Hemostatic strategies for uncontrolled bleeding: A comprehensive update

Alginate based hemostatic materials for bleeding management: A review

Severe bleeding has caused significant financial losses as well as a major risk to the lives and health of military and civilian populations. Under some situations, the natural coagulation mechanism of the body is unable to achieve fast hemostasis without the use of hemostatic drugs. Thus, the development of hemostatic materials and techniques is essential. Improving the quality of life and survival rate of patients and minimizing bodily damage requires fast, efficient hemostasis and prevention of bleeding. Alginate is regarded as an outstanding hemostatic polymer because of its non-immunogenicity, biodegradability, good biocompatibility, simple gelation, non-toxicity, and easy availability. This review summarizes the basics of hemostasis and emphasizes the recent developments regarding alginate-based hemostatic systems. Structural modifications and mixing with other materials have widely been used for the improvement of hemostatic characteristics of alginate and for making multifunctional medical devices that not only prevent uncontrolled bleeding but also have antibacterial characteristics, drug delivery abilities, and curing effects. This review is hoped to prepare critical insights into alginate modifications for better hemostatic properties.

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.

A Laparoscopically Compatible Rapid-Adhesion Bioadhesive for Asymmetric Adhesion, Non-Pressing Hemostasis, and Seamless Seal

Bioadhesive hydrogels offer unprecedented opportunities in hemostatic agents and tissue sealing; however, the application of existing bioadhesive hydrogels through narrow spaces to achieve strong adhesion in fluid-rich physiological environments is challenged either by undesired indiscriminate adhesion or weak wet tissue adhesion. Here, a laparoscopically compatible asymmetric adhesive hydrogel (aAH) composed of sprayable adhesive hydrogel powders and injectable anti-adhesive glue is proposed for hemostasis and to seal the bloody tissues in a non-pressing way, allowing for preventing postoperative adhesion. The powders can seed on the irregular bloody wound to rapidly absorb interfacial fluid, crosslink, and form an adhesive hydrogel to hemostatic seal (blood clotting time and tissue sealing in 10 s, ≈200 mm Hg of burst pressure in sealed porcine tissues). The aAH can be simply formed by crosslinking the upper powder with injectable glue to prevent postoperative adhesion (adhesive strength as low as 1 kPa). The aAH outperforms commercial hemostatic agents and sealants in the sealing of bleeding organs in live rats, demonstrating superior anti-adhesive efficiency. Further, the hemostatic seamless sealing by aAH succeeds in shortening the time of warm ischemia, decreasing the blood loss, and reducing the possibility of rebleeding in the porcine laparoscopic partial nephrectomy model.

The Role of Resuscitative Endovascular Balloon Occlusion of the Aorta

Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been utilized by trauma surgeons at the bedside for over a decade in both civilian and military settings. Both translational and clinical research suggest it is superior to resuscitative thoracotomy for specific patient populations. Technological advancements in recent years have significantly enhanced the safety profile of REBOA. Resuscitative balloon occlusion of the aorta has also swiftly found implementation in patients in shock from non-traumatic hemorrhage.

From emerging modalities to advanced applications of hydrogel piezoelectrics based on chitosan, gelatin and related biological macromolecules: A review

The rapid development of functional materials and manufacturing technologies is fostering advances in piezoelectric materials (PEMs). PEMs can convert mechanical energy into electrical energy. Unlike traditional power sources, which need to be replaced and are inconvenient to carry, PEMs have extensive potential applications in smart wearable and implantable devices. However, the application of conventional PEMs is limited by their poor flexibility, low ductility, and susceptibility to fatigue failure. Incorporating hydrogels, which are flexible, stretchable, and self-healing, providing a way to overcome these limitations of PEMs. Hydrogel-based piezoelectric materials (H-PEMs) not only resolve the shortcomings of traditional PEMs but also provide biocompatibility and more promising application potential. This paper summarizes the working principle of H-PEMs. Recent advances in the use of H-PEMs as sensors and in vitro energy harvesting devices for smart wearable devices are described in detail, with emphasis on application scenarios in human body like fingers, wrists, ankles, and feet. In addition, the recent progress of H-PEMs in implantable medical devices, especially the potential applications in human body parts such as bones, skin, and heart, are also elaborated. In addition, challenges and potential improvements in H-PEMs are discussed.

