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Chen S, Kong C, Yu N, Xu X, Li B, Zhang J. Management of non-compressible hemorrhage and re-bleeding by a liquid hemostatic polysaccharide floccuronic acid. Int J Biol Macromol 2024; 257:128695. [PMID: 38072343 DOI: 10.1016/j.ijbiomac.2023.128695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 11/28/2023] [Accepted: 12/07/2023] [Indexed: 01/27/2024]
Abstract
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.
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Affiliation(s)
- Shijunyin Chen
- Center for Molecular Metabolism, Nanjing University of Science & Technology, Nanjing 210094, China; Key laboratory of Metabolic Engineering and Biosynthesis Technology, Ministry of industry and information technology, Nanjing 210094, China
| | - Changchang Kong
- Center for Molecular Metabolism, Nanjing University of Science & Technology, Nanjing 210094, China; Key laboratory of Metabolic Engineering and Biosynthesis Technology, Ministry of industry and information technology, Nanjing 210094, China
| | - Ning Yu
- Center for Molecular Metabolism, Nanjing University of Science & Technology, Nanjing 210094, China; Key laboratory of Metabolic Engineering and Biosynthesis Technology, Ministry of industry and information technology, Nanjing 210094, China
| | - Xiaodong Xu
- Center for Molecular Metabolism, Nanjing University of Science & Technology, Nanjing 210094, China; Key laboratory of Metabolic Engineering and Biosynthesis Technology, Ministry of industry and information technology, Nanjing 210094, China
| | - Bing Li
- Nanjing Southern Element Biotechnology Co., Ltd, Nanjing 211899, China
| | - Jianfa Zhang
- Center for Molecular Metabolism, Nanjing University of Science & Technology, Nanjing 210094, China; Key laboratory of Metabolic Engineering and Biosynthesis Technology, Ministry of industry and information technology, Nanjing 210094, China.
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2
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Dorkhani E, Faryabi A, Noorafkan Y, Heirani A, Behboudi B, Fazeli MS, Kazemeini A, Keramati MR, Keshvari A, Ahmadi Tafti SM. Biomedical properties and hemostatic efficacy of polyvinyl alcohol (PVA) based hydrogel in experimental rat liver injury model. J Appl Biomater Funct Mater 2023; 21:22808000231198803. [PMID: 37811589 DOI: 10.1177/22808000231198803] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023] Open
Abstract
PURPOSE Bleeding is a leading cause of mortality and morbidity in the trauma and surgery field, using effective hemostatic agents can help us reduce bleeding especially in parenchymal hemorrhage. Nowadays polyvinyl alcohol (PVA) is known as a safe candidate for wound dressing and maybe a hemostatic agent. PVA-based hydrogel is a popular biocompatible material in the biomedical field especially when it has high water absorption. In this study, we investigated the PVA hydrogel's mechanical and biological properties as well as its hemostatic potential in parenchymal bleeding. METHODS PVA hydrogel had made by the freeze-thawing approach, we used PVA hydrogel in comparison to standard treatment to investigate hemostatic potency. Also, we performed MTT (3-(4,5-Dimethylthiazol-2-yl)-2,5-Diphenyltetrazolium Bromide) tests to survey PVA cellular toxicity. After an acute liver injury, two groups of 12 rats were treated with PVA hydrogel or standard treatment with sterile gauze. The results including the time and volume of bleeding, and the time and survival rate of the rats were measured and compared. RESULTS We saw that PVA hydrogel was safe with no cellular toxicity in the MTT assay. Regarding efficacy, PVA hydrogel increased rats' survival after bleeding from 75% to 91.7%, and decreased bleeding time (p: 0.015), and bleeding volume (p: 0.03) compared to the control group. CONCLUSION Polyvinyl alcohol is safe. It has good biological properties with no cellular toxicity and has a significant hemostatic effect and can be regarded in control of parenchymal hemorrhage.
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Affiliation(s)
- Erfan Dorkhani
- Colorectal Research Center, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
- School of Chemical Engineering, College of Engineering, University of Tehran, Tehran, Iran
| | - Ali Faryabi
- Colorectal Research Center, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
- Research Center for Advanced Technologies in Cardiovascular Medicine, Cardiovascular Diseases, Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Yasmin Noorafkan
- Research Center for Advanced Technologies in Cardiovascular Medicine, Cardiovascular Diseases, Research Institute, Tehran University of Medical Sciences, Tehran, Iran
- Department of Chemical Engineering, Isfahan University of Technology, Isfahan, Iran
| | - Asieh Heirani
- Research Center for Advanced Technologies in Cardiovascular Medicine, Cardiovascular Diseases, Research Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Behnam Behboudi
- Colorectal Research Center, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Sadegh Fazeli
- Colorectal Research Center, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Kazemeini
- Colorectal Research Center, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Reza Keramati
- Colorectal Research Center, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Keshvari
- Colorectal Research Center, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Mohsen Ahmadi Tafti
- Colorectal Research Center, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
- Research Center for Advanced Technologies in Cardiovascular Medicine, Cardiovascular Diseases, Research Institute, Tehran University of Medical Sciences, Tehran, Iran
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3
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Mecwan M, Li J, Falcone N, Ermis Sen M, Hassani A, Haghniaz R, Mandal K, Sharma S, Maity S, Zehtabi F, Zamanian B, Herculano R, Akbari M, John JV, Khademhosseini A. Recent advances in biopolymer-based hemostatic materials. Regen Biomater 2022; 9:rbac063. [PMID: 36196294 PMCID: PMC9522468 DOI: 10.1093/rb/rbac063] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 08/09/2022] [Accepted: 08/29/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
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.
