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

Novel Flowable Hemostatic Agent ActiClot: Efficacy and Safety Assessment in Rat and Porcine Models

Background/Objectives: This study evaluated the hemostatic performance and safety of ActiClot (ATC), a new flowable hemostatic agent, through in vivo tests. Methods: ATC was compared with the commercially available FLOSEAL®. ATC consists of carboxymethyl starch, thrombin, and sorbitol powders in Syringe I, and a calcium chloride solution in Syringe II. In vivo evaluation used rat liver bleeding and porcine heart bleeding models. Safety was assessed using a rat subcutaneous implantation model. Results: ATC significantly reduced hemostasis time (70.00 ± 7.35 s) compared to gauze control (240.63 ± 32.31 s) in the rat liver model, showing a 70% reduction. There was no significant difference between ATC and FLOSEAL® (58.75 ± 13.42 s). In the porcine heart model, both agents achieved 100% hemostasis within 3 min, with no significant difference in success rates within 2 min (ATC 87.5%, FLOSEAL® 75%). The gauze control group failed in all tests. The rat subcutaneous implantation model showed no visual ATC observation after 48 h, indicating biocompatibility, with no inflammation observed. Conclusions: ATC demonstrated effective hemostatic performance similar to FLOSEAL® in two in vivo models, with faster hemostasis in the rat liver model. It also showed excellent safety and biocompatibility, indicating its potential for surgical and emergency bleeding control.

In Vitro Hemostatic Activity of Novel Fish Gelatin-Alginate Sponge (FGAS) Prototype

A hemostatic sponge prototype was successfully synthesized from fish gelatin as an alternative to mammalian gelatin; it was mixed with alginate in certain combinations, double cross-linked with calcium ions, and gamma irradiated at a dose of 20 kGy to improve the characteristics and effectiveness of its function as a local hemostatic agent. There were improvements in the physicochemical and mechanical properties, porosity index, absorption capacity, biodegradation properties, biocompatibility, and hemocompatibility of the fish gelatin-alginate sponge (FGAS) prototypes compared with the pure fish gelatin sponge. Hemostatic activity tests showed that the means for clotting time, prothrombin time, and activated partial thromboplastin time were shorter in the FGAS prototype than in the negative control, and there was no significant difference compared with the commercial gelatin sponge. The hemostatic mechanism of the FGAS prototype combined a passive mechanism as a concentrator factor and an active mechanism through the release of calcium ions as a coagulation factor in the coagulation cascade process.

Chitosan Hemostatic Dressings: Properties and Surgical Applications

Wounds caused by trauma and/or surgery represent a significant challenge in contemporary medical practice, requiring innovative approaches to promote optimal healing and reduce the risk of bleeding and complications resulting from it. In this context, chitosan, a natural polysaccharide derived from chitin, represents an ideal material for the study and application of medical devices, in the form of dressings, in wound management for pre- and/or post-operative wounds due to its ability to induce hemostasis and its high biocompatibility with biological tissues. The aim of this work was to discuss the structural characteristics, properties and application of chitosan-based hemostatic dressings in hemostatic processes resulting from pre- or post-surgical approaches.

Silk Fibroin and Its Nanocomposites for Wound Care: A Comprehensive Review

For most individuals, wound healing is a highly organized, straightforward process, wherein the body transitions through different phases in a timely manner. However, there are instances where external intervention becomes necessary to support and facilitate different phases of the body's innate healing mechanism. Furthermore, in developing countries, the cost of the intervention significantly impacts access to treatment options as affordability becomes a determining factor. This is particularly true in cases of long-term wound treatment and management, such as chronic wounds and infections. Silk fibroin (SF) and its nanocomposites have emerged as promising biomaterials with potent wound-healing activity. Driven by this motivation, this Review presents a critical overview of the recent advancements in different aspects of wound care using SF and SF-based nanocomposites. In this context, we explore various formats of hemostats and assess their suitability for different bleeding situations. The subsequent sections discuss the primary causes of nonhealing wounds, i.e., prolonged inflammation and infections. Herein, different treatment strategies to achieve immunomodulatory and antibacterial properties in a wound dressing were reviewed. Despite exhibiting excellent pro-healing properties, few silk-based products reach the market. This Review concludes by highlighting the bottlenecks in translating silk-based products into the market and the prospects for the future.

Coagulant Protein-Free Blood Coagulation Using Catechol-Conjugated Adhesive Chitosan/Gelatin Double Layer

Since the discovery of polyphenolic underwater adhesion in marine mussels, researchers strive to emulate this natural phenomenon in the development of adhesive hemostatic materials. In this study, bio-inspired hemostatic materials that lead to pseudo-active blood coagulation, utilizing traditionally passive polymer matrices of chitosan and gelatin are developed. The two-layer configuration, consisting of a thin, blood-clotting catechol-conjugated chitosan (CHI-C) layer and a thick, barrier-functioning gelatin (Geln) ad-layer, maximizes hemostatic capability and usability. The unique combination of coagulant protein-free condition with CHI-C showcases not only coagulopathy-independent blood clotting properties (efficacy) but also exceptional clinical potential, meeting all necessary biocompatibility evaluation (safety) without inclusion of conventional coagulation triggering proteins such as thrombin or fibrinogen. As a result, the CHI-C/Geln is approved by the Ministry of Food and Drug Safety (MFDS, Republic of Korea) as a class II medical device. Hemostatic efficacy observed in multiple animal models further demonstrates the superiority of CHI-C/Geln sponges in achieving quick hemostasis compared to standard treatments. This study not only enriches the growing body of research on mussel-inspired materials but also emphasizes the potential of biomimicry in developing advanced medical materials, contributing a promising avenue toward development of readily accessible and affordable hemostatic materials.

Protein-based tissue adhesive reduces time to haemostasis in peripheral vascular surgery

OBJECTIVES

The aim of this study was to evaluate the effectiveness of protein-based tissue adhesive (Bioglue®) in reducing time to haemostasis in patients undergoing peripheral vascular surgery.

METHODS

From January to December 2021, 100 consecutive patients from 4 centres have been treated with open peripheral vascular surgery including upper and lower limb interventions. Patients have been allocated in each centre into control with no use of Bioglue® (Group no-Bio, 50 patients) or use of Bioglue® (Group Bio, 50 patients) by a block randomization method 10:10 until the required sample size was reached. Perioperative parameters including time to haemostasis, number of adjunctive stitches, and in-hospital bleeding have been analysed and compared in the two groups by means of mean independent-samples tT -test and Gehan-Breslow-Wilcoxon test.

RESULTS

Both groups were homogeneous in terms of demographic data, preoperative risk factors, and preoperative medical therapy except for a higher percentage of active smokers in Group Bio (52% vs. 24%, p = 0.004). Femoral endarterectomy was most common in Group Bio (44% vs. 24%, p = 0.03), whilst the percentage of lower limb vein bypasses was higher in Group no-Bio (50% vs. 36%, p = 0.03). Bovine pericardium was the preferred material in Group Bio (20 cases, 40%), whilst autologous vein is mostly used in Group no-Bio (26 cases, 52%) (p = 0.01). Time to haemostasis was faster in Group Bio (4.4 vs. 9.6 minutes, p < 0.001). The need for adjunctive stitches was higher in Group no-Bio (8 cases, 16%, Group Bio vs. 25 cases, 50%, Group no-Bio; p < 0.001). The overall rate of in-hospital bleeding, including those requiring reintervention, was not different between the two groups (9 cases, 18%, Group Bio vs. 7 cases, 14%, Group no-Bio; p = 0.39).

CONCLUSIONS

The protein-based tissue adhesive Bioglue® reduced time to haemostasis and need for adjunctive stitches in peripheral vascular surgery. However, it did not affect the overall rate of perioperative bleedings. Further studies with larger sample sizes are needed to validate these outcomes.