Quaternized chitosan/oxidized bacterial cellulose cryogels with shape recovery for noncompressible hemorrhage and wound healing

Management of noncompressible torso hemorrhage is an urgent clinical requirement, desiring biomaterials with rapid hemostasis, anti-infection and excellent resilient properties. In this research, we have prepared a highly resilient cryogel with both hemostatic and antibacterial effects by chemical crosslinking and electrostatic interaction. The network structure crosslinked by quaternized chitosan and genipin was interspersed with oxidized bacterial cellulose after lyophilization. The as-prepared cryogel can quickly return to the original volume when soaking in water or blood. The appropriately sized pores in the cryogel help to absorb blood cells and further activate coagulation, while the quaternary ammonium salt groups on quaternized chitosan inhibit bacterial infections. Both cell and animal experiments showed that the cryogel was hypotoxic and could promote the regeneration of wound tissue. This research provides a new pathway for the preparation of double crosslinking cryogels and offers effective and safe biomaterials for the emergent bleeding management of incompressible wounds.

Self-Oxidated Hydrophilic Chitosan Fibrous Mats for Fatal Hemorrhage Control

Enriching erythrocytes and platelets in seconds and providing a fast seal in bleeding sites is vital to fatal hemorrhage control. Herein, hydrophilic chitosan fibrous mats (CECS-D mats) are fabricated by introducing hydrophilic carboxyethyl groups and subsequent catechol groups onto chitosan fibers. Due to strong hydrophilicity, CECS-D mats exhibit rapid liquid-absorption capacity, especially instantaneous absorptivity to the rabbit blood, which can achieve erythrocyte and platelet aggregations quickly by concentrating blood, thus promoting the formation of blood clots. Furthermore, the mats are self-oxidated to form quinone-amine adducts or quinone multimers by adjusting pH conditions, which not only provides tissue adhesion but also induces erythrocyte aggregation and platelet adhesion, further enhancing the seal and triggering quick closure to achieve fast hemostasis. Therefore, the mats reveal superior hemostatic performance in rabbit liver and spleen models over CECS mats and gauze. Especially in the fatal femoral artery injury model of rabbits, the mats reduce the blood loss by ∼75% and shortened the bleeding time by ∼50% compared with CECS mats, which have been reported to have the same hemostatic effect as commercialized Celox products in a swine femoral artery injury model. Besides, the mats are cytocompatible and degradable as well as antibacterial. This chitosan mat is a promising hemostatic material for fatal hemorrhage control.

Functional hemostatic hydrogels: design based on procoagulant principles

Uncontrolled hemorrhage results in various complications and is currently the leading cause of death in the general population. Traditional hemostatic methods have drawbacks that may lead to ineffective hemostasis and even the risk of secondary injury. Therefore, there is an urgent need for more effective hemostatic techniques. Polymeric hemostatic materials, particularly hydrogels, are ideal due to their biocompatibility, flexibility, absorption, and versatility. Functional hemostatic hydrogels can enhance hemostasis by creating physical circumstances conducive to hemostasis or by directly interfering with the physiological processes of hemostasis. The procoagulant principles include increasing the concentration of localized hemostatic substances or establishing a physical barrier at the physical level and intervention in blood cells or the coagulation cascade at the physiological level. Moreover, synergistic hemostasis can combine these functions. However, some hydrogels are ineffective in promoting hemostasis or have a limited application scope. These defects have impeded the advancement of hemostatic hydrogels. To provide inspiration and resources for new designs, this review provides an overview of the procoagulant principles of hemostatic hydrogels. We also discuss the challenges in developing effective hemostatic hydrogels and provide viewpoints.

Management of non-compressible hemorrhage and re-bleeding by a liquid hemostatic polysaccharide floccuronic acid

Effective management of excessive bleeding requires liquid hemostatic agents, especially in scenarios involving uncompressible and postoperative hemorrhage. This study introduces the microbial exopolysaccharide floccuronic acid (FA) as a liquid hemostatic agent, characterized by a high weight average molecular weight of 2.38 × 108 Da. The investigation focuses on the flocculation effect, hemostatic efficiency in both in vitro and in vivo settings, elucidating its hemostatic mechanism, and assessing its safety profile. Results reveal that FA solution significantly accelerates the coagulation process, leading to the formation of compact clots while specifically interfering with fibrin. Notably, FA demonstrates excellent hemostatic effects in animal liver models and a rat arterial rebleeding model. The biocompatible and biodegradable characteristics further underscore FA's potential as a valuable liquid hemostatic material, particularly suited for non-compressible and re-bleeding scenarios.

