Topical Hemostatic Agents in Surgery: A Surgeon's Perspective

Postoperative bleeding can lead to complications such as hematoma, infection, dehiscence, and an unscheduled office visit. Topical hemostatic agents can be used to aid in hemostasis. The objective is to familiarize physicians with topical hemostatic agents--hydrophilic polymers with potassium salts (Urgent QR powder) and microporous polysaccharide hemispheres (Bleed-X). Two hemostatic agents, microporous polysaccharide hemospheres and hydrophilic polymers with potassium salt, are discussed. The literature is reviewed. Numerous types of hemostatic agents exist. Topical hemostatic agents are safe, cost-effective, and efficient. Microporous polysaccharide hemospheres and hydrophilic polymers with potassium salts can be an adjunct to hemostasis after cautery and ligation. Patients can apply hemostatic agents if they experience any bleeding leading to decreased office visits. Hemostatic agents used intraoperatively shorten bleeding time and enable the physician to use less cautery. Using hemostatic agents can lead to fewer hematomas, infections, and office visits.

Intraoperative control of bleeding during any surgical procedure is vital for achieving a positive patient outcome. Hemostasis can be achieved through practical and effective systemic or topical approaches. A variety of hemostatic methods can be employed, ranging from simple manual pressure application with one finger to electrical tissue cauterization, systemic administration of blood products, and systemic administration or topical application of procoagulation agents. The key to surgical success is critically dependent on knowledgeable use of a method appropriate for the level of bleeding experienced by the patient. Topical agents can be effective as adjuncts to aid in hemostasis when bleeding is not controllable with pressure application, vessel ligation, or electrocautery. Such adjunctive hemostatic treatments include topical gelatins, collagens, oxidized celluloses, thrombin and fibrin sealants, synthetic glues, and glutaraldehyde-based glues. As with the use of systemically delivered hemostatic agents, topical treatments also carry risks with their use, and their efficacy has not been extensively studied in large randomized, placebo-controlled prospective studies. The effective use of topical agents is highly dependent on the surgeon's experience or preference and their availability in the surgical setting. In this article, we review the currently available topical hemostatic agents, compare their efficacy, and give general recommendations for their use in the operating room.

The national usage and cost trends associated with hemostatic agents in major urologic procedures remain unknown. This study aims to describe the trends, costs, and predictors of local hemostatic use in major urologic surgeries. We utilized the Premier Healthcare Database to analyze 385,261 patient encounters between 2000 and 2020. Our primary objective was to describe the usage patterns of topical hemostatic agents in open and laparoscopic/robotic major urological surgeries. The data from the last 5 years (2015-2020) were used to characterize specific cost trends, and multivariable regression analysis was performed to identify predictors of hemostatic agent use in relation to surgical approach, patient, and hospital characteristics. By 2020, at least 1 topical hemostatic agent was used in 37.3% (95% CI: 35.5-39.1) of laparoscopic/robotic prostatectomies and 30.7% (95% CI: 24.2-37.1) of open prostatectomies; 60.8% (95% CI: 57.6-64.1) of laparoscopic/robotic partial nephrectomies and 55.9% (95% CI: 47.3-64.5) of open partial nephrectomies; 40.7% (95% CI: 36.9-44.3) of laparoscopic/robotic radical nephrectomies and 43.2% (95% CI: 38.8-47.6) of open radical nephrectomies; and 40.52% (95% CI: 35.02-46.02) of open radical cystectomies. For the 2015-2020 cohort, predictors for hemostatic agent use varied by surgery type and included gender, race, surgical approach, insurance coverage, geographical location, urbanicity, and attending volume. The cost of the hemostatic agent accounted for less than 1.6% of the total cost of hospitalization for each procedure. The use of hemostatic agents in major urologic surgeries has grown over the past 2 decades. For all procedures, the specific cost of using a hemostatic agent constitutes a small fraction of the total hospitalization cost and does not vary significantly between open and laparoscopic/robotic approaches. Some patient, surgeon, and hospital characteristics are highly correlated with their use.

The military has used topical hemostatic agents to successfully treat life-threatening external bleeding for years. In contrast to the military environment, the general population are increasingly prescribed anticoagulants. There are only few comparative evaluations of topical hemostatic agents with anticoagulated human blood. It is important to understand the impact of these agents on those who take anticoagulants. Citrated blood of patients treated with enoxaparin, heparin, and acetylsalicylic acid, apixaban or phenprocoumon was incubated with different hemostatic agents (QuikClot Gauze, Celox Granules, Celox Gauze, Chito SAM 100, WoundClot Trauma Gauze, QuikClot Gauze Moulage Trainer and Kerlix) and rotational thromboelastometry was performed with non-activated thromboelastometry (NATEM reagent). All tested agents improved the onset of coagulation in all anticoagulants, mostly to a significant degree. Most significant improvements were produced by QuikClot Gauze and QuikClot Gauze Moulage Trainer, followed by the tested chitosans (Celox Granules, Celox Gauze, Chito SAM 100). Of the anticoagulant groups, the most significant improvements were seen in enoxaparin. This was followed in order by apixaban, heparin, and acetylsalicylic acid, and phenprocoumon. All the hemostatic agents tested were able to activate the clotting cascade earlier and initiate faster clot formation in anticoagulated blood. A definitive head-to-head comparison is not feasible, because of the limitations of an in-vitro analysis. However, the sometimes-presented hypothesis that kaolin-based hemostatic agents are ineffective in anticoagulated blood is inaccurate according to our data. Hemostasis with hemostatic agents appears most challenging with phenprocoumon.

