Management of Surgical Hemostasis

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Management of

Surgical HemostasisAn Independent Study Guide

This education program was funded through the AORN Foundation y a grant from !thicon "iosurgery

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Management of Surgical Hemostasis

Contact Hours 2.4

Continuing !ducation contact hours are available for this activity. Earn contacthours by logging onto++ + . a o r n .o r g 6anage 8our !ducation AORN)ndependent 4tudy 6anagement of 4urgical 0emosta-sis )ndependent 4tudy"#$#' $$$" to read this article, review the overview and objectives, and

complete the online Examination and Evaluation.A score of $D correct on the e&amination is re(uired for credit. articipantsreceive feedbac; on incorrectans+ers. !ach applicant +ho successfully completesthis study can immediately print a certificate of comple-tion.

he contact hours !or this "ndependent #tudy expire $ecember %&, 2'&4.

Overview

!ffective management of bleeding is critical for promoting positive outcomes inthe surgical patient.hroughout a surgical procedure, bleeding must be

controlled not only to provide the best vie+ of the op-erative site, but also toprevent the adverse physiologic effects associated +ith blood loss. 9hen thenatural process of blood clotting does not occur or is adversely affected bysurgery, other methods of achieving and maintaining surgical hemostasis areoften indicated. he goal of this continuing education activity is to educateperioperative registered nurses ERNsF about the effective management ofhemostasis in the surgical patient. 2sing the nursing process and evidenced-based practices, this activity +ill assist the perioperativeRN to identify ris;s,benefits, indications, contraindications, and adverse effects +hen the variousmethods available for control of bleeding during surgery are used. he clinicalimplications of surgical bleeding and the importance of managing surgical

hemostasis +ill be discussed, follo+ed by a revie+ of the normal pro-cess of coagulation. he methods currently available to effectively managesurgical hemostasis G mechanical hemostatic techni(ues, thermal'energy-basedmethods, and the various types of topical hemostatic agentsG +ill be outlined. erioperative nursing care considerations related to themanagement of surgical hemo-stasis, including assessment factors to determinepatients at ris; for prolonged or e&cessive bleeding and ;eyconsiderations forthe selection and safe use of topical hemostatic products, +ill be discussed.

Objectives

After completion of this continuing nursing education activity, the participant +ill beable toH

". )dentify the clinical implications of surgical bleeding.

@. 7ifferentiate bet+een mechanical, energy-based, and chemical methods of surgicalhemostasis.

#. Compare the various categories of topical hemostatic products.

I. )dentify ;ey factors to consider in the selection of hemostatic products.

>. 7escribe perioperative nursing care for patients undergoing surgical hemostasis.
http://www.aorn.org/http://www.aorn.org/


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ntended Audience

his continuing education activity is intended for perioperative RNs +ho areinterested in learning moreabout the importance of and methods available forthe effective management of surgical hemostasis.


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Author!Subject Matter "#pert

Rose 6oss, 6N, RN, CNOR

erioperative NurseConsultant'6edical 9riter 6oss!nterprises 33C!liabeth, CO

7isclosureHNo conflict

AORNs policy is that the sub*ect matter e&perts for this product must discloseany financial relationship +ith a company providing grant funds and'or acompany +hose productEsF may be discussed or used duringthe educationalactivity. 1inancial disclosure +ill include the name of the company and'orproduct and thetype of financial relationship, and includes relationships that arein place at the time of the activity or +ere in place in the "@ months precedingthe activity. 7isclosures for this activity are indicated according to thefollo+ingnumeric categoriesH

". Consultant'4pea;ers Bureau @. !mployee

#. 4toc;holder I. roduct 7esigner

>. :rant'Research 4upport . Other relationship EspecifyF. 0as no financial interest