Kenaf Seed Cysteine Protease (KSCP) Inhibits the Intrinsic Pathway of the Blood Coagulation Cascade and Platelet Aggregation

BACKGROUND

Thrombosis is the key event that obstructs the flow of blood throughout the circulatory system, leading to stroke, myocardial infarction and severe cardiovascular complications. Currently, available antithrombotic drugs trigger several life-threatening side effects.

INTRODUCTION

Antithrombotic agents from natural sources devoid of adverse effects are grabbing high attention. In our previous study, we reported the antioxidant, anticoagulant and antiplatelet properties of kenaf seed protein extract. Therefore, in the current study, purification and characterization of cysteine protease from kenaf seed protein extract responsible for potential antithrombotic activity was undertaken.

METHODS

Purification of KSCP (Kenaf Seed Cysteine Protease) was carried out using gel permeation and ion exchange column chromatography. The purity of the enzyme was evaluated by SDS PAGE (Sodium Dodecyl-Sulfate Polyacrylamide Gel Electrophoresis). RP-HPLC (Reverse Phase High-Performance Liquid Chromatography), MALDI-TOF (Matrix-Assisted Laser Desorption Ionization Time-Of-Flight) and CD (Circular Dichroism techniques) were employed for its characterization. Proteolytic, fibrinolytic and kinetic study was done using spectroscopy. Plasma recalcification time, Prothrombin Time (PT), Thrombin clotting time (TCT), Activated Partial Thromboplastin Time (APTT), bleeding time and platelet aggregation studies were carried out for antithrombotic activity of KSCP.

RESULT

A single sharp band of KSCP was observed under both reduced and non-reduced conditions, having a molecular mass of 24.1667kDa. KSCP was found to contain 30.3% helix turns and 69.7% random coils without a beta-pleated sheet. KSCP digested casein and fibrin, and its activity was inhibited by iodoacetic acid (IAA). KSCP was optimally active at pH 6.0 at the temperature of 40°C. KSCP exhibited anticoagulant properties by interfering in the intrinsic pathway of the blood coagulation cascade. Furthermore, KSCP dissolved both whole blood and plasma clots and platelet aggregation.

CONCLUSION

KSCP purified from kenaf seed extract showed antithrombotic potential. Hence, it could be a better candidate for the management of thrombotic complications.

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.

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).

Biomimetic Hemostatic Powder Derived from Coacervate-Immobilized Thermogelling Copolymers

Intrinsic hemostasis is an innate body response to prevent bleeding based on the sol-gel transition of blood. However, it is often inadequate for exceptional situations, such as acute injury and coagulation disorders, which typically require immediate medical intervention. Herein, we report the preparation of an efficient hemostatic powder, composed of tannic acid (TA), poly(ethylene glycol) (PEG), and poly(d,l-lactide-co-glycolide)-b-poly(ethylene glycol)-b-poly(d,l-lactide-co-glycolide) triblock copolymer (TB), for biomimetic hemostasis at the bleeding sites. TA has a high affinity for biomolecules and cells and can form coacervates with PEG driven by hydrogen bonding. TB enhances the mechanical strength and provides thermoresponsiveness. The hemostatic powder can rapidly transit into a physical and biodegradable seal on wet substrates under physiological conditions, demonstrating its promise for the generation of instant artificial clots. Importantly, this process is independent of the innate blood clotting process, which could benefit those with blood clotting disorders. This biomimetic hemostatic powder is an adaptive topical sealing agent for noncompressible and irregular wounds, which is promising for biomedical applications.