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Affiliation(s)
- Marvin Mecwan
- Terasaki Institute for Biomedical Innovation , Los Angeles, CA, 90064, USA
| | - Jinghang Li
- Terasaki Institute for Biomedical Innovation , Los Angeles, CA, 90064, USA
| | - Natashya Falcone
- Terasaki Institute for Biomedical Innovation , Los Angeles, CA, 90064, USA
| | - Menekse Ermis Sen
- Terasaki Institute for Biomedical Innovation , Los Angeles, CA, 90064, USA
| | - Alireza Hassani
- Terasaki Institute for Biomedical Innovation , Los Angeles, CA, 90064, USA
| | - Reihaneh Haghniaz
- Terasaki Institute for Biomedical Innovation , Los Angeles, CA, 90064, USA
| | - Kalpana Mandal
- Terasaki Institute for Biomedical Innovation , Los Angeles, CA, 90064, USA
| | - Saurabh Sharma
- Terasaki Institute for Biomedical Innovation , Los Angeles, CA, 90064, USA
| | - Surjendu Maity
- Terasaki Institute for Biomedical Innovation , Los Angeles, CA, 90064, USA
| | - Fatemeh Zehtabi
- Terasaki Institute for Biomedical Innovation , Los Angeles, CA, 90064, USA
| | - Behnam Zamanian
- Terasaki Institute for Biomedical Innovation , Los Angeles, CA, 90064, USA
| | - Rondinelli Herculano
- Terasaki Institute for Biomedical Innovation , Los Angeles, CA, 90064, USA
- São Paulo State University (UNESP), Bioengineering & Biomaterials Group, School of Pharmaceutical Sciences , Araraquara, SP, Brazil
- São Paulo State University (UNESP), Department of Biotechnology, School of Sciences , Humanities and Languages, Assis, SP, Brazil
| | - Mohsen Akbari
- Terasaki Institute for Biomedical Innovation , Los Angeles, CA, 90064, USA
- University of Victoria Department of Mechanical Engineering, , Victoria, British Columbia, Canada
- Biotechnology Center, Silesian University of Technology , Akademicka 2A, Gliwice, 44-100, Poland
| | - Johnson V John
- Terasaki Institute for Biomedical Innovation , Los Angeles, CA, 90064, USA
| | - Ali Khademhosseini
- Terasaki Institute for Biomedical Innovation , Los Angeles, CA, 90064, USA
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4
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Percutaneous delivery of self-propelling thrombin-containing powder increases survival from non-compressible truncal hemorrhage in a swine model of coagulopathy and hypothermia. J Trauma Acute Care Surg 2022; 93:S86-S93. [PMID: 35545803 DOI: 10.1097/ta.0000000000003670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Non-compressible truncal hemorrhage (NCTH) remains a leading cause of preventable death on the battlefield. Definitively managing severe NCTH requires surgery within the first hour after injury, which is difficult when evacuating casualties from remote and austere environments. During delays to surgery, hemostatic interventions that are performed prehospital can prevent coagulopathy and hemorrhagic shock and increase the likelihood that casualties survive to receive definitive care. We previously reported that a self-propelling thrombin-containing powder (SPTP) can be delivered percutaneously into the abdomen as a minimally invasive intervention and can self-disperse through pooled blood to deliver the hemostatic agents thrombin and tranexamic acid (TXA) locally to noncompressible intracavitary wounds. We hypothesized that in swine with massive NCTH, dilutional coagulopathy and hypothermia, delivering SPTP could extend survival times. METHODS Ten swine (n = 5 per group) underwent NCTH from a Grade V liver injury following a midline laparotomy. The laparotomy was closed with sutures afterwards, creating a hemoperitoneum, and animals were managed with crystalloid fluid resuscitation, or crystalloid resuscitation and SPTP. SPTP was delivered into the closed abdomen using a CO2-powered spray device and a catheter placed into the hemoperitoneum, entering through the upper right quadrant using the Seldinger technique. Survival to one and three hours was recorded. In an additional animal, hemorrhage was created laparoscopically and SPTP was imaged in-situ within the abdomen to visually track dispersion of the particles. RESULTS SPTP dispersed as far as 35 +/- 5.0 cm within the abdomen. SPTP increased survival to one and three hours (Kaplan-Meier p = 0.007 for both). The median survival time was 61 minutes with SPTP and 31 minutes without (p = 0.016). CONCLUSION SPTP effectively disperses medications throughout a hemoperitoneum and increases survival in a model of NCTH. SPTP is a promising strategy for nonsurgical management of NCTH, warranting further testing of its safety and efficacy. LEVEL OF EVIDENCE Basic Science, N/A.
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5
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Naar L, Dorken Gallastegi A, Dowling M, Mashbari HNA, Wallace B, Bankhead-Kendall B, Beagle J, Pallotta JB, Breen K, Velmahos GC, Duggan MJ, King CDR. Chitosan-based lifefoam improves survival in lethal noncompressible abdominal bleeding in swine. Surgery 2022; 172:421-426. [DOI: 10.1016/j.surg.2022.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 12/19/2021] [Accepted: 01/16/2022] [Indexed: 11/15/2022]
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6
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A review of treatments for non-compressible torso hemorrhage (NCTH) and internal bleeding. Biomaterials 2022; 283:121432. [DOI: 10.1016/j.biomaterials.2022.121432] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 01/26/2022] [Accepted: 02/17/2022] [Indexed: 12/12/2022]
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7
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Pacheco M, Barros AA, Aroso IM, Autorino R, Lima E, Silva JM, Reis RL. Use of hemostatic agents for surgical bleeding in laparoscopic partial nephrectomy: Biomaterials perspective. J Biomed Mater Res B Appl Biomater 2020; 108:3099-3123. [PMID: 32458570 DOI: 10.1002/jbm.b.34637] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 04/29/2020] [Indexed: 12/20/2022]
Abstract
In recent years, there was an abrupt increase in the incidence of renal tumors, which prompt up the appearance of cutting-edge technology, including minimally invasive and organ-preserving approaches, such as laparoscopic partial nephrectomy (LPN). LPN is an innovative technique used to treat small renal masses that have been gaining popularity in the last few decades due to its promissory results. However, the bleeding control remains the main challenge since the majority of currently available hemostatic agents (HAs) used in other surgical specialities are inefficient in LPN. This hurried the search for effective HAs adapted for LPN surgical peculiarities, which resulted on the emergence of different types of topical HAs. The most promising are the natural origin HAs because of their inherent biodegradability, biocompatibility, and lowest toxicity. These properties turn them top interests' candidates as HAs in LPN. In this review, we present a deep overview on the progress achieved in the design of HAs based on natural origin polymers, highlighting their distinguishable characteristics and providing a clear understanding of their hemostat's role in LPN. This way it may be possible to establish a structure-composition properties relation, so that novel HAs for LPN can be designed to explore current unmet medical needs.