$lanning Committee

4usan J. Ba;e+ell, 64,RN-BC 7irector,erioperative !ducation

AORN Nursing7epartment7enver, CO

7isclosureHNo Conflict

!llice 6ellinger, 64, RN,CNOR erioperative!ducation 4pecialistAORNNursing 7epartment7enver, CO7isclosureHNo Conflict

ntroduction%

Hemostasis is the act of restricting or stopping blood flo+ from a damaged vesselor organ. Ad*unct hemo-static techni(ues are essential during surgery or otherinvasive procedures to provide hemostasis +hen thenormal coagulation processmay be unable to function." +o types of bleeding are seen during a surgical pro-cedure, arterial bleeding +hich can be seen to pulsate and venous bleeding +hichooes rather than pulsates. he need to control arterial bleeding is crucial becauselarge volumes of blood can be (uic;ly lost, ho+ever,slo+er, persistent loss of venousblood can contribute to significant blood loss if uncontrolled.@

6aintaining hemostasis during surgery is essential to preserve physiologicfunctions for the patient, providethe surgeon +ith the ability to see the operative


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field, and promote successful +ound management and pa-tient outcomes." )naddition, effective surgical hemostasis also results in fe+er blood transfusions,decreased operating time, and reduced morbidity and mortality for patients.#

Because the elimination of ris;s such asbleeding are considered components ofpatient-centered care,I managing surgical hemostasis through evi-dence-basedpractices is a ;ey role of the perioperative RN."

KNoteH erms in bold are defined in the glossary.


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Clinical mplications of Surgical &leeding

7uring any surgical procedure, maintaining the delicate balance bet+eenbleeding and clotting means thatblood must continue to flo+ to the tissues at theoperative site +hile the surgical team prevents e&cessive loss of blood. 0emostasisis important to the success of the procedure, as +ell as to patient outcomes.#

herefore,a revie+ of the clinical implications of surgical bleeding is helpful inunderstanding the importance of effec-tively managing this balance. he factors

that contribute to surgical bleeding, the adverse effects of surgical bleeding, andthe importance of managing hemostasis during surgery +ill be revie+ed.

Factors that Contribute to Surgical Bleeding

6ultiple factors contribute to bleeding during or after surgical intervention Eable"F that are related to either the surgical procedure itself or the individual patientand can have a profound effect on e&pected outcomes.",#

Table 1 Factors that Contribute to Surgical Bleeding

#rocedural Factors$ Type of procedure$ #atient position$ Surgical incisions

$ !%posed one &eg' spinal reconstructi(e procedures)$ *arge surfaces of e%posed capillaries$ +nseen sources of leeding$ Tissues that cannot e sutured or low,pressure suture lines$ Adhesions stripped during surgery

#atient Factors$ Specific anatomical considerations$ Medications &eg' anticoagulants)$ -oagulopathies

#latelet dysfunction or deficiencyFirinolytic acti(ity-oagulation factor deficiencies

$ Medical conditions$ Nutritional status

Adapted with permission from: Samudrala S. Topical hemostatic agents in surgery: a surgeons perspective.AORN ./ 2008;88!":S2#S$$.

Adverse Effects of Surgical Bleeding

7uring surgery, uncontrolled or diffuse bleeding can lead to multiple clinicaland economic adverse patientoutcomes.> hese adverse effects includeH

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Lhrombocytopenia. his is a common hemostatic deficiency that may developduring surgery because of massive blood loss re(uiring replacement or afterthe administration of heparin Eie, heparin-induced thrombocytopeniaF." heeffects of thrombocytopenia include hemorrhage or thrombotic events.

L0ypovolemic shoc;. his occurs as a result of vascular volume depletion fromhemorrhage during surgery and can reduce cardiac output because theheart is unable to completely fill. After the patient loses "$D of his or hertotal blood volume, cardiac output and central pressure begin to fall."As a

result, the body compensates by causing peripheral vasoconstriction toimprove cardiac output and pulmonary


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gas e&change, and diaphoresis occurs. hese changes can result incompensated shoc;, and the body isable to compensate for the volume loss.0o+ever, if the blood loss is not stopped and volume replaced,compensatorymechanisms eventually fail and the follo+ing events occurH

Pvasoconstriction reduces o&ygenation of peripheral cells,

P o&ygen deprived peripheral cells begin to function anaerobically,

P metabolic +aste products build in the cells,

P cells begin to die and release inflammatory mediators,

P cell death and inflammatory mediators cause capillary permeability andvasodilation,

P blood pressure falls as a result of vasodilation, and

P the patient eventually dies."