Lyophilized apoptotic vesicle-encapsulated adhesive hydrogel sponge as a rapid hemostat for traumatic hemorrhage in coagulopathy

Rapid hemostasis of uncontrolled bleeding following traumatic injuries, especially accompanied by coagulopathies, remains a significant clinical challenge. Extracellular vesicles (EVs) show therapeutic effects for fast clotting. However, low yield, specific storage conditions, and lack of proper carriers have hindered EVs' clinical application. Herein, we establish an optimized procedure method to generate lyophilized mesenchymal stem cell-derived apoptotic vesicles (apoVs) with adhesive hydrogel sponge to show superior procoagulant activity for traumatic hemorrhage. Mechanistically, apoVs' procoagulant ability stems from their high tissue factor (TF) and phosphatidylserine (PS) expression independent of hemocytes and circulating procoagulant microparticles (cMPs). Their stable hemostatic capability was maintained after 2-month room temperature storage. Subsequently, we mixed apoVs with both phenylboronic acid grafted oxidized hyaluronic acid (PBA-HA) and poly(vinyl alcohol) (PVA) simultaneously, followed by lyophilization to construct a novel apoV-encapsulated hydrogel sponge (apoV-HS). Compared to commercial hemostats, apoV-HS exhibits rapid procoagulant ability in liver-laceration and femoral artery hemorrhage in rat and rabbit models of coagulopathies. The combination of high productivity, physiological stability, injectability, plasticity, excellent adhesivity, biocompatibility, and rapid coagulant property indicates that apoV-HS is a promising therapeutic approach for heavy hemorrhage in civilian and military populations.

Sea Cucumber-Inspired Aerogel for Ultrafast Hemostasis of Open Fracture

The symptomatic management of hemorrhagic shock complicated by open fractures is a great challenge, because it is also complicated by complex wound bleeding, bacterial infection, and bone defects. Inspired by the water absorption and cross-sectional microstructure of sea cucumbers, in this study, a new sea cucumber-like aerogel (GCG) is proposed. Its aligned porous structure and composition can stop bleeding rapidly and effectively with a blood clotting index of 3.73 ± 1.8%. More importantly, the data of in vivo hemostasis test in an amputating rat tail hemostatic model (15.69 ± 2.45 s, 26.95 ± 8.43 mg) and liver puncture bleeding model (23.77 ± 2.68 s, 36.22 ± 16.92 mg) also indicate the excellent hemostatic performance of GCG. In addition, GCG also shows a significant inhibitory effect on S. aureus and E. coli, which can prevent the occurrence of postoperative osteomyelitis. Not only that, after filling in the bone defect, it is shown that this GCG aerogel completely degrades eight weeks after surgery and induces new bone ingrowth, achieving functional regeneration after hemostasis of an open fracture defect. Generally, because of its combination of hemostatic, antibacterial, and osteogenic activities, this new aerogel is a promising option for open fractures treatment.

Use of Tranexamic Acid With Resuscitative Endovascular Balloon Occlusion of the Aorta is Associated With Higher Distal Embolism Rates: Results From the American Association of Surgery for Trauma Aortic Occlusion and Resuscitation for Trauma and Acute Care Surgery Trial

INTRODUCTION

Tranexamic acid (TXA) use has been associated with thrombotic complications.

OBJECTIVE

We aim to investigate outcomes associated with TXA use in the setting of high- (HP) and low-profile (LP) introducer sheaths for resuscitative endovascular balloon occlusion of the aorta (REBOA).

PARTICIPANTS

The Aortic Occlusion and Resuscitation for Trauma and Acute Care Surgery (AORTA) database was queried for patients who underwent REBOA using a low-profile 7 French (LP) or high-profile, 11-14 French (HP) introducer sheaths between 2013 and 2022. Demographics, physiology, and outcomes were examined for patients who survived beyond the index operation.

RESULTS

574 patients underwent REBOA (503 LP, 71 HP); 77% were male, mean age was 44 ± 19 and mean injury severity score (ISS) was 35 ± 16. 212 patients received TXA (181 [36%] LP, 31 [43.7%] HP). There were no significant differences in admission vital signs, GCS, age, ISS, SBP at AO, CPR at AO, and duration of AO among LP and HP patients. Overall, mortality was significantly higher in the HP (67.6%) vs the LP group (54.9%; P = .043). Distal embolism was significantly higher in the HP group (20.4%) vs the LP group (3.9%; P < .001). Logistic regression demonstrated that TXA use was associated with a higher rate of distal embolism in both groups (OR = 2.92; P = .021). 2 LP patients (one who received TXA) required an amputation.

CONCLUSION

Patients who undergo REBOA are profoundly injured and physiologically devastated. Tranexamic acid was associated with a higher rate of distal embolism in those who received REBOA, regardless of access sheath size. For patients receiving TXA, REBOA placement should be accompanied by strict protocols for immediate diagnosis and treatment of thrombotic complications.