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Affiliation(s)
- Margarida Pacheco
- 3B's Research Group-Research Institute on Biomaterials, Biodegradables and Biomimetics, University of Minho, Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine, Avepark-Parque de Ciência e Tecnologia, Barco Guimarães, Portugal.,ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Alexandre A Barros
- 3B's Research Group-Research Institute on Biomaterials, Biodegradables and Biomimetics, University of Minho, Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine, Avepark-Parque de Ciência e Tecnologia, Barco Guimarães, Portugal.,ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Ivo M Aroso
- 3B's Research Group-Research Institute on Biomaterials, Biodegradables and Biomimetics, University of Minho, Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine, Avepark-Parque de Ciência e Tecnologia, Barco Guimarães, Portugal.,ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | | | - Estêvão Lima
- School of Health Sciences, Life and Health Sciences Research Institute (ICVS), University of Minho, Braga, Portugal.,Surgical Sciences Research Domain, Life and Health Sciences Research Institute, University of Minho, Braga, Portugal
| | - Joana M Silva
- 3B's Research Group-Research Institute on Biomaterials, Biodegradables and Biomimetics, University of Minho, Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine, Avepark-Parque de Ciência e Tecnologia, Barco Guimarães, Portugal.,ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Rui L Reis
- 3B's Research Group-Research Institute on Biomaterials, Biodegradables and Biomimetics, University of Minho, Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine, Avepark-Parque de Ciência e Tecnologia, Barco Guimarães, Portugal.,ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal
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8
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A highly efficient, in situ wet-adhesive dextran derivative sponge for rapid hemostasis. Biomaterials 2019; 205:23-37. [DOI: 10.1016/j.biomaterials.2019.03.016] [Citation(s) in RCA: 97] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 03/06/2019] [Accepted: 03/13/2019] [Indexed: 01/15/2023]
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9
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Hickman DA, Pawlowski CL, Sekhon UDS, Marks J, Gupta AS. Biomaterials and Advanced Technologies for Hemostatic Management of Bleeding. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2018; 30:10.1002/adma.201700859. [PMID: 29164804 PMCID: PMC5831165 DOI: 10.1002/adma.201700859] [Citation(s) in RCA: 260] [Impact Index Per Article: 43.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Revised: 06/18/2017] [Indexed: 05/03/2023]
Abstract
Bleeding complications arising from trauma, surgery, and as congenital, disease-associated, or drug-induced blood disorders can cause significant morbidities and mortalities in civilian and military populations. Therefore, stoppage of bleeding (hemostasis) is of paramount clinical significance in prophylactic, surgical, and emergency scenarios. For externally accessible injuries, a variety of natural and synthetic biomaterials have undergone robust research, leading to hemostatic technologies including glues, bandages, tamponades, tourniquets, dressings, and procoagulant powders. In contrast, treatment of internal noncompressible hemorrhage still heavily depends on transfusion of whole blood or blood's hemostatic components (platelets, fibrinogen, and coagulation factors). Transfusion of platelets poses significant challenges of limited availability, high cost, contamination risks, short shelf-life, low portability, performance variability, and immunological side effects, while use of fibrinogen or coagulation factors provides only partial mechanisms for hemostasis. With such considerations, significant interdisciplinary research endeavors have been focused on developing materials and technologies that can be manufactured conveniently, sterilized to minimize contamination and enhance shelf-life, and administered intravenously to mimic, leverage, and amplify physiological hemostatic mechanisms. Here, a comprehensive review regarding the various topical, intracavitary, and intravenous hemostatic technologies in terms of materials, mechanisms, and state-of-art is provided, and challenges and opportunities to help advancement of the field are discussed.
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Affiliation(s)
- DaShawn A Hickman
- Case Western Reserve University School of Medicine, Department of Pathology, Cleveland, Ohio 44106, USA
| | - Christa L Pawlowski
- Case Western Reserve University, Department of Biomedical Engineering, Cleveland, Ohio 44106, USA
| | - Ujjal D S Sekhon
- Case Western Reserve University, Department of Biomedical Engineering, Cleveland, Ohio 44106, USA
| | - Joyann Marks
- Case Western Reserve University, Department of Biomedical Engineering, Cleveland, Ohio 44106, USA
| | - Anirban Sen Gupta
- Case Western Reserve University, Department of Biomedical Engineering, Cleveland, Ohio 44106, USA
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10
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Huang Y, Feng L, Zhang Y, He L, Wang C, Xu J, Wu J, Kirk TB, Guo R, Xue W. Hemostasis mechanism and applications of N-alkylated chitosan sponge. POLYM ADVAN TECHNOL 2017. [DOI: 10.1002/pat.4003] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Yuchen Huang
- Key Laboratory of Biomaterials of Guangdong Higher Education Institutes; Guangzhou 510632 China
- Department of Biomedical Engineering; Jinan University; Guangzhou 510632 China
| | - Longbao Feng
- Key Laboratory of Biomaterials of Guangdong Higher Education Institutes; Guangzhou 510632 China
- Department of Biomedical Engineering; Jinan University; Guangzhou 510632 China
| | - Yi Zhang
- Key Laboratory of Biomaterials of Guangdong Higher Education Institutes; Guangzhou 510632 China
- Department of Biomedical Engineering; Jinan University; Guangzhou 510632 China
| | - Liumin He
- Key Laboratory of Biomaterials of Guangdong Higher Education Institutes; Guangzhou 510632 China
- Department of Biomedical Engineering; Jinan University; Guangzhou 510632 China
| | - Changyong Wang
- Department of Advanced Interdisciplinary Studies; Institute of Basic Medical Sciences and Tissue Engineering Research Center, Academy of Military Medical Sciences; Beijing 100850 China
| | - Jiake Xu
- School of Pathology and Laboratory Medicine; University of Western Australia; Perth WA 6009 Australia
| | - Jianping Wu
- 3D Imaging and Bioengineering Laboratory, the Department of Mechanical Engineering; Curtin University; Perth WA Australia
| | - Thomas Brett Kirk
- 3D Imaging and Bioengineering Laboratory, the Department of Mechanical Engineering; Curtin University; Perth WA Australia
| | - Rui Guo
- Key Laboratory of Biomaterials of Guangdong Higher Education Institutes; Guangzhou 510632 China
- Department of Biomedical Engineering; Jinan University; Guangzhou 510632 China
| | - Wei Xue