L!conomic conse(uences. he economic effects of bleeding can be substantial,primarily because of theincreased need forH

P patient monitoring,

P specialist consultations,

P e&tended length of hospital stay,

P

further surgical intervention,P longer procedure times and'or a return to the OR,

P postoperative intensive care unit E)C2F stays re(uiring mechanical

ventilation, and

P additional medical interventions.>

ImportanceBenefits of !anaging "emostasis during Surger#

As discussed, effectively managing hemostasis during a procedure helps tomaintain a clear field of vision for the surgeon this is especially important as itmay help to reduce time in the OR and the need for blood transfusions.6inimiing blood loss and reducing the need for blood transfusions during

surgery are asso-ciated +ith beneficial outcomes for the patient, such as shorterstays in the )C2 and the hospital and lo+er ris;s for infection and postoperativecomplications."$,""All of these benefits translate to a decrease in health carecosts for both patients and health care facilities.

$ormal Coagulation %rocess

o understand the effect of surgical bleeding, as +ell as the means to controlbleeding, it is helpful to un-derstand coagulation, the bodys mechanism tocontrol bleeding. Coagulation is a process that changescompounds circulating inthe blood into an insoluble gel, +hich is able to plug lea;s in the blood vessels andthus stop the loss of blood. )n*ury to a blood vessel causes the recruitment andactivation of platelets, +hich adhere to each other at the in*ury site this leads to

the initial formation of a platelet plug and eventually, theformation of a fibrinclot./"Ep"#%F he follo+ing three components are re(uired for this processH

(coagulation !actors, +hich are produced by the liverLcalcium, +hich is recruited from intracellular sources in the blood and

L phospholipids, +hich are components of platelets."

latelets are re(uired in the coagulation process because their aggregationbegins the initial formation of a platelet plug."


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After a loss of vascular integrity Eeg, an in*ury to a vesselF, four ma*or events occur inthe follo+ing se(uenceH

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I. 1ibrinolysis. !ventually, a clot must dissolve to allo+ the normal flo+ of blood afterthe tissue repair

occurs. he occurs through the action of plasmin."@

he normal process of hemostasis is outlined in greater detail in 1igure ".

Figure 1 The Coagulation Se&uence1'(

References

1. Stassen, !, Arnout, , "ec#myn, $. The hemostatic system. Curr 6ed Chem. %&&'(11)1*+( %%'-%%&.

%. /roos 0, eys $/, de!eyer S, 2anhoorel3e#e 0, "ec#myn $. 4latelets at5or# in primary hemostasis. Blood Rev.%&11( %)'+61-1*.

Intrinsic and E)trinsic %ath*a#she bodys response to bleeding is a se(uence of physiologic interactionsdescribed as the coagulation cascade. 7uring this process, coagulation occurs

via intrinsic or e&trinsic path+ays, +hich are triggered bydifferent events butare interrelated and complete the process through a common path+ay E1igure@F."


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Figure ( Coagulation Cascade +Intrinsic and E)trinsic %ath*a#s,

he intrinsic path+ay is triggered by events that occur +ithin a blood vessel Eie,damage to the vesselsendotheliumF, +hile the e&trinsic path+ay is triggered+hen an in*ury to a vessel occurs Eie, a vessel is cut during surgeryF. Bothpath+ays begin +ithin seconds after platelets are e&posed to and activated bycollagen.his causes them to form the initial platelet plug. 9hen an in*ury to a

vessel occurs and initiates the e&trin-sic path+ay, the clotting cascade occursmore (uic;ly because some of the steps necessary for the intrinsicpath+ay are

bypassed. )n both path+ays, thrombin is re(uired to form a hemostatic plug.hrombin gener-ation occurs after an in*ury to a blood vessel. )n*ury to a vessele&poses tissue factor, +hich then interacts+ith activated factor