Review of Evidence Supporting the Arista™ Absorbable Powder Hemostat

Background

Uncontrolled and diffuse bleeding is a dreaded event during open and laparoscopic surgery that may lead to postoperative complications, obstruction of the surgical field that reduces visualization, and prolonged operating times. Powder hemostats can be used to control bleeding and are easy to use, have a safe profile, and can achieve broad coverage area at a low cost.

Methods

A strategic literature search of peer-reviewed, English language studies was conducted to capture evidence on the clinical efficacy and safety of a Microporous Polysaccharide Hemosphere (MPH) based Hemostat (Arista™ Absorbable Hemostat (Arista™ AH)).

Results

Six preclinical studies were found which supported the use of MPH in various animal models of laparoscopic and open surgery, all of which demonstrated its safety and efficacy. Five single-arm and 11 comparative clinical studies similarly supported the efficacy and safety of MPH in various surgery types, including cardiac, renal, and dermatologic surgery.

Conclusion

Published evidence supports the safe and effective use of MPH across a variety of surgical settings.

Protective Topical Dual-Sided Nanofibrous Hemostatic Dressing Using Mussel and Silk Proteins with Multifunctionality of Hemostasis and Anti-Bacterial Infiltration

Topical hemostatic agents are preferred for application to sensitive bleeding sites because of their immediate locoregional effects with less tissue damage. However, the majority of commercial hemostatic agents fail to provide stable tissue adhesion to bleeding wounds or act as physical barriers against contaminants. Hence, it has become necessary to investigate biologically favorable materials that can be applied and left within the body post-surgery. In this study, a dual-sided nanofibrous dressing for topical hemostasis is electrospun using a combination of two protein materials: bioengineered mussel adhesive protein (MAP) and silk fibroin (SF). The wound-adhesive inner layer is fabricated using dihydroxyphenylalanine (DOPA)-containing MAP, which promotes blood clotting by aggregation of hemocytes and activation of platelets. The anti-adhesive outer layer is composed of alcohol-treated hydrophobic SF, which has excellent spinnability and mechanical strength for fabrication. Because both proteins are fully biodegradable in vivo and biocompatible, the dressing would be suitable to be left in the body. Through in vivo evaluation using a rat liver damage model, significantly reduced clotting time and blood loss are confirmed, successfully demonstrating that the proposed dual-sided nanofibrous dressing has the right properties and characteristics as a topical hemostatic agent having dual functionality of hemostasis and physical protection.

Hypersensitive Reaction of Oxidized Regenerated Cellulose Powder in Total Knee Arthroplasty

The powdered form of oxidized regenerated cellulose (ORC powder) is a widely used biodegradable hemostatic material in the field of surgery. There are several reports of its effectiveness and safety; however, excessive foreign body reactions remain a concern for surgeons in total knee arthroplasty (TKA). A 70-year-old woman who underwent unilateral TKA using ORC powder to control perioperative blood loss exhibited a skin rash around her operated knee at six days postoperatively. These reactions were potentially hypersensitive to ORC powder. After receiving antiallergic medication for 18 days, the skin rash disappeared. Although there are several reports on the safety of ORC powder, inadequate intraoperative lavage of the product may induce hypersensitive reactions such as skin rash.

Hemostatic Efficacy of Oxidized Regenerated Cellulose Powder in Le Fort 1 Osteotomy

A challenging aspect of Le Fort I osteotomy is bleeding control. Osteotomy techniques, devices, drugs, and anesthetic management have been reported to reduce bleeding; however, there are no reports on the use of hemostatic agents. We aimed to evaluate the hemostatic efficacy of a new topical absorbent hemostatic agent, Surgicel Powder, consisting of oxidized regenerated cellulose (ORC). We reviewed the records of 40 patients who underwent Le Fort I surgery for jaw deformities, with or without cleft lip and palate. Twenty of the 40 patients did not have cleft lips or cleft palates (CLCP); the remaining 20 had CLCP. In each group, an absorbent hemostatic agent was used in 10 patients but not in the other 10. Total blood loss and operative time for each group were evaluated. In the jaw deformity without CLCP group, the amount of bleeding with or without ORC was 112.0±33.8 and 158.6±75.3 mL, respectively, with a significant difference between groups ( P <0.05). Operative time with or without ORC was 206.4±31.3 and 238.3±42.5 minutes, respectively, with a significant difference observed between groups ( P <0.05). In the jaw deformity with CLCP group, the amount of bleeding with or without ORC was 199.7±64.6 and 476.8±104.8 mL, respectively, with a significant difference between groups ( P <0.05). Operative time with or without ORC was 213.7±27.6 and 220.8±41.5 minutes, respectively, with no significant difference between groups ( P =0.329). In conclusion, oxidized regenerated cellulose powder may be a beneficial hemostatic agent for reducing blood loss during Le Fort I osteotomy.

In situ generated hemostatic adhesives: From mechanisms of action to recent advances and applications

Conventional surgical closure techniques, such as sutures, clips, or skin closure strips, may not always provide optimal wound closure and may require invasive procedures, which can result in potential post-surgical complications. As result, there is a growing demand for innovative solutions to achieve superior wound closure and improve patient outcomes. To overcome the abovementioned issues, in situ generated hemostatic adhesives/sealants have emerged as a promising alternative, offering a targeted, controllable, and minimally invasive procedure for a wide variety of medical applications. The aim of this review is to provide a comprehensive overview of the mechanisms of action and recent advances of in situ generated hemostatic adhesives, particularly protein-based, thermoresponsive, bioinspired, and photocrosslinkable formulations, as well as the design challenges that must be addressed. Overall, this review aims to enhance a comprehensive understanding of the latest advancements of in situ generated hemostatic adhesives and their mechanisms of action, with the objective of promoting further research in this field.

Comparison of a gelatin thrombin versus a modified absorbable polymer as a unique treatment for severe hepatic hemorrhage in swine

There are many surgical techniques (packing, Pringle maneuver, etc.) and hemostatic agents to manage hepatic bleeding in trauma surgery. This study compares the effectiveness of two different types of hemostatic agents, one is an active flowable hemostat and the other is a passive hemostat made of modified absorbable polymers [MAP]. Both surgical technique and hemostatic agents can be used together as a means of controlling bleeding. We have hypothesized that a single hemostatic agent might be as effective as a unique hemostatic surgical technique. Twenty swine were prospectively randomized to receive either active Flowable (Floseal) or passive MAP powder (PerClot) hemostatic agents. We used a novel severe liver injury model that caused exsanguinating hemorrhage. The main outcome measure was total blood loss volume. The total volume of blood loss, from hepatic injury to minute 120, was significantly lower in the Flowable group (407.5 cm3; IqR: 195.0-805.0 cm3) compared to MAP group (1107.5 cm3; IqR: 822.5 to 1544.5 cm3) (Hodges-Lehmann median difference: - 645.0 cm3; 95% CI: - 1144.0 to - 280.0 cm3; p = 0.0087). The rate of blood loss was significantly lower in the flowable group compared with the MAP group as measured from time of injury to minutes 3, 9, 12, and 120 (except for 6 min). The mean arterial pressure gradually recovered in the flowable group by 24 h, whereas in the MAP group, the mean arterial pressure was consistently stayed below baseline values. Kaplan-Meier survival analysis indicated similar rates of death between study groups (Logrank test p = 0.3395). Both the flowable and the MAP hemostatic agents were able to effectively control surgical bleeding in a novel severe liver injury model, however, the flowable gelatin-thrombin agent provided quicker and better bleed control.