- Key Laboratory of Biomaterials of Guangdong Higher Education Institutes; Guangzhou 510632 China
- Department of Biomedical Engineering; Jinan University; Guangzhou 510632 China
- Key Laboratory of Functional Protein Research of Guangdong Higher Education Institute; Guangzhou 510632 China
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11
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Study on preparation of fibrinogen-loaded poly (L-lactic) acid nano-fabrics and its haemostatic performance in swine traumatic haemorrhage models. Blood Coagul Fibrinolysis 2015; 25:486-91. [PMID: 24509325 DOI: 10.1097/mbc.0000000000000090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Haemorrhage is the major cause of death in civilian trauma and the leading cause of preventable death in military trauma. It is very important to develop a haemostatic material with definite haemostatic effects. In this study, a nano-fabric membrane containing fibrinogen (Fbg) (2.5%, w/v) was successfully prepared by electrospinning as a haemostatic dressing. The average fibre diameter was 400 nm by scanning electron microscope (SEM), and it was indicated that fibrinogen and fibrin possessed excellent compatibility with poly (L-lactic)-acid (PLLA) from X-ray diffraction (XRD). Swine traumatic haemorrhage models including spleen haemorrhage, liver haemorrhage and femoral arteriovenous fistula haemorrhage were developed to detect haemostatic effects of this dressing. The results showed that the Fbg-loaded PLLA nano-fibre can significantly decrease the bleeding time, blood loss and mortality rate, which suggested that Fbg-loaded PLLA nano-fibre was efficacious on the models of traumatic uncontrolled haemorrhage, and further study of this dressing would be warranted to determine its potential in first aid and field trauma care.
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12
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Dowling MB, MacIntire IC, White JC, Narayan M, Duggan MJ, King DR, Raghavan SR. Sprayable Foams Based on an Amphiphilic Biopolymer for Control of Hemorrhage Without Compression. ACS Biomater Sci Eng 2015; 1:440-447. [PMID: 33445247 DOI: 10.1021/acsbiomaterials.5b00067] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Hemorrhage (severe blood loss) from traumatic injury is a leading cause of death for soldiers in combat and for young civilians. In some cases, hemorrhage can be stopped by applying compression of a tourniquet or bandage at the injury site. However, the majority of hemorrhages that prove fatal are "non-compressible", such as those due to an internal injury in the truncal region. Currently, there is no effective way to treat such injuries. In this initial study, we demonstrate that a sprayable polymer-based foam can be effective at treating bleeding from soft tissue without the need for compression. When the foam is sprayed into an open cavity created by injury, it expands and forms a self-supporting barrier that counteracts the expulsion of blood from the cavity. The active material in this foam is the amphiphilic biopolymer, hydrophobically modified chitosan (hmC), which physically connects blood cells into clusters via hydrophobic interactions (the hemostatic mechanism of hmC is thus distinct from the natural clotting cascade, and it works even with heparinized or citrated blood). The amphiphilic nature of hmC also allows it to serve as a stabilizer for the bubbles in the foam. We tested the hmC-based hemostatic foam for its ability to arrest bleeding from an injury to the liver in pigs. Hemostasis was achieved within minutes after application of the hmC foams (without the need for external compression). The total blood loss was 90% lower with the hmC foam relative to controls.
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Affiliation(s)
- Matthew B Dowling
- Fischell Department of Bioengineering, University of Maryland, College Park, Maryland 20742, United States
| | - Ian C MacIntire
- Department of Chemical and Biomolecular Engineering, University of Maryland, College Park, Maryland 20742-2111, United States
| | - Joseph C White
- Department of Chemical and Biomolecular Engineering, University of Maryland, College Park, Maryland 20742-2111, United States
| | - Mayur Narayan
- R. Adams Cowley Shock/Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland 21202, United States
| | - Michael J Duggan
- Department of Emergency Surgery, Trauma and Critical Care, Massachusetts General Hospital, Boston, Massachusetts 08174, United States
| | - David R King
- Department of Emergency Surgery, Trauma and Critical Care, Massachusetts General Hospital, Boston, Massachusetts 08174, United States
| | - Srinivasa R Raghavan
- Fischell Department of Bioengineering, University of Maryland, College Park, Maryland 20742, United States.,Department of Chemical and Biomolecular Engineering, University of Maryland, College Park, Maryland 20742-2111, United States
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13
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Traumatic intra-abdominal hemorrhage control: has current technology tipped the balance toward a role for prehospital intervention? J Trauma Acute Care Surg 2015; 78:153-63. [PMID: 25539217 DOI: 10.1097/ta.0000000000000472] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND The identification and control of traumatic hemorrhage from the torso remains a major challenge and carries a significant mortality despite the reduction of transfer times. This review examines the current technologies that are available for abdominal hemorrhage control within the prehospital setting and evaluates their effectiveness. METHODS A systematic search of online databases was undertaken. Where appropriate, evidence was highlighted using the Oxford levels of clinical evidence. The primary outcome assessed was mortality, and secondary outcomes included blood loss and complications associated with each technique. RESULTS Of 89 studies, 34 met the inclusion criteria, of which 29 were preclinical in vivo trials and 5 were clinical. Techniques were subdivided into mechanical compression, endovascular control, and energy-based hemostatic devices. Gas insufflation and manual pressure techniques had no associated mortalities. There was one mortality with high intensity focused ultrasound. The intra-abdominal infiltration of foam treatment had 64% and the resuscitative endovascular balloon occlusion of the aorta had 74% mortality risk reduction. In the majority of cases, morbidity and blood loss associated with each interventional procedure were less than their respective controls. CONCLUSION Mortality from traumatic intra-abdominal hemorrhage could be reduced through early intervention at the scene by emerging technology. Manual pressure or the resuscitative endovascular balloon occlusion of the aorta techniques have demonstrated clinical effectiveness for the control of major vessel bleeding, although complications need to be carefully considered before advocating clinical use. At present, fast transfer to the trauma center remains paramount. LEVEL OF EVIDENCE Systematic review, level IV.