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Coagulation Factors

Coagulation factors Eable @F are proteins that cause successive reactions in theclotting process in a cas-cade-li;e se(uence Eie, one factor is re(uired for theactivation of the ne&t factorF." he number associated +ith the factor, ho+ever,does not reflect the order in +hich it is involved in the coagulation cascade. helac; of any coagulation factor can impair the clotting process."

Table ( Coagulation Factors

Number 'Name!Substance( )unction's(Factor I &Firinogen) -on(erted to firin y thromin/

Factor II rothromin) -on(erted to thromin y Factor 0/After acti(ation thromin con(erts to firinogen &factor 1)2 itssynthesis is (itamin 3 dependent/

Factor III &Tissue factor or tissue thromoplas,tin)

Interacts with Factor 4II2 is the primary reaction that initiatesthe e%trinsic pathway/

Factor I4 &-alcium) !nhances platelet aggregation and red lood cell clumpingalong with Factors 4II' I0' 0' and 0III' which re5uire calcium toe acti(ated/

Factor 4 *eiden roaccelerin'acceleratorgloulin' laile factor)

!ssential for con(erting prothromin to thromin/

Factor 4I &Accelerin) A suset of Factor 42 also 6nown as Factor 4a &there is noactual Factor 4I in lood coagulation)/

Factor 4II rocon(ertin' cothromoplastin'Serum prothromin con(ersion accelerator)

"inds to Factor III &tissue factor)' then acti(ates Factors I0 and0/ !ssential for the con(ersion of prothromin to thromin2 itssynthesis is (itamin 3 dependent/

Factor 4III &Antihemophilic gloulin) A sustance similar to Factor 4 that acti(ates other steps inthe coagulation process/ The lac6 of this factor is the cause ofhemophilia A/

Factor I0 &-hristmas factor) Reacts with other factors to acti(ate Factor 0/ !ssential in thecommon pathway etween the intrinsic and e%trinsic path,

ways/ The lac6 of this factor is the cause of hemophilia "/

Factor 0 &Stuart,#rower factor) Reacts with other factors to acti(ate the con(ersion ofpro,

thromin to thromin/

Factor 0I lasma thromoplastin antecedent'Fletcher factor 7or pre6alli6rein8 and high,mo,lecular,weight 6ininogen)

#art of a comple% chain reaction that cataly9es other parts ofthe coagulation proce &acti(ation of Factor I0)/ #atients defi,cient in Factor 0I often ha(e mild leeding prolems postoper,ati(ely/

Factor 0II &Hageman factor or contact factor) A sustance that reacts with other factors to acti(ate Factor 0Iin the intrinsic pathway/

Factor 0III &Firin,staili9ing factor and protein-)

Aids in the formation of cross,lin6s among firin threads toform firin clot/

Adapted with permission from: %c&arthy '(. %ethods for assuring surgical hemostasis. )n:Assisting in Sur,gery: #atient,-entered -are/ '& (othroc*+ ,& Seifert+ eds. -enver+ &: &&); 200/:$0.

Surgical "emostasis Techni&ues

here are several methods available to manage bleeding in the OR includingmechanical hemostatic tech-ni(ues, thermal'energy-based methods, andchemical methods, +hich include the use of topical hemostaticproducts Eable#F."