Influence of Lavender Essential Oil on the Physical and Antibacterial Properties of Chitosan Sponge for Hemostatic Applications

Uncontrollable bleeding continues to stand as the primary cause of fatalities globally following surgical procedures, traumatic incidents, disasters, and combat scenarios. The swift and efficient management of bleeding through the application of hemostatic agents has the potential to significantly reduce associated mortality rates. One significant drawback of currently available hemostatic products is their susceptibility to bacterial infections at the bleeding site. As this is a prevalent issue that can potentially delay or compromise the healing process, there is an urgent demand for hemostatic agents with antibacterial properties to enhance survival rates. To mitigate the risk of infection at the site of a lesion, we propose an alternative solution in the form of a chitosan-based sponge and antimicrobial agents such as silver nanoparticles (AgNPs) and lavender essential oil (LEO). The aim of this work is to provide a new type of hemostatic sponge with an antibacterial barrier against a wide range of Gram-positive and Gram-negative microorganisms: Staphylococcus epidermidis 2018 and Enterococcus faecalis VRE 2566 (Gram-positive strains) and Klebsiella pneumoniae ATCC 10031 and Escherichia coli ATCC 35218 (Gram-negative strains).

Effects of Thrombin-Based Hemostatic Agent in Total Knee Arthroplasty: Meta-Analysis

The effectiveness of Floseal, a thrombin-based hemostatic matrix, in total knee arthroplasty (TKA) in minimizing blood loss and transfusion requirements remains a topic of debate. This meta-analysis aims to evaluate the up-to-date randomized controlled trials (RCTs) on the efficacy and safety of Floseal in TKA. A comprehensive search was conducted in electronic databases to identify relevant RCTs. The methodological quality of the included studies was assessed, and data extraction was performed. The pooled effect sizes were calculated using standardized mean difference (SMD) or odds ratios (OR) with 95% confidence intervals (CIs). Eight studies involving 904 patients were included in the meta-analysis. The use of a thrombin-based hemostatic agent significantly reduced hemoglobin decline (SMD = -0.49, 95% CI: -0.92 to -0.07) and the risk of allogenic transfusion (OR = 0.45, 95% CI: 0.25 to 0.81) but showed no significant difference in the volume of drainage or total blood loss. Funnel plots showed no evidence of publication bias. This meta-analysis provides robust evidence supporting the effectiveness of Floseal in reducing hemoglobin decline and transfusion in TKA. Further well-designed RCTs with longer follow-up periods are warranted to assess long-term efficacy and safety.

Prevention of esophageal stenosis via in situ cross-linkable alginate/gelatin powder in a new submucosal exfoliation model in rats

Endoscopic submucosal dissection (ESD) for the treatment of esophageal mucosal lesions often leads to postoperative stenosis, causing difficulty in swallowing, known as dysphagia. In this study, we developed an in situ cross-linkable powder composed of alginate, gelatin, transglutaminase (TG), and calcium chloride ions (Ca2+), which can be administered through a 1.5 m-long and 3.2 mm-diameter endoscopic instrument channel. The powdered mixture of alginate and gelatin quickly formed a hydrogel by absorbing body fluids and was cross-linked by TG and Ca2+, which adhered ex vivo to porcine submucosal layers for over 2 weeks. In addition, we developed a new submucosal exfoliation model in rats that induced severe stenosis, similar to the ESD-induced stenosis models in clinical practice. When administered to the new rat model, the powder system effectively reduced the severity of esophageal stenosis based on body weight change monitoring, anatomical findings, and histological analysis. The body weight of the rats was maintained at the initial weight on postoperative day 14 (POD14), and epithelialization on POD7 and 14 improved to almost 100%. Additionally, collagen accumulation and the number of α-SMA-positive cells decreased due to powder administration. Therefore, these findings indicate that the in situ cross-linkable powder can prevent esophageal stenosis after ESD.

Short Peptide Nanofiber Biomaterials Ameliorate Local Hemostatic Capacity of Surgical Materials and Intraoperative Hemostatic Applications in Clinics

Short designer self-assembling peptide (dSAP) biomaterials are a new addition to the hemostat group. It may provide a diverse and robust toolbox for surgeons to integrate wound microenvironment with much safer and stronger hemostatic capacity than conventional materials and hemostatic agents. Especially in noncompressible torso hemorrhage (NCTH), diffuse mucosal surface bleeding, and internal medical bleeding (IMB), with respect to the optimal hemostatic formulation, dSAP biomaterials are the ingenious nanofiber alternatives to make bioactive neural scaffold, nasal packing, large mucosal surface coverage in gastrointestinal surgery (esophagus, gastric lesion, duodenum, and lower digestive tract), epicardiac cell-delivery carrier, transparent matrix barrier, and so on. Herein, in multiple surgical specialties, dSAP-biomaterial-based nano-hemostats achieve safe, effective, and immediate hemostasis, facile wound healing, and potentially reduce the risks in delayed bleeding, rebleeding, post-operative bleeding, or related complications. The biosafety in vivo, bleeding indications, tissue-sealing quality, surgical feasibility, and local usability are addressed comprehensively and sequentially and pursued to develop useful surgical techniques with better hemostatic performance. Here, the state of the art and all-round advancements of nano-hemostatic approaches in surgery are provided. Relevant critical insights will inspire exciting investigations on peptide nanotechnology, next-generation biomaterials, and better promising prospects in clinics.

Pediatric surgical interventions on ECMO

Extra Corporeal Membrane Oxygenation (ECMO) has historically been reserved for refractory pulmonary and cardiac support in children and adult. Operative intervention on ECMO was traditionally contraindicated due to hemorrhagic complications exacerbated by critical illness and anticoagulation needs. With advancements in ECMO circuitry and anticoagulation strategies operative procedures during ECMO have become feasible with minimal hemorrhagic risks. Here we review anticoagulation and operative intervention considerations in the pediatric population during ECMO cannulation. Pediatric surgical interventions currently described in the literature while on ECMO support include thoracotomy/thoracoscopy, tracheostomy, laparotomy, and injury related procedures i.e. wound debridement. A patient should not be precluded from a surgical intervention while on ECMO, if the surgery is indicated.

The novel use and feasibility of hemostatic oxidized regenerated cellulose agent (SurgiGuard®): multicenter retrospective study

Background

SurgiGuard® is an absorbent hemostatic agent based on oxidized regenerated cellulose. The efficacy, effects and safety of SurgiGuard® are equivalent to existing hemostatic agents in animal experiments. This study was designed to confirm that the use of SurgiGuard® alone is effective, safe and feasible compared to combination with other hemostatic methods.

Methods

We retrospectively reviewed clinical data from 12 surgery departments in seven tertiary centers in South Korea nationwide. All surgeries were performed between January and December 2018.

Results

A total of 807 patients were enrolled; 447 patients (55.4%) had comorbidities. The rate of major surgery (operative time ≥4 hours) was 44% (n=355 patients). Regarding the type of SurgiGuard® used in surgery, more than 70% of minor surgeries used non-woven types. In major surgery, more than five SurgiGuards® were used in 7.3% (26 patients), and the proportion of co-usage (with four other hemostatic products) was 19.7% (70 patients). The effectiveness score was higher when SurgiGuard® was used alone in both major (5.3±0.5 vs. 5.1±0.6, P=0.048) and minor surgery (5.4±0.6 vs. 5.2±0.4, P<0.001). Seven patients had immediate re-bleeding, and all of them used SurgiGuard® and other products together. Nine patients reported adverse effects, such as abscess, bleeding, or leg swelling, but we found no direct correlation with SurgiGuard®.

Conclusions

SurgiGuard® exhibited greater effectiveness when used alone. No direct adverse effects associated with SurgiGuard® use were reported, and SurgiGuard® had stable feasibility. Prospective comparative studies are needed in the future.

