications), and increasing numbers of these medications for physicians to choose from to manage thrombo-embolic diseases or the risk for thrombo-embolic diseases in their patients. Consequently, oral and maxillofacial surgeons are called upon to treat patients with medication-induced alterations in hemostasis in their offices on a routine basis.

The literature has recognized, and oral and maxillofacial surgeons have witnessed and managed, excessive surgical/post-surgical bleeding in patients with defects in hemostasis—including medication-induced alterations. However, the literature is also replete with the potential dangers to patients when anticoagulation medications are withheld. Managing patients peri-operatively is now seen as a balance between minimizing surgical/post-surgical bleeding and minimizing the risks of a thrombo-embolic event peri-operatively. Inherent in minimizing these risks is a thorough understanding of hemostasis, the medications impacting normal hemostasis, and medical and surgical options to aid in peri-operative hemostasis.

This presentation is intended as a review for the practicing oral and maxillofacial surgeon. The physiology and pathophysiology of hemostasis and natural anti-coagulation will be reviewed in detail. A central theme will be a thorough review of contemporary pharmacologic agents impacting on hemostasis and thrombosis. A literature-based review of the peri-operative management of patients on medications affecting hemostasis will be provided. Also, the future of pharmacologic agents in hemostasis will be reviewed.

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References 

1. Assael LA. Hemostasis is a Shared Responsibility. J Oral Maxillofac Surg. 2003;61:1377–1378
2. Todd DW. Evidence to Support an Individual Approach to Modification of Oral Anticoagulant Therapy for Ambulatory Oral Surgery. J Oral Maxillofac Surg. 2005;63:536–539
3. Beirne OR. Evidence to Continue Oral Anticoagulant Therapy for Ambulatory Oral Surgery. J Oral Maxillofac Surg. 2005;63:540–545
4. In:  Hoffman R, et al. editor. Hematology: Basic Principles and Practice second edition. New York: Churchilll Livingstone; 1995;