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.

Hemostasis Strategies and Recent Advances in Nanomaterials for Hemostasis

The development of materials that effectively stop bleeding and prevent wound adhesion is essential in both military and medical fields. However, traditional hemostasis methods, such as cautery, tourniquets, and gauze, have limitations. In recent years, new nanomaterials have gained popularity in medical and health fields due to their unique microstructural advantages. Compared to traditional materials, nanomaterials offer better adhesion, versatility, and improved bioavailability of traditional medicines. Nanomaterials also possess advantages such as a high degree and stability, self-degradation, fewer side effects, and improved wound healing, which make them ideal for the development of new hemostatic materials. Our review provides an overview of the currently used hemostatic strategies and materials, followed by a review of the cutting-edge nanomaterials for hemostasis, including nanoparticles and nanocomposite hydrogels. The paper also briefly describes the challenges faced by the application of nanomaterials for hemostasis and the prospects for their future development.

Chitosan-Based Biomaterials for Hemostatic Applications: A Review of Recent Advances

Hemorrhage is a detrimental event present in traumatic injury, surgery, and disorders of bleeding that can become life-threatening if not properly managed. Moreover, uncontrolled bleeding can complicate surgical interventions, altering the outcome of surgical procedures. Therefore, to reduce the risk of complications and decrease the risk of morbidity and mortality associated with hemorrhage, it is necessary to use an effective hemostatic agent that ensures the immediate control of bleeding. In recent years, there have been increasingly rapid advances in developing a novel generation of biomaterials with hemostatic properties. Nowadays, a wide array of topical hemostatic agents is available, including chitosan-based biomaterials that have shown outstanding properties such as antibacterial, antifungal, hemostatic, and analgesic activity in addition to their biocompatibility, biodegradability, and wound-healing effects. This review provides an analysis of chitosan-based hemostatic biomaterials and discusses the progress made in their performance, mechanism of action, efficacy, cost, and safety in recent years.

Resuscitative balloon occlusion of the aorta in the modern era: Expanding indications, optimal techniques, unresolved issues, and current results

Resuscitative endovascular balloon occlusion of the aorta has been used by trauma surgeons at the bedside for more than a decade in civilian and military settings. Translational and clinical research suggests it is superior to resuscitative thoracotomy for select patients. Clinical research suggests outcomes are superior in patients who received resuscitative balloon occlusion of the aorta compared with those who did not. Technology has advanced considerably in the past several years, leading to the improved safety profile and wider adoption of resuscitative balloon occlusion of the aorta. In addition to trauma patients, resuscitative balloon occlusion of the aorta has been rapidly implemented for patient with nontraumatic hemorrhage.

Application of Biomedical Microspheres in Wound Healing

Tissue injury, one of the most common traumatic injuries in daily life, easily leads to secondary wound infections. To promote wound healing and reduce scarring, various kinds of wound dressings, such as gauze, bandages, sponges, patches, and microspheres, have been developed for wound healing. Among them, microsphere-based tissue dressings have attracted increasing attention due to the advantage of easy to fabricate, excellent physicochemical performance and superior drug release ability. In this review, we first introduced the common methods for microspheres preparation, such as emulsification-solvent method, electrospray method, microfluidic technology as well as phase separation methods. Next, we summarized the common biomaterials for the fabrication of the microspheres including natural polymers and synthetic polymers. Then, we presented the application of the various microspheres from different processing methods in wound healing and other applications. Finally, we analyzed the limitations and discussed the future development direction of microspheres in the future.

Multifunctional and Tunable Coacervate Powders to Enable Rapid Hemostasis and Promote Infected Wound Healing