Physico chemical characterisation of pectin incorporated gelatin sponge and its functional evaluation in modulating contact activation haemostasis

Even though it is a common occurrence in practice, maintaining haemostasis can sometimes become a challenging issue in case of trauma, perioperative period, coagulation disorders, cancers, etc. Hemostatic materials are extensively used to assist in the cessation of bleeding. However, the definition of efficiency of haemostasis varies between intended procedures. This paper explores the feasibility of incorporating agents to increase the efficiency of local haemostasis. Pectin or β -D galacto hexopyranuronic acid/β Gal A, a structural polysaccharide widely present in terrestrial plants having an intrinsic hemostatic potential, is blended with gelatin and is explored in modulating passive haemostasis. The sponges are physico chemically characterized, and their hemostatic efficiency is evaluated in vitro using various assays. Biocompatibility evaluation is done by in vitro cytotoxicity assay. The results suggest that this biopolymer combination is a promising candidate for hemostatic control.

Synthetic Pressure Sensitive Adhesives for Biomedical Applications

Pressure sensitive adhesives are components of everyday products found in homes, offices, industries, and hospitals. Serving the general purpose of fissure repair and object fixation, pressure sensitive adhesives indiscriminately bind surfaces, as long as contact pressure is administered at application. With that being said, the chemical and material properties of the adhesive formulation define the strength of a pressure sensitive adhesive to a particular surface. Given our increased understanding of the viscoelastic material requirements as well as the intermolecular interactions at the binding interface required for functional adhesives, pressure sensitive adhesives are now being explored for greater use. New polymer formulations impart functionality and degradability for both internal and external applications. This review highlights the structure-property relationships between polymer architecture and pressure sensitive adhesion, specifically for medicine. We discuss the rational, molecular-level design of synthetic polymers for durable, removable, and biocompatible adhesion to wet surfaces like tissue. Finally, we examine prevalent challenges in biomedical wound closure and the new, innovative strategies being employed to address them. We conclude by summarizing the progress of current research, identifying additional clinical opportunities, and discussing future prospects.

Fibrin Sealant TISSEEL Lyo as a haemostatic agent in vascular surgery: Results of randomized, controlled, patient-blinded, multicentre clinical study in the Russian population

BACKGROUND

This phase III, controlled, patient-blinded, multicentre study in two parallel, equal-sized treatment groups compared the efficacy and safety of TISSEEL Lyo, fibrin sealant versus Manual Compression (MC) with surgical gauze pads for use as a haemostatic agent in patients who underwent vascular surgery in Russia.

METHODS

Adult patients, both genders, who received peripheral vascular expanded polytetrafluoroethylene conduits and had suture line bleeding after surgical haemostasis were enrolled. Patients were randomized to be treated with TISSEEL Lyo or MC. The bleeding needed additional treatment and had to be assessed as grade 1 or 2 bleeding according to the Validated Intraoperative Bleeding scale. The primary efficacy endpoint was the proportion of patients achieving haemostasis at 4 min after treatment application (T4) at the study suture line, which was maintained until the closure of the surgical wound. The secondary efficacy endpoints included the proportion of patients achieving haemostasis at 6 min (T6) and 10 min (T10) after treatment application at the study suture line, which was maintained until closure of the surgical wound, as well as the proportion of patients with intraoperative and postoperative rebleeding. Safety outcomes included incidence of adverse events (AEs), surgical site infections and graft occlusions.

RESULTS

A total of 110 patients were screened; 104 patients were randomized: (TISSEEL Lyo: 51 [49%] patients; MC: 53 [51%] patients). T4 haemostasis was achieved in 43 (84.3%) patients in the TISSEEL Lyo group and in 11 (20.8%) patients in the MC group (p < 0.001). Significantly more patients in TISSEEL Lyo group achieved the haemostasis at T6 (relative risk (RR) of achieving haemostasis 1.74 [95% confidence interval (CI) 1.37; 2.35]) and T10 (RR 1.18 [95% CI 1.05; 1.38]) versus MC. No one had intraoperative rebleeding. Postoperative rebleeding was reported only in one patient in the MC group. No treatment-emergent serious AEs (TESAEs) related to TISSEEL Lyo/MC, TESAEs leading to withdrawal and TESAEs leading to death were reported in patients during the study.

CONCLUSIONS

Data demonstrated TISSEEL Lyo had clinically and statistically significant superiority to MC as a haemostatic agent in vascular surgery at all measured time points including 4, 6 and 10 min and had proven to be safe.

Poly-Catecholic Functionalization of Biomolecules for Rapid Gelation, Robust Injectable Bioadhesion, and Near-Infrared Responsiveness

Mussel-inspired catechol-functionalization of degradable natural biomaterials has garnered significant interest as an approach to achieve bioadhesion for sutureless wound closure. However, conjugation capacity in standard coupling reactions, such as carbodiimide chemistry, is limited by low yield and lack of abundant conjugation sites. Here, a simple oxidative polymerization step before conjugation of catechol-carrying molecules (i.e., 3,4-dihydroxy-l-phenylalanine, l-DOPA) as a potential approach to amplify catechol function in bioadhesion of natural gelatin biomaterials is proposed. Solutions of gelatin modified with poly(l-DOPA) moieties (GelDOPA) are characterized by faster physical gelation and increased viscosity, providing better wound control on double-curved tissue surfaces compared to those of l-DOPA-conjugated gelatin. Physical hydrogels treated topically with low concentrations of NaIO4 solutions are crosslinked on-demand via through-thickness diffusion. Poly(l-DOPA) conjugates enhance crosslinking density compared to l-DOPA conjugated gelatin, resulting in lower swelling and enhanced cohesion in physiological conditions. Together with cohesion, more robust bioadhesion at body temperature is achieved by poly(l-DOPA) conjugates, exceeding those of commercial sealants. Further, poly(l-DOPA) motifs introduced photothermal responsiveness via near-infrared (NIR) irradiation for controlled drug release and potential applications in photothermal therapy. The above functionalities, along with antibacterial activity, render the proposed approach an effective biomaterial design strategy for wound closure applications.

A Comparison of Hemostatic Activities of Zeolite-Based Formulary Finishes on Cotton Dressings

The need for affordable effective prehospital hemostatic dressings to control hemorrhage has led to an increased interest in new dressing design approaches. Here we consider the separate components of fabric, fiber, and procoagulant nonexothermic zeolite-based formulations on design approaches to accelerated hemostasis. The design of the fabric formulations was based on incorporation of zeolite Y as the principal procoagulant, with calcium and pectin to adhere and enhance the activity. Unbleached nonwoven cotton when combined with bleached cotton displays enhanced properties related to hemostasis. Here, we compare sodium zeolite with ammonium zeolite formulated on fabrics utilizing pectin with pad versus spray-dry-cure and varied fiber compositions. Notably, ammonium as a counterion resulted in shorter times to fibrin and clot formation comparable to the procoagulant standard. The time to fibrin formation as measured by thromboelastography was found to be within a range consistent with modulating severe hemorrhage control. The results indicate a correlation between fabric add-on and accelerated clotting as measured by both time to fibrin and clot formation. A comparison between the time to fibrin formation in calcium/pectin formulations and pectin alone revealed an enhanced clotting effect with calcium decreasing by one minute the time to fibrin formation. Infra-red spectra were employed to characterize and quantify the zeolite formulations on the dressings.

Multidisciplinary paper on patient blood management in cardiothoracic surgery in the UK: perspectives on practice during COVID-19

The coronavirus (COVID-19) pandemic disrupted all surgical specialties significantly and exerted additional pressures on the overburdened United Kingdom (UK) National Health Service. Healthcare professionals in the UK have had to adapt their practice. In particular, surgeons have faced organisational and technical challenges treating patients who carried higher risks, were more urgent and could not wait for prehabilitation or optimisation before their intervention. Furthermore, there were implications for blood transfusion with uncertain patterns of demand, reductions in donations and loss of crucial staff because of sickness and public health restrictions. Previous guidelines have attempted to address the control of bleeding and its consequences after cardiothoracic surgery, but there have been no targeted recommendations in light of the recent COVID-19 challenges. In this context, and with a focus on the perioperative period, an expert multidisciplinary Task Force reviewed the impact of bleeding in cardiothoracic surgery, explored different aspects of patient blood management with a focus on the use of haemostats as adjuncts to conventional surgical techniques and proposed best practice recommendations in the UK.

