A systematic review on the use of topical hemostats in trauma and emergency surgery

Abstract

BackgroundA wide variety of hemostats are available as adjunctive measures to improve hemostasis during surgical procedures if residual bleeding persists despite correct application of conventional methods for hemorrhage control. Some are considered active agents, since they contain fibrinogen and thrombin and actively participate at the end of the coagulation cascade to form a fibrin clot, whereas others to be effective require an intact coagulation system. The aim of this study is to provide an evidence-based approach to correctly select the available agents to help physicians to use the most appropriate hemostat according to the clinical setting, surgical problem and patient’s coagulation status.MethodsThe literature from 2000 to 2016 was systematically screened according to PRISMA [Preferred Reporting Items for Systematic Reviews and Meta-Analyses] protocol. Sixty-six articles were reviewed by a panel of experts to assign grade of recommendation (GoR) and level of evidence (LoE) using the GRADE [Grading of Recommendations Assessment, Development and Evaluation] system, and a national meeting was held.ResultsFibrin adhesives, in liquid form (fibrin glues) or with stiff collagen fleece (fibrin patch) are effective in the presence of spontaneous or drug-induced coagulation disorders. Mechanical hemostats should be preferred in patients who have an intact coagulation system. Sealants are effective, irrespective of patient’s coagulation status, to improve control of residual oozing. Hemostatic dressings represent a valuable option in case of external hemorrhage at junctional sites or when tourniquets are impractical or ineffective.ConclusionsLocal hemostatic agents are dissimilar products with different indications. A knowledge of the properties of each single agent should be in the armamentarium of acute care surgeons in order to select the appropriate product in different clinical conditions.

A Comparative Efficacy Evaluation of Recombinant Topical Thrombin (RECOTHROM®) With A Gelatin Sponge Carrier Versus Topical Oxidized Regenerated Cellulose (TABOTAMP®/SURGICEL®) In A Porcine Liver Bleeding Model

“…Hemostatic agent failure is associated with increased blood loss and the corresponding greater likelihood of blood product transfusion, longer operative times, and greater use of surgical consumables, which result in poorer patient outcomes and higher economic costs. 4,9,10,12 When the time to hemostasis of all ORC Orange-yellow coloring represents fresh fibrin, red represents mature fibrin, erythrocytes are stained yellow, and connective tissue is shown in blue. Liver tissue can be seen in the lower part of each picture with the patch material covering the superficial organ defect on top.…”

“…11 However, the efficacy of ORC is reduced in patients with coagulopathy and may therefore be an inappropriate choice of hemostat when treating these patients. 12 Hemostatic agents can be broadly characterized as active or passive based on their mechanism of action (MoA). Active hemostatic agents, such as thrombin (stand-alone or combined with gelatin), fibrin sealants and advanced patches act biologically at the end of the coagulation cascade, accelerating the natural clotting process, and are effective regardless of whether patients have received anticoagulants or antiplatelet therapies, or not.…”

Comparison of the efficacy of five standard topical hemostats: a study in porcine liver and spleen models of surgical bleeding

“…A variety of absorbable topical hemostats, including mechanical hemostats, are available to help control bleeding during a range of surgical procedures [7][8][9][10][11]. When directly applied to the bleeding surface, mechanical hemostats, which are appropriate for use in patients with an intact coagulation system, provide a barrier to stop the ow of blood and a surface that passively promotes platelet activation and aggregation, and assists clot formation [8][9][10][11]. Mechanical hemostats are among the easiest to use, safest, and most low-cost hemostats available [12][13][14].…”

“…Gelatin sponge products differ with respect to gelatin density and porosity, which affects their biochemical and biological effects [16][17][18]. ORC hemostatic products contain plant-derived continuous cellulose bers in fabric formats that are easier to handle than gelatin sponge products, and as opposed to pH-neutral gelatin products, have a pH-lowering effect that contributes to hemostatic and bactericidal properties [7,8,10]. Thanks to these features, ORC products are especially well known and widely used [19][20][21].…”

Bleeding in Dental Surgery

“…Bleeding control is an important step during dental surgery procedures [2] because excessive bleeding complicates surgery and increases the risk of morbidity. To avoid such complications when long-lasting bleeding occurs, despite the proper use of traditional techniques for hemorrhage control, a broad range of hemostatic agents are available, as adjunctive measures to enhance hemostasis in the course of dental surgeries [3]. Despite the expressive rise in the amount and types of topical hemostats in the past decade, high-level evidence regarding the management of these agents during bleeding in dental surgery is still lacking.…”