A variety of local haemostatic agents is now available to stop troublesome bleeding. These agents are indicated for use during surgical interventions where conventional methods of haemostasis are not applicable because of the site of surgery or the degree of bleeding. A literature search using the PubMed and ISI Web of Knowledge databases identified relevant studies on topical haemostatic agents. Manufacturers' recommendations were also sought through commercial websites. A significant body of evidence now exists to support the use of topical haemostatic agents in a wide variety of clinical situations. The advantages and disadvantages of many of these agents are highlighted.

Bleeding following liver resection continues to be a significant morbidity of the procedure. Fibrin sealants represent an improvement over conventional topical hemostatic agents, because they contain components that actively form clot. However, most available agents contain nonhuman protein, which represents an immunologic risk. An investigational surgical fibrin sealant (Crosseal; American Red Cross, Washington, DC) composed of human clottable proteins and human thrombin is more effective than standard topical hemostatic agents in reducing the time required to achieve hemostasis after liver resection. Prospective, randomized, controlled trial. Fifteen major referral centers in the United States and the United Kingdom. After liver resection using standard surgical techniques, 121 patients seen between May 1999 and May 2000 were randomized to treatment with a 2-component fibrin sealant (n=58) or to standard topical hemostatic agents, used singly or in combination (n=63). Up to 10 mL of Crosseal was administered by a spray applicator, as recommended by the manufacturer, whereas agents used in the control group were applied according to their instructions for use. The primary outcome measured was time to hemostasis. Secondary outcomes measured included blood loss between application of the hemostatic agent and closure of the abdomen, duration of postoperative biliary drainage, and the occurrence of complications, defined a priori as reoperation for any reason, development of abdominal fluid collections, or bilious appearance of drained fluid for at least 1 day postoperatively. The mean time to hemostasis was 282 seconds with Crosseal, compared with 468 seconds with standard agents (2-sided; P =.06), for the 116 efficacy-evaluable patients. Hemostasis was achieved within 10 minutes in 53 patients (91.4%) treated with the study fibrin sealant and in 44 control patients (69.8%) (2-sided; P =.003). Intraoperative blood loss was similar in the 2 groups. In the Crosseal group, the percentage of patients developing postoperative complications was 17.2%, compared with 36.5% in the control group (2-sided; P =.02). Compared with the use of standard topical hemostatic agents, Crosseal fibrin sealant significantly reduced the time to achieve hemostasis following liver resection. Patients treated with the new fibrin sealant also experienced significantly fewer postoperative complications.

Topical hemostatic agents are used in all surgical disciplines. Most of these hemostats are based on animal-derived products like collagen and gelatin. They carry the potential risk of pathogen transmission. A newly developed biodegradable, fully synthetic hemostatic agent based on polyurethane foam (PU) with 55 % polyethylene glycol (PEG) would prevent these potential risks. The hemostatic efficacy of this new agent was compared to gelatin and collagen in humans who underwent extraction of an upper and lower molar (split-mouth model). After extraction of a molar in the maxilla and mandible, a PU foam and collagen or gelatin were inserted in the extraction socket for 2 min. Hereafter, the agents were removed and stored in ethylenediaminetetraacetic acid to stop coagulation. Then, the concentration of coagulation parameters thrombin-antithrombin III (TAT) complexes, fibrinogen, and thromboxane B2 (TxB2) in blood extracts from the agents was measured. The concentrations were also determined in baseline blood samples which were collected from the extraction socket. The concentrations of TAT and TxB2 were significantly increased, and fibrinogen concentration was significantly reduced compared to baseline wound blood concentrations indicating enhanced hemostasis. No significant differences were seen in the concentrations of these coagulation parameters in the three different hemostatic agents. These results show that PU combined with 55 % PEG is a promising alternative for the animal-derived hemostatic agents. The synthetic hemostatic agent could replace the animal-derived products like collagen and gelatin and therewith prevent the potential risk of pathogen transmission.