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14
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Self-expanding foam for prehospital treatment of intra-abdominal hemorrhage: 28-day survival and safety. J Trauma Acute Care Surg 2014; 77:S127-33. [PMID: 25159345 DOI: 10.1097/ta.0000000000000380] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Intracavitary noncompressible hemorrhage remains a significant cause of preventable death on the battlefield and in the homeland. We previously demonstrated the hemostatic efficacy of an in situ self-expanding poly(urea)urethane foam in a severe, closed-cavity, hepatoportal exsanguination model in swine. We hypothesized that treatment with, and subsequent explantation of, foam would not adversely impact 28-day survival in swine. METHODS Following a closed-cavity splenic transection, animals received either fluid resuscitation alone (control group, n = 6) or resuscitation plus foam treatment at doses of 100 mL (n = 6), 120 mL (n = 6), and 150 mL (n = 2). Foam was allowed to polymerize in situ and was explanted after 3 hours. The animals were recovered and monitored for 28 days. RESULTS All 18 animals in the 100-mL, 120-mL, and control groups survived to the 28-day endpoint without complications. The 150-mL group was terminated after the acute phase (n = 2). En bloc explantation of the foam took less than 2 minutes and was associated with millimeter-sized remnant particles. All foam animals required some level of enteric repair (imbrication or resection). Excluding the aborted 150-mL group, all animals survived, with no differences in renal or hepatic function, serum chemistries, or semiquantitative abdominal adhesion scores. Histologic analysis demonstrated that remnant particles were associated with a fibrotic capsule and mild inflammation, similar to that of standard suture reaction. In addition, safety testing (including genotoxicity, pyrogenicity, and cytotoxicity) was performed consistent with the ISO-10993 standard, and the materials passed all tests. CONCLUSION For a distinct dose range, 28-day recovery after foam treatment and explantation for noncompressible, intra-abdominal hemorrhage is not associated with significant physiologic or biochemical evidence of end-organ dysfunction. A foam volume exceeding the maximum tolerable dose was identified. Bowel repair is required to ensure survival.
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Development of a fatal noncompressible truncal hemorrhage model with combined hepatic and portal venous injury in normothermic normovolemic swine. PLoS One 2014; 9:e108293. [PMID: 25251401 PMCID: PMC4176969 DOI: 10.1371/journal.pone.0108293] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Accepted: 08/18/2014] [Indexed: 12/02/2022] Open
Abstract
Noncompressible truncal hemorrhage and brain injury currently account for most early mortality of warfighters on the battlefield. There is no effective treatment for noncompressible truncal hemorrhage, other than rapid evacuation to a surgical facility. The availability of an effective field treatment for noncompressible truncal hemorrhage could increase the number of warfighters salvaged from this frequently-lethal scenario. Our intent was to develop a porcine model of noncompressible truncal hemorrhage with a ∼50% one-hour mortality so that we could develop new treatments for this difficult problem. Normovolemic normothermic domestic swine (barrows, 3 months old, 34–36 kg) underwent one of three injury types through a midline incision: 1) central stellate injury (N = 6); 2) excision of a portal vein branch distal to the main PV trunk (N = 6); or 3) hemi-transection of the left lateral lobe of the liver at its base (N = 10). The one-hour mortality of these injuries was 0, 82, and 40%, respectively; the final mean arterial pressure was 65, 24, and 30 mm Hg, respectively; and the final hemoglobin was 8.3, 2.3, and 3.6 g/dL, respectively. Hemi-transection of the left lateral lobe of the liver appeared to target our desired mortality rate better than the other injury mechanisms.
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Dowling MB, Smith W, Balogh P, Duggan MJ, MacIntire IC, Harris E, Mesar T, Raghavan SR, King DR. Hydrophobically-modified chitosan foam: description and hemostatic efficacy. J Surg Res 2014; 193:316-23. [PMID: 25016441 DOI: 10.1016/j.jss.2014.06.019] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Revised: 05/06/2014] [Accepted: 06/09/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Trauma represents a significant public health burden, and hemorrhage alone is responsible for 40% of deaths within the first 24 h after injury. Noncompressible hemorrhage accounts for the majority of hemorrhage-related deaths. Thus, materials which can arrest bleeding rapidly are necessary for improved clinical outcomes. This preliminary study evaluated several self-expanding hydrophobically modified chitosan (HM-CS) foams to determine their efficacy on a noncompressible severe liver injury under resuscitation. METHODS Six HM-CS foam formulations (HM-CS1, HM-CS2, HM-CS3, HM-CS4, HM-CS5, and HM-CS6) of different graft types and densities were synthesized, characterized, and packaged into spray canisters using dimethyl ether as the propellant. Expansion profiles of the foams were evaluated in bench testing. Foams were then evaluated in vitro, interaction with blood cells was determined via microscopy, and cytotoxicity was assessed via live-dead cell assay on MCF7 breast cancer cells. For in vivo evaluation, rats underwent a 14 ± 3% hepatectomy. The animals were treated with either: (1) an HM-CS foam formulation, (2) CS foam, and (3) no treatment (NT). All animals were resuscitated with lactated Ringer solution. Survival, total blood loss, mean arterial pressures (MAP), and resuscitation volume were recorded for 60 min. RESULTS Microscopy showed blood cells immobilizing into colonies within tight groups of adjacent foam bubbles. HM-CS foam did not display any toxic effects in vitro on MCF7 cells over a 72 h period studied. Application of HM-CS foam after hepatectomy decreased total blood loss (29.3 ± 7.8 mL/kg in HM-CS5 group versus 90.9 ± 20.3 mL/kg in the control group; P <0.001) and improved survival from 0% in controls to 100% in the HM-CS5 group (P <0.001). CONCLUSIONS In this model of severe liver injury, spraying HM-CS foams directly on the injured liver surface decreased blood loss and increased survival. HM-CS formulations with the highest levels of hydrophobic modification (HM-CS4 and HM-CS5) resulted in the lowest total blood loss and highest survival rates. This pilot study suggests HM-CS foam may be useful as a hemostatic adjunct or solitary hemostatic intervention.