Hemostatic powders provide an important treatment approach for time-sensitive hemorrhage control. Conventional hemostatic powders are challenged by the lack of tissue adhesiveness, insufficient hemostatic efficacy, limited infection control, and so forth. This study develops a hemostatic powder from tricomponent GTP coacervates consisting of gelatin, tannic acid (TA), and poly(vinyl alcohol) (PVA). The physical cross-linking by TA results in facile preparation, good storage stability, ease of application to wounds, and removal, which provide good potential for clinical translation. When rehydrated, the coacervate powders rapidly form a cohesive layer with interconnected microporous structure, competent flexibility, switchable wet adhesiveness, and antibacterial properties, which facilitate the hemostatic efficacy for treating irregular, noncompressible, or bacteria-infected wounds. Compared to commercial hemostats, GTP treatment results in significantly accelerated hemostasis in a liver puncture model (∼19 s, >30% reduction in the hemostatic time) and in a tail amputation model (∼38 s, >60% reduction in the hemostatic time). In the GTP coacervates, gelatin functioned as the biodegradable scaffold, while PVA introduced the flexible segments to enable shape-adaptability and interfacial interactions. Furthermore, TA contributed to the physical cross-linking, adhesiveness, and antibacterial performance of the coacervates. The study explores the tunability of GTP coacervate powders to enhance their hemostatic and wound healing performances.

Chitosan-Based Hemostatic Hydrogels: The Concept, Mechanism, Application, and Prospects

The design of new hemostatic materials to mitigate uncontrolled bleeding in emergencies is challenging. Chitosan-based hemostatic hydrogels have frequently been used for hemostasis due to their unique biocompatibility, tunable mechanical properties, injectability, and ease of handling. Moreover, chitosan (CS) absorbs red blood cells and activates platelets to promote hemostasis. Benefiting from these desired properties, the hemostatic application of CS hydrogels is attracting ever-increasing research attention. This paper reviews the recent research progress of CS-based hemostatic hydrogels and their advantageous characteristics compared to traditional hemostatic materials. The effects of the hemostatic mechanism, effects of deacetylation degree, relative molecular mass, and chemical modification on the hemostatic performance of CS hydrogels are summarized. Meanwhile, some typical applications of CS hydrogels are introduced to provide references for the preparation of efficient hemostatic hydrogels. Finally, the future perspectives of CS-based hemostatic hydrogels are presented.

Characterization and Analysis of Chitosan-Gelatin Composite-Based Biomaterial Effectivity as Local Hemostatic Agent: A Systematic Review

Chitosan and gelatin were the most widely used natural materials in pharmaceutical and medical fields, especially as local hemostatic agents, independently or as a composite material with the addition of other active substances. Chitosan and gelatin have excellent properties in biocompatibility, biodegradability, non-toxicity and water absorption capacity. The objective of this review was to analyze the characteristics of chitosan-gelatin (CG) composite-based biomaterial and its effectivity as a local hemostatic agent. We used PRISMA guidelines and the PICO framework to compile this review. The findings demonstrated that the CG composite-based biomaterial had excellent physical, chemical, mechanical properties and local hemostatic agent activity by adding other active substances such as oxidized fibers (OF), silica nanoparticles (SiNPs), calcium (Ca) and biphasic calcium phosphate (BCP) or by setting the CG composite proportion ratio.

Multifunctionalized alginate/polydopamine cryogel for hemostasis, antibacteria and promotion of wound healing

Hemostasis and anti-infection are crucial for emergency treatment of severe trauma. Developing functional biomaterial with efficient hemostasis, antibacterial activity and wound healing is of great social significance and clinical value to fast stop bleeding and save lives, but it is still challenged. Here we designed a series of multifunctionalized SA/PDA cryogels by using two-step cross-linking of dopamine and sodium alginate. The resulting interpenetrating network structure had good swelling ratio, excellent mechanical and shape memory properties. Compared with cotton gauze and gelatin sponge, the cryogels exhibited excellent activation of coagulation cascade, more blood cells and platelet adhesion. Due to the action of polydopamine, the cryogel also showed good antioxidant activity and photothermal antibacterial ability assisted by near-infrared radiation, as well as better wound healing performance than gelatin sponge and Tegaderm™ film. Moreover, in the tests of mouse tail docking model, rat femoral artery hemostasis model and non-compressible rabbit liver defect model, the treatment by SA/PDA cryogels presented less blood loss and shorter hemostasis time than cotton gauze and gelatin sponge. Therefore, SA/PDA cryogels with simple preparation process, low cost, and good biocompatibility would be applied in the variety of great clinical applications in bleeding control, anti-infection and wound healing, etc.