Death from exsanguinating hemorrhage remains a priority in the management of combat casualties and civilian trauma patients with truncal and junctional injuries. Appropriate use of hemostatic agents and dressings in the prehospital setting may allow for earlier control and an improved survival rate. Third-generation chitosan-based hemostatic agents and dressings appear to be equally efficacious to the dressing currently deployed by the US military forces in the management of hemorrhage not amenable to tourniquet placement. Unfortunately, a lack of clinical trials places a heavy reliance on anecdotal reports and laboratory studies in agent selection and application. Efficacy of currently available hemostatic agents and dressings appears to have plateaued in recent years although new agents and delivery mechanisms under development may improve control in cases of severe hemorrhage.

QS52. Efficacy of Three Topical Hemostatic Agents Applied by Medics in a Lethal Groin Injury Model

Randomized clinical trial of fibrin sealant in patients undergoing resternotomy or reoperation after cardiac operations: A multicenter study

Many research efforts have been directed toward enhancing the bone-cement interface of total joint arthroplasties. Hemostatic agents have been popularized as effective means of retarding the development of potentially harmful debris interposition adjacent to, and blood lamination patterns within, the methylmethacrylate. The hemostatic effectiveness of hydrogen peroxide was tested on six metaphyseal bone beds in ten mongrel dogs: three sites were treated with hydrogen peroxide and three were saline-treated control sites. The hemostatic effect of the treatments was determined by comparing blood loss per unit area per minute before and after application of the test solutions. The results indicate that hydrogen peroxide is an effective hemostatic agent and reduces the amount of blood and debris trapped within the trabecular bone methylmethacrylate interface.

Introduction. Operative blood loss is still a great obstacle to liver resection, and various topical hemostatic agents were introduced to reduce it. The aim of the current study is to evaluate effects of 3 different types of these agents. Methods. In this randomized clinical trial, 45 patients undergoing liver resection were assigned to receive TachoSil, Surgicel, and Glubran 2 for controlling bleeding. Intraoperative and postoperative findings were compared between groups. Results. Postoperative bleeding (0 versus 33.3%, P = 0.04) and drainage volume first day after surgery (281.33 ± 103.98 versus 150.00 ± 60.82 mL, P = 0.02) were significantly higher in Surgicel than in TachoSil group. Postoperative complications included bile leak (3 cases in Surgicel, 1 case in TachoSil and Glubran 2), noninfectious collection (2 cases in TachoSil and Surgicel and 1 case in Glubran 2), perihepatic abscess, and massive hematoma around hepatectomy site both in Surgicel group. There was no death during the study period. Conclusion. Due to higher complications in Surgicel group, its application as hemostatic agent after liver resection is not recommended. Better results in TachoSil in comparison to the other two are indicative of its better efficacy and superiority in controlling hemostasis.

Aim. To evaluate the biliostatic properties of modern topical hemostatic agents used in liver surgery in experiment. Materials and methods. The analysis of applied topical hemostatics in medical institutions of Chuvash Republic with liver resection is performed. A number of studies on the evaluation of adhesion properties in Vistar rats weighing 180-200 g were carried out using a device for determining the hermeticity of the liver stump by hydroporation. A comparative evaluation of the elasticity and adhesion strength of hemostatic agents was carried out. The polyurethane glue for medical purposes was developed and studied in the experiment. Results. To prevent bleeding and bile leakage, the most commonly used adhesive compositions are Bioglue, Tissucol, a gemostatic sponge, Tachocomb, a gelatin sponge Spongostan, a cellulose plate Sergisel. The adhesive adhesives Bioglue, Tissucol and the hemostatic sponge Tachocomb and the polyurethane composition of medical purpose with an adhesive strength of more than 600 mm of water column (mmW) at p <0.05 have the highest adhesion properties at p <0,05, based on the experimental. It has been established that a glue composition Bioglue and a polyurethane adhesive composition have a significant adhesive strength (more than 4.6 kgf / cm2) and elasticity (more than 140%). Conclusions. For the reliable prevention of bile leakage after liver resection, it is necessary to use topical hemostatic agents with an adhesive strength of more than 600 mm. water column. More preferable in this case is the use of adhesive compositions; they have good elasticity, viscosity and form a large area of contact with the bile ducts as compared with the plates and sponges.

Quick clots for tiny spots: Hemostatic agents in action.

Advanced breast cancer can present with bleeding tumors that are difficult to control using traditional techniques. The use of topical agents has been reported in the local management of bleeding malignant tumors. We report a challenging case of persistent bleeding in a 40-year-old female patient with metastatic breast cancer, presenting with significant uncontrollable bleeding from the fungating breast tumor where conventional measures failed to halt blood loss. We report the successful hemostasis using Floseal(topical hemostatic agent) in combination with local dressing. We recommend that topical application of Flosealshould be considered in the management of uncontrolled bleeding due to fungating malignant wounds. Liaising with tissue viability specialists is essential for optimum management and other symptomcontrol. Larger scale comparative studies are needed to further explore these findings.