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Affiliation(s)
- Matthew B Dowling
- Fischell Department of Bioengineering, University of Maryland, College Park, Maryland
| | - William Smith
- Division of Trauma, Acute Care Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Peter Balogh
- Division of Trauma, Acute Care Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Michael J Duggan
- Division of Trauma, Acute Care Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Ian C MacIntire
- Department of Chemical & Biomolecular Engineering, University of Maryland, College Park, Maryland
| | - Erica Harris
- Fischell Department of Bioengineering, University of Maryland, College Park, Maryland
| | - Tomaz Mesar
- Division of Trauma, Acute Care Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Srinivasa R Raghavan
- Fischell Department of Bioengineering, University of Maryland, College Park, Maryland; Department of Chemical & Biomolecular Engineering, University of Maryland, College Park, Maryland
| | - David R King
- Division of Trauma, Acute Care Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts.
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Self-expanding foam for prehospital treatment of severe intra-abdominal hemorrhage: dose finding study. J Trauma Acute Care Surg 2014; 76:619-23; discussion 623-4. [PMID: 24553527 DOI: 10.1097/ta.0000000000000126] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Noncompressible abdominal bleeding is a significant cause of preventable death on the battlefield and in the civilian trauma environment, with no effective therapies available at point of injury. We previously described the development of a percutaneously administered, self-expanding, poly(urea)urethane foam that improved survival in a lethal Grade V hepatic and portal vein injury model in swine. In this study, we hypothesized that survival with foam treatment is dose dependent. METHODS A high-grade hepatoportal injury was created in a closed abdominal cavity, resulting in massive noncompressible hemorrhage. After injury, the animals were divided into five groups. The control group (n = 12) was treated only with fluid resuscitation, and four polymer groups received different dose volumes (Group 1, n = 6, 64 mL; Group 2, n = 6, 85 mL; Group 3, n = 18, 100 mL; and Group 4, n = 10, 120 mL) in addition to fluids. Ten minutes after injury, the foam was percutaneously administered, and animals were monitored for 3 hours. RESULTS Survival with hepatoportal injury was highest in Group 4 (90%) and decreased in a dose-dependent fashion (Group 3, 72%; Group 2, 33%; Group 1, 17%). All polymer groups survived significantly longer than the controls (8.3%). Hemorrhage rate was reduced in all groups but lowest in Group 4 versus the control group (0.34 [0.052] vs. 3.0 [1.3] mL/kg/min, p < 0.001). Increasing foam dose volume was associated with increased peak intra-abdominal pressure (88.2 [38.9] in Group 4 vs. 9.5 [3.2] in the controls, p < 0.0001) and increased incidence of focal bowel injuries. CONCLUSION The self-expanding foam significantly improves survival in a dose-dependent fashion in an otherwise lethal injury. Higher doses are associated with better survival but resulted in the need for bowel resection.
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Peng HT, Shek PN. Novel wound sealants: biomaterials and applications. Expert Rev Med Devices 2014; 7:639-59. [DOI: 10.1586/erd.10.40] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Self-expanding polyurethane polymer improves survival in a model of noncompressible massive abdominal hemorrhage. J Trauma Acute Care Surg 2013; 74:1462-7. [PMID: 23694873 DOI: 10.1097/ta.0b013e31828da937] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Intracavitary noncompressible hemorrhage remains a significant cause of preventable death on the battlefield. Two dynamically mixed and percutaneously injected liquids were engineered to create an in situ self-expanding polymer foam to facilitate hemostasis in massive bleeding. We hypothesized that intraperitoneal injection of the polymer could achieve conformal contact with sites of injury and improve survival in swine with lethal hepatoportal injury. METHODS High grade hepatoportal injury was created in a closed abdominal cavity, resulting in massive noncoagulopathic, noncompressible hemorrhage. Animals received either standard battlefield fluid resuscitation (control, n = 12) or fluid resuscitation plus intraperitoneal injection of hemostatic foam (polymer, n = 15) and were monitored for 3 hours. Blood loss was quantified, and all hepatoportal injuries were inspected for consistency. RESULTS Before intervention, all animals initially experienced severe, profound hypotension and near-arrest (mean arterial pressure at 10 minutes, 21 [5.3] mm Hg). Overall survival at 3 hours was 73% in the polymer group and 8% in the control group (p = 0.001). Median survival time was more than 150 minutes in the polymer group versus 23 minutes (19-41.5 minutes) in the control group (p < 0.001), and normalized blood loss in the polymer group was 0.47 (0.30) g/kg per minute versus 3.0 (1.3) g/kg per minute in the controls (p = < 0.001). All hepatoportal injuries were anatomically similar, and the polymer had conformal contact with injured tissues. CONCLUSION Intraperitoneal polymer injection during massive noncompressible hemorrhage reduces blood loss and improves survival in a lethal, closed-cavity, hepatoportal injury model. Chronic safety and additional efficacy studies in other models are needed.