Inorganic-based biomaterials for rapid hemostasis and wound healing

The challenge for the treatment of severe traumas poses an urgent clinical need for the development of biomaterials to achieve rapid hemostasis and wound healing. In the past few decades, active inorganic components and their derived composites have become potential clinical products owing to their excellent performances in the process of hemorrhage control and tissue repair. In this review, we provide a current overview of the development of inorganic-based biomaterials used for hemostasis and wound healing. We highlight the methods and strategies for the design of inorganic-based biomaterials, including 3D printing, freeze-drying, electrospinning and vacuum filtration. Importantly, inorganic-based biomaterials for rapid hemostasis and wound healing are presented, and we divide them into several categories according to different chemistry and forms and further discuss their properties, therapeutic mechanisms and applications. Finally, the conclusions and future prospects are suggested for the development of novel inorganic-based biomaterials in the field of rapid hemostasis and wound healing.

Intravenous Hemostats: Foundation, Targeting, and Controlled-Release

Uncontrollable blood loss is the greatest cause of mortality in prehospital patients and the main source of disability and death in hospital care. Compared with external hemostats, intravenous hemostats are more appropriate for preventing and treating uncontrolled bleeding in vivo and large bleeding on the body surface. This Review initially establishes intravenous hemostats' response basis, including the coagulation mechanism, fibrinolytic pathway, and protein corona. Second, the study of advancement of intravenous hemostat targeting was expanded from two perspectives, cellular hemostatic agents and synthetic hemostatic agents. Meanwhile, after discussing the progress of controlled-release intravenous hemostats with platelets as the stimuli, this Review offers insight into the possibility of controlled-release intravenous hemostats with microenvironment as the stimuli, combining the studies of controlled-release targeted thrombolysis.

Design of biopolymer-based hemostatic material: Starting from molecular structures and forms

Uncontrolled bleeding remains as a leading cause of death in surgical, traumatic, and emergency situations. Management of the hemorrhage and development of hemostatic materials are paramount for patient survival. Owing to their inherent biocompatibility, biodegradability and bioactivity, biopolymers such as polysaccharides and polypeptides have been extensively researched and become a focus for the development of next-generation hemostatic materials. The construction of novel hemostatic materials requires in-depth understanding of the physiological hemostatic process, fundamental hemostatic mechanisms, and the effects of material chemistry/physics. Herein, we have recapitulated the common hemostatic strategies and development status of biopolymer-based hemostatic materials. Furthermore, the hemostatic mechanisms of various molecular structures (components and chemical modifications) are summarized from a microscopic perspective, and the design based on them are introduced. From a macroscopic perspective, the design of various forms of hemostatic materials, e.g., powder, sponge, hydrogel and gauze, is summarized and compared, which may provide an enlightenment for the optimization of hemostat design. It has also highlighted current challenges to the development of biopolymer-based hemostatic materials and proposed future directions in chemistry design, advanced form and clinical application.

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Biopolymers possess sound biocompatibility, biodegradability and bioactivity for the design of hemostatic materials.

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Molecular structure designs including component and chemical modification are summarized from a microscopic perspective.

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Design of various forms of hemostatic materials is discussed and compared synthetically from a macroscopic perspective.

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.

Preparation of methacrylated hyaluronate/methacrylated collagen sponges with rapid shape recovery and orderly channel for fast blood absorption as hemostatic dressing

Uncontrolled hemorrhage of deep, narrow, and non-compressible perforating wounds is responsible for many trauma deaths. In this study, a rapid hemostatic sponge with an orderly channel based on methacrylated collagen (ColMA) was prepared via directional freeze-drying technology. The methacrylated hyaluronate (HAMA) was added to further enhance the mechanical properties of the sponge. The sponge presents excellent mechanical strength, rapid shape recovery, and absorption speed, which was faster than those of many reported natural polymer hemostatic sponges. Moreover, ColMA/HAMA sponge showed much better blood-clotting capacity and superior hemostasis performance than commercially available collagen sponges in vitro and in the rat-liver injury model. This study demonstrated a feasible strategy to construct the rapid hemostatic sponge with an orderly channel for the deep and non-compressible perforating wound.