Efficacy of a novel polyoxazoline-based hemostatic patch in liver and spleen surgery

BACKGROUND

A new hemostatic sealant based on a N-hydroxy-succinimide polyoxazoline (NHS-POx) polymer was evaluated to determine hemostatic efficacy and long-term wound healing and adverse effects in a large animal model of parenchymal organ surgical bleeds.

METHODS

Experiment 1 included 20 pigs that were treated with two NHS-POx patch prototypes [a gelatin fibrous carrier (GFC) with NHS-POx and an oxidized regenerated cellulose (ORC) with poly(lactic-co-glycolic acid)-NHS-POx:NU-POx (nucleophilically activated polyoxazoline)], a blank gelatin patch (GFC Blank), TachoSil^® and Veriset™ to stop moderate liver and spleen punch bleedings. After various survival periods (1-6 weeks), pigs were re-operated to evaluate patch degradation and parenchymal healing. During the re-operation, experiment 2 was performed: partial liver and spleen resections with severe bleeding, and hemostatic efficacy was evaluated under normal and heparinized conditions of the two previous prototypes and one additional NHS-POx patch. In the third experiment an improved NHS-POx patch (GATT-Patch; GFC-NHS-POx and added 20% as nucleophilically activated polyoxazoline; NU-POx) was compared with TachoSil^®, Veriset™ and GFC Blank on punch bleedings and partial liver and spleen resections for rapid (10s) hemostatic efficacy.

RESULTS

NHS-POx-based patches showed better (GFC-NHS-POx 83.1%, ORC-PLGA-NHS-POx: NU-POx 98.3%) hemostatic efficacy compared to TachoSil^® (25.0%) and GFC Blank (43.3%), and comparable efficacy with Veriset™ (96.7%) on moderate standardized punch bleedings on liver and spleen. All patches demonstrated gradual degradation over 6 weeks with a reduced local inflammation rate and an improved wound healing. For severe bleedings under non-heparinized conditions, hemostasis was achieved in 100% for Veriset™, 40% for TachoSil and 80-100% for the three NHS-POx prototypes; similar differences between patches remained for heparinized conditions. In experiment 3, GATT-Patch, Veriset™, TachoSil and GFC Blank reached hemostasis after 10s in 100%, 42.8%, 7.1% and 14.3%, respectively, and at 3 min in 100%, 100%, 14.3% and 35.7%, respectively, on all liver and spleen punctures and resections.

CONCLUSIONS

NHS-POx-based patches, and particularly the GATT-Patch, are fast in achieving effective hemostatic sealing on standardized moderate and severe bleedings without apparent long-term adverse events.

Preparation of Nile tilapia skin collagen powder by low-temperature and comprehensive evaluation of hemostasis and wound healing

Nile tilapia (hereinafter referred to as tilapia) is a species with high economic value and extensive cultivation. In this study, the low-temperature Nile tilapia skin collagen powder (TSCP) was prepared by liquid nitrogen freeze pulverization. After physical and chemical analysis of its properties, it was found that its characteristics were similar to those of type I collagen. The three-dimensional helix structure of protein peptide is good and non denatured. It shows that cryogenic temperature guarantees the activity of TSCP. In addition, TSCP has good biocompatibility. Specifically, it has good blood compatibility, lacks cytotoxicity, will not cause intradermal stimulation and acute systemic toxicity, and has no obvious rejection after implantation. In the rat liver hemorrhage model and wound repair model, compared with the commercially available bovine collagen powder (BSCP), TSCP has better blood coagulation ability: the shortest hemostatic time (135 s) and wound healing efficiency: the wound healing is obvious on the 14th day. The results of this study indicate that the TSCP is an ideal candidate for hemostatic agents and wound healing dressings.

Endoscopic Management Using Novel Haemostatic Agents for Immediate Bleeding during Endoscopic Retrograde Cholangio-Pancreatography

Bleeding after endoscopic sphincterotomy (ES) remains as a major challenge during ERCP procedure. Standard endoscopic haemostatic procedures have demonstrated good performance for bleeding control. Novel endoscopic haemostatic agents have also been widely used in gastrointestinal bleeding management. Regardless, there is still a paucity of high-quality evidence evaluating the practicality of these agents in ERCP. This case series study was performed on the patients who underwent ERCP procedure in a tertiary referral private hospital within 2 years period. Post-ES immediate bleeding is defined as the onset of bleeding at the time of sphincterotomy. Treatment groups for post-ES bleeding are divided into (1) standard haemostatic methods and (2) novel haemostatic agents. There were 40 patients who received standard haemostatic treatment and 60 patients who received novel haemostatic agents. Initial haemostasis was achieved in all patients. Two patients who received standard haemostatic treatment had rebleeding. Meanwhile, no patients in novel haemostatic treatment group had rebleeding. In conclusion, novel haemostatic agent can be considered as an easy and practical method in daily practice, especially when an ERCP procedure is performed. Further studies with larger sample size which, if possible, can also include a cost-effectiveness analysis are still required to implement these agents as a standard procedure in clinical practice. (This abstract has been presented at the American College of Gastroenterology meeting October 2021).

Time-dependent effects of cellulose and gelatin-based hemostats on cellular processes of wound healing

INTRODUCTION

Oxidized regenerated cellulose-based (ORC - TABOTAMP), oxidized non-regenerated cellulose-based (ONRC - RESORBA CELL), and gelatin-based (GELA - GELITA TUFT-IT) hemostats are commonly used in surgery. However, their impact on the wound healing process remains largely unexplored. We here assess time-dependent effects of exposure to these hemostats on fibroblast-related wound healing processes.

MATERIAL AND METHODS

Hemostats were applied to fibroblast cell cultures for 5-10 (short-), 30 and 60 min (intermediate-) and 24 h (long-term). Representative images of the hemostat degradation process were obtained, and the pH value was measured. Cell viability, apoptosis and migration were analyzed after the above exposure times at 3, 6 and 24 h follow-up. Protein levels for tumor necrosis factor α (TNF-α) and transforming-growth factor β (TGF-β) were assessed.

RESULTS

ORC and ONRC reduced pH values during degradation, while GELA proved to be pH-neutral. Hemostat structural integrity was prolonged for GELA (vs. ORC and ONRC). TGF-β and TNF-α levels were reduced for ORC and ONRC (vs. GELA and control) (p < 0.05). Further, exposure of ORC and ONRC for longer than 5-10 min reduced cell viability vs. GELA and control at 3 h post-exposure (p < 0.05). Similarly, cell migration was impaired with ORC and ONRC exposure longer than 60 min at 24 h follow-up (p < 0.05).

CONCLUSIONS

Short-term exposure to ORC and ONRC impairs relevant wound healing-related processes in fibroblasts, and alters protein levels of key mediating cytokines. GELA does not show similar effects. We conclude that GELA may be preferred over ORC and ONRC over short-, intermediate- and long-term exposures. Future validation of the clinical relevance is warranted.