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Burnett LR, Richter JG, Rahmany MB, Soler R, Steen JA, Orlando G, Abouswareb T, Van Dyke ME. Novel keratin (KeraStat™) and polyurethane (Nanosan®-Sorb) biomaterials are hemostatic in a porcine lethal extremity hemorrhage model. J Biomater Appl 2013; 28:869-79. [DOI: 10.1177/0885328213484975] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Traumatic injury is the leading cause of death in people aged 44 or less in the US. It is also estimated that 82% of deaths from battlefield hemorrhage may be survivable with better treatment options. In this study, two biomaterial hemostats having disparate mechanisms were evaluated in a large animal lethal hemorrhage model and compared to a commercial product and standard cotton gauze. We hypothesized that the biomaterial with a biologically active mechanism, as opposed to a mechanical mechanism, would be the most effective in this model. Using a published study protocol, the femoral artery in swine was punctured and treated. KeraStat™ (KeraNetics) and Nanosan®-Sorb (SNS Nano) hemostats were compared to a commercial chitosan dressing (second generation Hemcon®) and cotton gauze. Both KeraStat and Nanosan increased survival, significantly increased mean arterial pressure (MAP), and significantly decreased shock index compared to both controls. The Hemcon dressing was no different than gauze. Platelet adhesion assays suggested that the KeraStat mechanism of action involves β1 integrin mediated platelet adhesion while Nanosan-Sorb operates similar to one reported mechanism for Hemcon, absorbing fluid and concentrating clotting components. The Nanosan also swelled considerably and created pressure within the wound site even after direct pressure was removed.
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Affiliation(s)
| | - Jillian G Richter
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Maria B Rahmany
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Roberto Soler
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Julie A Steen
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Giuseppe Orlando
- Division of Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Tamer Abouswareb
- Wake Forest Institute for Regenerative Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Mark E Van Dyke
- Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
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Duggan MJ, Mejaddam AY, Beagle J, Demoya MA, Velmahosa GC, Alam HB, Rago A, Zugates G, Busold R, Freyman T, Sharma U, King DR. Development of a lethal, closed-abdomen grade V hepato-portal injury model in non-coagulopathic swine. J Surg Res 2012; 182:101-7. [PMID: 22921917 DOI: 10.1016/j.jss.2012.07.048] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2012] [Revised: 07/05/2012] [Accepted: 07/13/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Hemorrhage within an intact abdominal cavity remains a leading cause of preventable death on the battlefield. Despite this need, there is no existing closed-cavity animal model to assess new hemostatic agents for the preoperative control of intra-abdominal hemorrhage. METHODS We developed a novel, lethal liver injury model in non-coagulopathic swine by strategic placement of two wire loops in the medial liver lobes including the hepatic and portal veins. Distraction resulted in grade V liver laceration with hepato-portal injury, massive bleeding, and severe hypotension. Crystalloid resuscitation was started once mean arterial pressure (MAP) fell below 65 mm Hg. Monitoring continued for up to 180 min. RESULTS We demonstrated 90% lethality (9/10) in swine receiving injury and fluid resuscitation, with a mean survival time of 43 min. Previous efforts in our laboratory to develop a consistently lethal swine model of abdominal solid organs, including preemptive anticoagulation, a two-hit injury with controlled hemorrhage prior to liver trauma, and the injury described above without resuscitation, consistently failed to result in lethal injury. CONCLUSION This model can be used to screen other interventions for pre hospital control of noncompressible.
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Affiliation(s)
- Michael J Duggan
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital/Harvard Medical School, Boston, MA 02114, USA
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Duarte A, Coelho J, Bordado J, Cidade M, Gil M. Surgical adhesives: Systematic review of the main types and development forecast. Prog Polym Sci 2012. [DOI: 10.1016/j.progpolymsci.2011.12.003] [Citation(s) in RCA: 168] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Abstract
The incidence of complications after hepatectomy has been considerably reduced over the last 20 years. Better knowledge of liver anatomy and liver regeneration, and methods preventing bleeding during surgery have resulted in morbidity rates below 20% and mortality rates less than 5%. The treatment of the liver cross section remains controversial. Experimental studies have reported convincing biological effects of fibrin sealants or compresses when applied on the liver to decrease hemorrhagic or biliary complications. However, clinical studies are very heterogeneous, providing conflicting results compromising recommendations for routine use.
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Zhao A, Wang T, Yao M, Li H. Effects of chitosan-TPP nanoparticles on hepatic tissue after severe bleeding. ACTA ACUST UNITED AC 2011. [DOI: 10.1016/s1000-1948(11)60054-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
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Baer DG, Dubick MA, Wenke JC, Brown KV, McGhee LL, Convertino VA, Cancio LC, Wolf SE, Blackbourne LH. Combat casualty care research at the U.S. Army Institute of Surgical Research. J ROY ARMY MED CORPS 2011; 155:327-32. [PMID: 20397612 DOI: 10.1136/jramc-155-04-17] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
The Institute of Surgical Research is the U.S. Army's lead research laboratory for improving the care of combat casualties. The Institute follows a rigorous process for analyzing patterns of injury and the burden of disease to determine where research can be conducted in order to positively impact care. These analyses led the ISR to focus research on: preventing death from bleeding; developing improved pain control techniques; developing improved vital signs analysis techniques; improving the treatment of extremity injuries; preventing burn injuries on the battlefield; and improving critical care for combat casualties. This process has resulted in numerous improvements in care on the battlefield. Highlights include development, fielding, and efficiency testing of tourniquets and improved dressings for bleeding control. Significant progress has also been made in the resuscitation of combat casualties using blood products instead of crystalloid or colloid solutions. Improvements in pain control include assessments of the effect of perioperative anaesthetics on the development of post-traumatic stress disorder [PTSD]. Novelvital signs analyses have been successful in identifying promising techniques which may improve the medic's ability to accurately triage patients. Current research in extremity injuries has focused on optimizing the use of negative pressure wound therapy for contaminated wounds. Burn research has focused on improving personnel protective equipment and implementing continuous renal replacement therapy. This research program is soldier focused and addresses care from self aid and buddy aid through all echelons of care. Many of these advances have been adopted in civilian medical centres as well, benefiting not only the military trauma patient, but also the civilian trauma patient.