A keratin/chitosan sponge with excellent hemostatic performance for uncontrolled bleeding

Uncontrolled bleeding leads to a higher fatality rate in the situation of surgery, traffic accidents and warfare. Traditional hemostatic materials such as bandages are not ideal for uncontrolled or incompressible bleeding. Therefore, it is of great significance to develop a new medical biomaterial with excellent rapid hemostatic effect. Keratin is a natural, biocompatible and biodegradable protein which contains amino acid sequences that induce cell adhesion. As a potential biomedical material, keratin has been developed and paid attention in tissue engineering fields such as promoting wound healing and nerve repair. Herein, a keratin/chitosan (K/C) sponge was prepared to achieve rapid hemostasis. The characterizations of K/C sponge were investigated, including SEM, TGA, liquid absorption and porosity, showing that the high porosity up to 90.12 ± 2.17 % resulted in an excellent blood absorption. The cytotoxicity test and implantation experiment proved that the K/C sponge was biocompatible and biodegradable. Moreover, the prepared K/C sponge showed better hemostatic performance than chitosan sponge (CS) and the commercially available gelatin sponge in both rat tail amputation and liver trauma bleeding models. Further experiments showed that K/C sponge plays a hemostatic role through the endogenous coagulation pathway, thus shortening the activated partial thromboplastin time (APTT) effectively. Therefore, this study provided a K/C sponge which can be served as a promising biomedical hemostatic material.

Synthesis and Hemostatic Activity of New Amide Derivatives

Eight dipeptides containing antifibrinolytic agents (tranexamic acid, aminocaproic acid, 4-(aminomethyl)benzoic acid, and glycine—natural amino acids) were synthesized in a three-step process with good or very good yields. DMT/NMM/TsO⁻ (4-(4,6-dimethoxy-1,3,5-triazin-2-yl)-4-methylmorpholinium toluene-4-sulfonate) was used as a coupling reagent. Hemolysis tests were used to study the effects of the dipeptides on blood components. Blood plasma clotting tests were used to examine their effects on thrombin time (TT), prothrombin time (PT), and the activated partial thromboplastin time (aPTT). The level of hemolysis did not exceed 1%. In clotting tests, TT, PT, and aPTT did not differentiate any of the compounds. The prothrombin times for all amides 1–8 were similar. The obtained results in the presence of amides 1–4 and 8 were slightly lower than for the other compounds and the positive control, and they were similar to the results obtained for TA. In the case of amide 3, a significantly decreased aPTT was observed. The aPTTs observed for plasma treated with amide 3 and TA were comparable. In the case of amide 6 and 8, TT values significantly lower than for the other compounds were found. The clot formation and fibrinolysis (CFF) assay was used to assess the influence of the dipeptides on the blood plasma coagulation cascade and the fibrinolytic efficiency of the blood plasma. In the clot formation and fibrinolysis assay, amides 5 and 7 were among the most active compounds. The cytotoxicity and genotoxicity of the synthesized dipeptides were evaluated on the monocyte/macrophage peripheral blood cell line. The dipeptides did not cause hemolysis at any concentrations. They exhibited no significant cytotoxic effect on SC cells and did not induce significant DNA damage.

Hemostatic Electrospun Nanocomposite Containing Poly(lactic acid)/Halloysite Nanotube Functionalized by Poly(amidoamine) Dendrimer for Wound Healing Application: In Vitro and In Vivo Assays

The main challenge in treating injuries is excessive bleeding whereas intervention is required if the body's hemostatic systems fail to control the bleeding. Herein, a novel nanocomposite consisting of poly(lactic acid) (PLA) and poly(amidoamine) (PAMAM) dendrimer functionalized halloysite nanotube (HNT) with a highly porous structure via electrospinning is developed. HNT is functionalized by PAMAM via divergent synthetic routes from zero to third-generation numbers. The effect of different percentages and generation numbers of PAMAM dendrimer (G1, G2, and G3) functionalized HNT on PLA is studied using physicochemical nanocomposite characteristics. These resultant nanocomposites provide a nanofibrous structure with appropriate physicochemical characteristics such as mechanical properties, surface wettability, and water permeability. The hemostatic assays indicate that nanocomposite with PAMAM G3 functionalized HNT have the quickest blood clotting time due to the abundant amino functional group. Furthermore, the nanocomposites with 10 wt% of nanoparticles significantly promote cellular behavior in vitro. The in vivo study demonstrates that PLA/PAMAM G3 functionalized HNT promotes angiogenesis, collagen deposition, and re-epithelialization in the wound sites of the rat model, as well as inhibiting inflammatory response. The findings indicate that nanofibrous structure and the presence of dendrimer functionalized HNT have a synergetic effect on the enhanced nanocomposite wound healing performance.