Safety and Hemostatic Effectiveness of SURGICEL® Powder in Mild and Moderate Intraoperative Bleeding

This postmarket clinical study evaluated the safety and effectiveness of the novel adjunctive topical hemostat SURGICEL® Powder (SURGICEL®-P), a powdered form of oxidized regenerated cellulose. In a prospective, open-label, single-arm multicenter trial, adult surgical subjects with mild-to-moderate bleeding for which conventional hemostatic methods were impractical/ineffective were treated with SURGICEL®-P. Descriptive analyses included hemostatic success rate at 3, 5, and 10 min, rebleeding and thromboembolic events, SURGICEL®-P-related serious adverse events requiring surgical intervention, and SURGICEL®-P ease of use (questionnaire). In 8 centers, 103 subjects were enrolled with a median (range) age of 64.0 (33.0-88.0) years. Surgeries were open (53.4%) or laparoscopic/thoracoscopic (46.6%) and mostly urological (37.9%) and abdominal (32.0%) procedures. Bleeding sites included various tissue types, with a median (range) surface area of 4 (0.02-72.0) cm2. Hemostatic success rates were 77.7%, 87.4%, and 92.2% at 3, 5, and 10 min, respectively. In 7 subjects (6.8%), investigators reverted to standard of care. No safety signals were identified. Two deaths occurred with causes unrelated to SURGICEL®-P. Investigators favorably evaluated the ease of use of the SURGICEL®-P device. SURGICEL®-P is safe and effective in controlling mild-to-moderate bleeding in a broad range of surgical procedures. The trial was registered at https://clinicaltrials.gov as NCT03762200.

Advances in Hemostatic Hydrogels That Can Adhere to Wet Surfaces

Currently, uncontrolled bleeding remains a serious problem in emergency, surgical and battlefield environments. Despite the specific properties of available hemostatic agents, sealants, and adhesives, effective hemostasis under wet and dynamic conditions remains a challenge. In recent years, polymeric hydrogels with excellent hemostatic properties have received much attention because of their adjustable mechanical properties, high porosity, and biocompatibility. In this review, to investigate the role of hydrogels in hemostasis, the mechanisms of hydrogel hemostasis and adhesion are firstly elucidated, the adhesion design strategies of hemostatic hydrogels in wet environments are briefly introduced, and then, based on a comprehensive literature review, the studies and in vivo applications of wet-adhesive hemostatic hydrogels in different environments are summarized, and the improvement directions of such hydrogels in future studies are proposed.

Idebenone-loaded wound dressings promote diabetic wound healing through downregulation of Il1b, Nfkb genes and upregulation of Fgf2 gene

Reactive oxygen species (ROS) are overproduced in diabetic wounds and retard the healing response. Considering the antioxidative function of idebenone, its exogenous administration may quench excessive ROS and promote diabetic wound healing. In the current study, idebenone was loaded into polyvinyl alcohol (PVA) /calcium alginate scaffolds at three different concentrations of 1 w/w%, 2 w/w%, and 3 w/w%. Various in vitro experiments were performed to characterize the developed wound dressings. Cell viability assay showed that scaffolds loaded with 1 w/w% idebenone had significantly better protection under oxidative stress and exhibited higher cell viability. Therefore, the dressings containing 1% drug was chosen to treat diabetic wounds in rat model. Wound healing assay showed that the dressings loaded with 1% drug had significantly higher rate of wound size reduction, collagen deposition, and epithelial thickness. Gene expression study showed that wound healing was accompanied by modulation of inflammatory response, protection against oxidative stress, and increasing angiogenesis-related genes. This preliminary research suggests that PVA/calcium alginate/1% idebenone scaffolds can be considered as a potential treatment modality to treat diabetic wounds in the clinic. However, more extensive studies at gene and protein expression levels are required to understand its exact mechanism of healing effects.

Validity of a novel ex vivo porcine liver perfusion model for studying haemostatic products

Introduction

We developed a novel normothermic ex vivo porcine liver perfusion model with whole blood in order to have alternatives for animal experiments in the research and development of new local haemostatic agents. This study aims to assess the construct and content validity of this model.

Methods

In this study we performed two ex vivo experiments using nine livers and one in vivo experiment using six female Norsvin Topigs pigs: (1) ex vivo liver perfusion for establishing physiological blood parameters of the perfused liver and controlled heparinization, (2) ex vivo liver perfusion with a surgical injury and (3) a surgical liver injury in anaesthetized pigs with and without heparin.

Results

Ex vivo coagulation parameters were comparable to in vivo with heparin. Blood gas values and metabolic parameters were comparable between ex vivo and in vivo with heparin, but significantly different compared with in vivo baseline, with the exception of (partial pressure of oxygen (PO2). Activated clotting time (ACT) values significantly differed depending on the heparin doses. The coagulation parameters fibrinogen, activated partial thromboplastin time, prothrombin time and ACT were rather constant during the 4 h ex vivo perfusion. Haemostatic efficacy of commercially available products was comparable between in vivo with heparin and the ex vivo liver perfusion experiment.

Conclusion

This novel ex vivo liver perfusion model demonstrates good construct and content validity for at least 4 h of perfusion. The model is an easily accessible, table-top, tunable and effective alternative for the in vivo testing of (new) haemostatic products on their haemostatic properties. Validité d'un nouveau modèle de perfusion hépatique porcin ex-vivo pour l'étude des produits hémostatiques Résumé

Gelatin-based hemostatic agents for medical and dental application at a glance: A narrative literature review

Uncontrolled bleeding is linked to higher treatment costs, risk of post-surgical infection and increased disease and death. Hemostatic agents are used to treat excessive bleeding. A good hemostatic agent controls bleeding effectively, reduces the need for blood transfusion, removes the need for systemic drugs to control bleeding, results in shorter surgery time, and reduces the cost and length of hospital stay of the patient. Gelatin-based hemostatic agents have been widely used in medical and dental procedures, owing to their biodegradability and biocompatibility, as well as availability and low cost of raw materials. In this narrative literature review, we discuss the background and different types of gelatin-based hemostatic agents in medical and dental procedures, the comparison of gelatin-based and non-gelatin-based hemostatic agents, and the usage and development of enhanced or novel gelatin-based hemostatic agents. Gelatin-based hemostatic agents are effective and important part of bleeding control, as evidenced by its wide application in medicine and dentistry. The development of novel combination gelatin-based hemostatic agents has much potential for effective control of excessive bleeding.

Complications of oxidised regenerated cellulose at Caesarean section: A report of two cases

Two patients underwent surgical deliveries within four months of one another at a single maternity unit. Both patients had complications of infection-like symptoms such as offensive vaginal discharge and pyrexia, months following their caesarean sections resulting in further surgery. The incidents were thought to be secondary to woven oxidised regenerated cellulose (ORC) use. ORC must be used according to its relevant product literature which can vary between brands. Surgeons must keep abreast of changes to the haemostatic material provided to them and therefore the properties of each type, especially when faced with bleeding not suitable for suturing or electrocautery.

Recent advances in biopolymer-based hemostatic materials

Hemorrhage is the leading cause of trauma-related deaths, in hospital and pre-hospital settings. Hemostasis is a complex mechanism that involves a cascade of clotting factors and proteins that result in the formation of a strong clot. In certain surgical and emergency situations, hemostatic agents are needed to achieve faster blood coagulation to prevent the patient from experiencing a severe hemorrhagic shock. Therefore, it is critical to consider appropriate materials and designs for hemostatic agents. Many materials have been fabricated as hemostatic agents, including synthetic and naturally derived polymers. However, compared to synthetic polymers, natural polymers or biopolymers, which include polysaccharides and polypeptides, have greater biocompatibility, biodegradability, and processibility. Thus, in this review, we focus on biopolymer-based hemostatic agents of different forms, such as powder, particles, sponges, and hydrogels. Finally, we discuss biopolymer-based hemostats currently in clinical trials and offer insight into next-generation hemostats for clinical translation.

Effectiveness of Hemopatch® versus Surgicel® Original to control mild and moderate liver bleeding

Background

Adjunct hemostats can be of use in certain surgical settings. We compared the effectiveness of two hemostats, Hemopatch® and Surgicel® Original in controlling bleeding from liver lesions in an experimental model.

Methods

Control of grades 1 (mild) and 2 (moderate) bleeding (according to the Validated Intraoperative Bleeding [VIBe] SCALE) was assessed for 10 min after Hemopatch® (n = 198) or Surgicel® Original (n = 199) application on 397 liver surface lesions. The primary endpoint was hemostatic success (reaching VIBe SCALE grade 0 at 10 min). The secondary endpoint was time to hemostasis (time to reach and maintain grade 0). A generalized linear mixed model and an accelerated failure time model were used to assess the primary and secondary endpoints, respectively.