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Affiliation(s)
- D G Baer
- U.S. Army Institute of Surgical Research, 3400 Rawley E. Chambers Ave. San Antonio, Texas 78234, USA.
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Ellis‐Behnke R. At the nanoscale: nanohemostat, a new class of hemostatic agent. WILEY INTERDISCIPLINARY REVIEWS-NANOMEDICINE AND NANOBIOTECHNOLOGY 2010; 3:70-8. [DOI: 10.1002/wnan.110] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Rutledge Ellis‐Behnke
- Department of Anatomy, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong SAR, China
- State Key Laboratory for Brain and Cognitive Science, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong SAR, China
- Research Centre of Heart, Brain, Hormone and Healthy Aging, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong SAR, China
- Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology, Cambridge, MA, USA
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Comparison of 10 hemostatic dressings in a groin puncture model in swine. J Vasc Surg 2009; 50:632-9, 639.e1. [PMID: 19700097 DOI: 10.1016/j.jvs.2009.06.010] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2009] [Revised: 05/06/2009] [Accepted: 06/04/2009] [Indexed: 11/22/2022]
Abstract
BACKGROUND The use of mineral (clay) or biologic (chitosan) materials has improved the efficacy of dressings used in the bleeding control of noncompressible areas. A series of novel manufactured products already evaluated in a vascular transection model was further compared in a severe vascular puncture injury model. METHODS Ten hemostatic dressings were tested in anesthetized Yorkshire swine hemorrhaged for 45 seconds in a femoral arterial puncture model. Application of these dressings was followed by 5 minutes of compression (about 175 mm Hg), and at 15 minutes, 500 mL resuscitation fluid (Hextand) was infused during a 30-minute period. The animals were monitored for a 3-hour experimental observation period. Primary outcomes were incidence of bleeding after dressing application and animal survival. RESULTS Blood loss was 18.8% +/- 5.2% estimated blood volume (EBV) after 45 seconds of free bleeding. Relative performance of dressings is characterized as groups of dressings that performed similarly. Recurrence of bleeding after application was observed with most dressings and was lower with Woundstat, Celox, X-Sponge, and ACS+ (35% +/- 49%) compared with FP-21, Hemcon, Chitoflex, and Bloodstop (79% +/- 43%; P < .01). Blood loss after treatment was 25.3% +/- 18.4% EBV for the top four dressings and 53.0% +/- 18.4% EBV for the bottom four (P < .05). Survival was higher for top four vs bottom four dressings (78% +/- 12% vs 25% +/- 0%, respectively; P < .01). Overall performance of these dressings according to survival, incidence of bleeding, and post-treatment blood loss, yielded similar ranking as with a previously tested transection injury model. CONCLUSIONS The findings indicated that the efficacy of Woundstat, Celox, X-Sponge, and ACS+ were similar and superior in improving survival, hemostasis, and maintenance of mean arterial pressure in an actively bleeding wound caused in this severe vascular injury model.
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Karakaya K, Ucan HB, Tascılar O, Emre AU, Cakmak GK, Irkorucu O, Ankarali H, Comert M. Evaluation of a New Hemostatic Agent Ankaferd Blood Stopper in Experimental Liver Laceration. J INVEST SURG 2009; 22:201-6. [DOI: 10.1080/08941930902866246] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Exsanguination in trauma: A review of diagnostics and treatment options. Injury 2009; 40:11-20. [PMID: 19135193 DOI: 10.1016/j.injury.2008.10.007] [Citation(s) in RCA: 130] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2007] [Revised: 10/01/2008] [Accepted: 10/07/2008] [Indexed: 02/02/2023]
Abstract
Trauma patients with haemorrhagic shock who only transiently respond or do not respond to fluid therapy and/or the administration of blood products have exsanguinating injuries. Recognising shock due to (exsanguinating) haemorrhage in trauma is about constructing a synthesis of trauma mechanism, injuries, vital signs and the therapeutic response of the patient. The aim of prehospital care of bleeding trauma patients is to deliver the patient to a facility for definitive care within the shortest amount of time by rapid transport and minimise therapy to what is necessary to maintain adequate vital signs. Rapid decisions have to be made using regional trauma triage protocols that have incorporated patient condition, transport times and the level of care than can be performed by the prehospital care providers and the receiving hospitals. The treatment of bleeding patients is aimed at two major goals: stopping the bleeding and restoration of the blood volume. Fluid resuscitation should allow for preservation of vital functions without increasing the risk for further (re)bleeding. To prevent further deterioration and subsequent exsanguinations 'permissive hypotension' may be the goal to achieve. Within the hospital, a sound trauma team activation system, including the logistic procedure as well as activation criteria, is essential for a fast and adequate response. After determination of haemorrhagic shock, all efforts have to be directed to stop the bleeding in order to prevent exsanguinations. A simultaneous effort is made to restore blood volume and correct coagulation. Reversal of coagulopathy with pharmacotherapeutic interventions may be a promising concept to limit blood loss after trauma. Abdominal ultrasound has replaced diagnostic peritoneal lavage for detection of haemoperitoneum. With the development of sliding-gantry based computer tomography diagnostic systems, rapid evaluation by CT-scanning of the trauma patient is possible during resuscitation. The concept of damage control surgery, the staged approach in treatment of severe trauma, has proven to be of vital importance in the treatment of exsanguinating trauma patients and is adopted worldwide. When performing 'blind' transfusion or 'damage control resuscitation', a predetermined fixed ratio of blood components may result in the administration of higher plasma and platelets doses and may improve outcome. The role of thromboelastography and thromboelastometry as point-of-care tests for coagulation in massive blood loss is emerging, providing information about actual clot formation and clot stability, shortly (10min) after the blood sample is taken. Thus, therapy guided by the test results will allow for administration of specific coagulation factors that will be depleted despite administration with fresh frozen plasma during massive transfusion of blood components.
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