Results

The overall hemostatic success rate of Hemopatch® was statistically significantly superior to that of Surgicel® Original (83.8% versus 73.4%; p = 0.0036; odds ratio [OR] 2.38, 95% confidence interval [CI] 1.33–4.27) and time to hemostasis was reduced by 15.9% (p = 0.0032; 95% CI 0.749–0.944). Grade 2 bleeds treated with Hemopatch® had statistically significantly higher hemostatic success (71.7% versus 48.5%; p = 0.0007; OR 2.97, 95% CI 1.58–5.58) and shorter time to hemostasis (49.6% reduction, p = 3.6 × 10^–8); differences for grade 1 bleeds (hemostatic success rate or time to hemostasis) were not statistically significant.

Conclusions

Hemopatch® provided better control of VIBe SCALE bleeding compared to Surgicel® Original for Grade 2 bleeds in this porcine model, highlighting the importance of choosing a suitable hemostat to optimize control of bleeding during surgery.

Effects of Algan hemostatic agent foam in rat femoral artery injury model: A randomized animal trial

Background/Aim: Nowadays, many deaths are related to vessel injury-induced blood loss. Failure to control bleeding also increases the risk of death. This study aimed to investigate the hemostatic effects of the Algan Hemostatic Agent (AHA) foam application in a rat model in which severe femoral artery bleeding was induced. Methods: Fourteen rats were randomly assigned to two groups: (1) control (physiological saline) (n = 7) and (2) AHA foam (n = 7). The left femoral artery of the rats was incised and when the bleeding started, and the area was pressed with another sponge for 10 s in all rats. Afterwards, physiological saline solution impregnated gauze or AHA foam was placed over same area. A chronometer was started and area was checked after 2 min. If no bleeding occurred during the first 2 min of application, it was recorded as “successful”. If bleeding occurred, the same procedure was repeated up to three times. If hemostasis could not be achieved even after the third application, it was considered a failure, and “failed” was recorded. All animals were sacrificed under high anesthesia for least 10 min after the experiment. Results: Application of AHA resulted in complete (100%) control of bleeding in all rats within the first 2 min. In control group, hemostasis was achieved in 1 out of 7 (14.3%) rats by the third application. Failure was recorded for the remaining six rats. The hemostatic success rate of the AHA foam was significantly higher than the rates of control group (P = 0.005). Conclusion: AHA foam is a very effective hemostatic agent and can be applied easily on vascular trauma models. Further studies are needed to elucidate hemostatic features of AHA.

Facing Trauma and Surgical Emergency in Space: Hemorrhagic Shock

Although the risk of trauma in space is low, unpredictable events can occur that may require surgical treatment. Hemorrhage can be a life-threatening condition while traveling to another planet and after landing on it. These exploration missions call for a different approach than rapid return to Earth, which is the policy currently adopted on the International Space Station (ISS) in low Earth orbit (LEO). Consequences are difficult to predict, given the still scarce knowledge of human physiology in such environments. Blood loss in space can deplete the affected astronaut’s physiological reserves and all stored crew supplies. In this review, we will describe different aspects of hemorrhage in space, and by comparison with terrestrial conditions, the possible solutions to be adopted, and the current state of the art.

Exploring Adverse Events and Utilization of Topical Hemostatic Agents in Surgery

Background and Objectives:

This retrospective study provides preliminary qualitative assessment of the adverse events (AEs), focusing on pelvic and abdominal AEs and patient outcomes reported for three hemostatic agents used in gynecologic surgery.

Methods:

Utilization rates for oxidized regenerated cellulose powder (ORC), polysaccharide powder (PSP), and fibrin sealant solution (FSS) were obtained from hospitals via the Premier Healthcare databases for all surgical procedures from January 1, 2018 to September 30, 2020. All reported cases were extracted from the Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE) database for ORC and PSP and from the FDA Adverse Event Reporting System (FAERS) database for FSS. Distributions of AEs by anatomical site (MAUDE/FAERS) and surgical procedures by specialty (Premier) were evaluated for each product. Number of cases and number and types of AEs were compared to the total utilization for each product.

Results:

PSP was the most used product during the period analyzed (n = 126,509 uses), followed by FSS (n = 80,628 uses), and ORC (n = 41,583 uses). Distribution of surgical procedures by anatomical site varied significantly between hemostatic agents (p < 0.001). ORC was associated with more patient cases with AEs and numbers of reported AEs compared with PSP and FSS (p < 0.001). ORC was associated with higher number of infections than PSP (p < 0.001) and FSS (p < 0.001).

Conclusion:

These findings suggest that ORC use in abdominal and pelvic surgery may result in more postoperative complications compared with non-ORC hemostatic agents. Further prospective randomized studies are needed to compare efficacy and safety of these products.

In Vitro Evaluation of Real-Time Viscoelastic and Coagulation Properties of Various Classes of Topical Hemostatic Agents Using a Novel Contactless Nondestructive Technology

Hemorrhaging is the main cause of death among combat and civilian injuries and has significant clinical and economic consequences. Despite their vital roles in bleeding management, an optimal topical hemostatic agent (HA) has yet to be developed for a particular scenario. This is partly due to a lack of an overarching quantitative testing technology to characterize the various classes of HAs in vitro. Herein, the feasibility of a novel, contactless, and nondestructive technique to quantitatively measure the shear storage modulus (G') and clotting properties of whole blood in contact with different dosages of eight topical HAs, including particulates and gauze-like and sponge-like systems, was assessed. The real-time G'-time profiles of these blood/HA systems revealed their distinct biomechanical behavior to induce and impact coagulation. These were analyzed to characterize the clot initiation time, clotting rate, clotting time, and apparent stiffness of the formed clots (both immediately and temporally), which were correlated with their reported hemostatic mechanisms of action. Moreover, the HAs that worked independently from the natural blood clotting cascade were identified and quantified through this technology. In sum, this study indicated that the nondestructive nature of the technology may offer a promising tool for accurate, quantitative in vitro measurements of the clotting properties of various classes of HAs, which may be used to better predict their in vivo outcomes.

Engineered Molecular Therapeutics Targeting Fibrin and the Coagulation System: a Biophysical Perspective

The coagulation cascade represents a sophisticated and highly choreographed series of molecular events taking place in the blood with important clinical implications. One key player in coagulation is fibrinogen, a highly abundant soluble blood protein that is processed by thrombin proteases at wound sites, triggering self-assembly of an insoluble protein hydrogel known as a fibrin clot. By forming the key protein component of blood clots, fibrin acts as a structural biomaterial with biophysical properties well suited to its role inhibiting fluid flow and maintaining hemostasis. Based on its clinical importance, fibrin is being investigated as a potentially valuable molecular target in the development of coagulation therapies. In this topical review, we summarize our current understanding of the coagulation cascade from a molecular, structural and biophysical perspective. We highlight single-molecule studies on proteins involved in blood coagulation and report on the current state of the art in directed evolution and molecular engineering of fibrin-targeted proteins and polymers for modulating coagulation. This biophysical overview will help acclimatize newcomers to the field and catalyze interdisciplinary work in biomolecular engineering toward the development of new therapies targeting fibrin and the coagulation system.

Hemostats in Spine Surgery: Literature Review and Expert Panel Recommendations

Bleeding in spine surgery is a common occurrence but when bleeding is uncontrolled the consequences can be severe due to the potential for spinal cord compression and damage to the central nervous system. There are many factors that influence bleeding during spine surgery including patient factors and those related to the type of surgery and the surgical approach to bleeding. There are a range of methods that can be employed to both reduce the risk of bleeding and achieve hemostasis, one of which is the adjunct use of hemostatic agents. Hemostatic agents are available in a variety of forms and materials and with considerable variation in cost, but specific evidence to support their use in spine surgery is sparse. A literature review was conducted to identify the pre-, peri-, and postsurgical considerations around bleeding in spine surgery. The review generated a set of recommendations that were discussed and ratified by a wider expert group of spine surgeons. The results are intended to provide a practical guide to the selection of hemostats for specific bleeding situations that may be encountered in spine surgery.

2021 ELSO Adult and Pediatric Anticoagulation Guidelines

DISCLAIMER

These guidelines for adult and pediatric anticoagulation for extracorporeal membrane oxygenation are intended for educational use to build the knowledge of physicians and other health professionals in assessing the conditions and managing the treatment of patients undergoing ECLS / ECMO and describe what are believed to be useful and safe practice for extracorporeal life support (ECLS, ECMO) but these are not necessarily consensus recommendations. The aim of clinical guidelines are to help clinicians to make informed decisions about their patients. However, adherence to a guideline does not guarantee a successful outcome. Ultimately, healthcare professionals must make their own treatment decisions about care on a case-by-case basis, after consultation with their patients, using their clinical judgment, knowledge and expertise. These guidelines do not take the place of physicians' and other health professionals' judgment in diagnosing and treatment of particular patients. These guidelines are not intended to and should not be interpreted as setting a standard of care or be deemed inclusive of all proper methods of care nor exclusive of other methods of care reasonably directed to obtaining the same results. The ultimate judgment must be made by the physician and other health professionals and the patient in light of all the circumstances presented by the individual patient, and the known variability and biological behavior of the clinical condition. These guidelines reflect the data at the time the guidelines were prepared; the results of subsequent studies or other information may cause revisions to the recommendations in these guidelines to be prudent to reflect new data, but ELSO is under no obligation to provide updates. In no event will ELSO be liable for any decision made or action taken in reliance upon the information provided through these guidelines.

Biomaterials for Hemostasis

Uncontrolled bleeding is a major problem in trauma and emergency medicine. While materials for trauma applications would certainly find utility in traditional surgical settings, the unique environment of emergency medicine introduces additional design considerations, including the need for materials that are easily deployed in austere environments. Ideally, these materials would be available off the shelf, could be easily transported, and would be able to be stored at room temperature for some amount of time. Both natural and synthetic materials have been explored for the development of hemostatic materials. This review article provides an overview of classes of materials used for topical hemostats and newer developments in the area of injectable hemostats for use in emergency medicine. Expected final online publication date for the Annual Review of Biomedical Engineering, Volume 24 is June 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Pro-Con Debate: Viscoelastic Hemostatic Assays Should Replace Fixed Ratio Massive Transfusion Protocols in Trauma

Major trauma patients at risk of traumatic coagulopathy are commonly treated with early clotting factor replacement to maintain hemostasis and prevent microvascular bleeding. In the United States, trauma transfusions are often dosed by empiric, low-ratio massive transfusion protocols, which pair plasma and platelets in some ratio relative to the red cells, such as the "1:1:1" combination of 1 units of red cells, 1 unit of plasma, and 1 donor's worth of pooled platelets. Empiric transfusion increases the rate of overtransfusion when unnecessary blood products are administered based on a formula and not on at patient's hemostatic profile. Viscoelastic hemostatic assays (VHAs) are point-of-care hemostatic assays that provided detailed information about abnormal clotting pathways. VHAs are used at many centers to better target hemostatic therapies in trauma. This Pro/Con section will address whether VHA guidance should replace empiric fixed ratio protocols in major trauma.

Comparison of Efficacy and Safety of Non-Regenerated and Regenerated Oxidized Cellulose Based Fibrous Haemostats

Purpose: Various forms of local haemostats are increasingly used routinely in surgical procedures. Our work is the first comparison of the efficacy and safety of non-regenerated and regenerated oxidized cellulose based fibrous haemostats. Methods: The haemostatic efficacy and safety of fibrous haemostats based on ONRC and ORC were compared in a randomized multicenter study. The primary endpoint was successful haemostasis within 3 minutes of application and no need for surgical revision within 12 hours after the procedure for recurrent bleeding. Results: There was a significant difference in the rate of successful haemostasis in 3 minutes that was achieved in 82% and 55% in the ONRC and ORC groups, respectively (confidence interval 99%; p = 0.009). Mean time to haemostasis was 133.9 ± 53.95 seconds and 178.0 ± 82.33 seconds, in the ONRC, and ORC group, respectively (p = 0.002). Revision surgery for re-bleeding was necessary in 0 (0%), and 1 (2%) of patients in the ONRC, and ORC group, respectively. No adverse events were reported. Conclusion: Fibrous haemostat based on ONRC was non-inferior compared to fibrous haemostat based on ORC when used in accordance with its intended purpose, and was safe and efficient.

Engineering a naturally derived hemostatic sealant for sealing internal organs

Controlling bleeding from a raptured tissue, especially during the surgeries, is essentially important. Particularly for soft and dynamic internal organs where use of sutures, staples, or wires is limited, treatments with hemostatic adhesives have proven to be beneficial. However, major drawbacks with clinically used hemostats include lack of adhesion to wet tissue and poor mechanics. In view of these, herein, we engineered a double-crosslinked sealant which showed excellent hemostasis (comparable to existing commercial hemostat) without compromising its wet tissue adhesion. Mechanistically, the engineered hydrogel controlled the bleeding through its wound-sealing capability and inherent chemical activity. This mussel-inspired hemostatic adhesive hydrogel, named gelatin methacryloyl-catechol (GelMAC), contained covalently functionalized catechol and methacrylate moieties and showed excellent biocompatibility both in vitro and in vivo. Hemostatic property of GelMAC hydrogel was initially demonstrated with an in vitro blood clotting assay, which showed significantly reduced clotting time compared to the clinically used hemostat, Surgicel®. This was further assessed with an in vivo liver bleeding test in rats where GelMAC hydrogel closed the incision rapidly and initiated blood coagulation even faster than Surgicel®. The engineered GelMAC hydrogel-based seaalant with excellent hemostatic property and tissue adhesion can be utilized for controlling bleeding and sealing of soft internal organs.

Polymeric Materials for Hemostatic Wound Healing

Hemorrhage is one of the greatest threats to life on the battlefield, accounting for 50% of total deaths. Nearly 86% of combat deaths occur within the first 30 min after wounding. While external wound injuries can be treated mostly using visual inspection, abdominal or internal hemorrhages are more challenging to treat with regular hemostatic dressings because of deep wounds and points of injury that cannot be located properly. The need to treat trauma wounds from limbs, abdomen, liver, stomach, colon, spleen, arterial, venous, and/or parenchymal hemorrhage accompanied by severe bleeding requires an immediate solution that the first responders can apply to reduce rapid exsanguinations from external wounds, including in military operations. This necessitates the development of a unique, easy-to-use, FDA-approved hemostatic treatment that can deliver the agent in less than 30 s and stop bleeding within the first 1 to 2 min at the point of injury without application of manual pressure on the wounded area.

Topical hemostatic agents in neurosurgery, a comprehensive review: 15 years update

Hemostasis in neurosurgery is of utmost importance. Bleeding management is one of the crucial steps of each neurosurgical procedure. Several strategies, namely thermal, mechanical, electric, and chemical, have been advocated to face blood loss within the surgical field. Over time, countless hemostatic agents and devices have been proposed. Furthermore, the ever-growing recent technological innovation has made available several novel and interesting tools. Pursuant to their impact on surgical practice, we perceived the imperative to update our previous disclosure paper. Therefore, we reviewed the literature and analyzed technical data sheets of each product in order to provide an updated and comprehensive overview in regard to chemical properties, mechanisms of action, use, complications, tricks, and pitfalls of topical hemostatic agents.