Table - !ethods to Achieve Surgical "emostasis

Mechanical methods $ ;irect pressure

$ Faric pads


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*hermal!energy+based methods , "lectrosurge

ry

Monopolar&ipolar

"ipolar (essel sealing de(ice

Argon enhanced coagulation

, -ltrasonic device

Chemical methods

, $harmacological agents

, *opical hemostatic agents

$ !pinephrine

$ 4itamin 3$ #rotamine

$ ;esmopressin

$ *ysine analogues &eg' aminocaproic acid' trane%amic acid)

$ #assi(e &ie' mechanical)

agents -ollagen,ased

products-ellulose

Gelatin

#olysaccharide spheres

$ Acti(e agents

Thromin products

$ Flowales

$ Sealants

Firin sealants#olyethylene glycol !G) polymers

Alumin and glutaraldehyde

-yanoacrylate

Adapted with permission from: Samudrala S. Topical hemostatic agents in surgery: a surgeons perspective.AORN ./ 2008;88!": S2#S$$.

!echanical !ethods

A surgeon can use direct pressure fabric pads, gaues, or sponges sutures staples orclips to mechanically

control bleeding."#

L7irect pressure. he use of direct pressure or compression +ith one or more fingersat a bleeding

site is typically a surgeons first choice to attempt to control bleeding, as thismay be the simplest and fastest method.#Arterial bleeding is more easilycontrolled +ith direct pressure than venous bleeding."


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the team mem-ber +ho places them should communicate the number ofsponges that have been pac;ed to ensureall items used are retrieved before +ound closure and to prevent a retainedsurgical item. Removal ofpac;ing should also be reported.",#,"# Compressionor other mechanical methods may not al+ays be


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appropriate# in cases of e&treme bleeding, pressure may only be atemporary measure and the use ofsutures, staples, or ligating clips may beneeded to achieve ade(uate hemostasis."#

L4utures'staples'ligating clips. hese mechanical methods are useful if the source of

bleeding is easily

identifiable and able to be sealed.#

P 4utures."I 4utures and ties are used during operative procedures asligatures to tie off blood vessels and control bleeding. he three primarycharacteristics of suture material are physical configuration Eeg, single-or multi-strand diameter, tensile strength, elasticity memoryF, han-dling Eeg, pliability, tissue drag, ;not tying capability, slippage(ualitiesF, and the tissue reaction itcauses Eeg, inflammatory reactions,absorption effects, potentiation of infection, allergic reac-tionsF.Because allergic reactions to suture material have been reported, theperioperative teamshould assess if the patient is allergic to certainsuture materials. Considerations +hen using su-ture include the type oftissue it +ill be used on, its tensile strength and +hether it is as strongasthe tissue it must appro&imate, and +hether it +ill last Eie, not resorbFuntil the tissue is healed.he smallest diameter suture possible should

be used to minimie tissue reaction and in*ury."I

P 4taples.","# 4terile, disposable stapling devices place staggered ro+s oftitanium staples and then divide the tissue located bet+een the ro+s ofstaples. hese devices may be used in both open and minimally invasiveprocedures and are a safe and efficient method to achieve hemostasis+hen dividing tissue. he manufacturers instructions should befollo+ed for the proper use ofany stapling device.","#

P 3igating clips.","# 3igating, or hemostatic, clips are used to ligate bloodvessels. Because they are(uic; and easy to apply, they achievehemostasis efficiently and also reduce the ris; of foreign body reactionthat may occur +ith suture material. 3igating clips are available in

various si-es and must be used +ith the corresponding sie applier. Before theapplication of clips, the surgeon must determine the appropriateness ofusing clips. he scrub person should chec; theclip appliers to ensurethat they are functioning properly. he *a+s should be symmetrical andthey should hold the clip securely and close +ithout overlapping. Beforeapplication, the surgeon or assistant should blot the bleeding site +ith asponge and apply direct pressure if necessary to ma;e the site more

visible.","#

ThermalEnerg#.Based !ethods

Over the last several decades, thermal means to achieve hemostasis Eeg, heatgenerated from electrosurgery,ultrasonic devices, lasersF have become feasibleoptions to control surgical bleeding." 9hen any energy-based tool is used forhemostasis, all members of the perioperative team should understand theunderlying princi-ples of the modality and use safety precautions during its use.

L !lectrosurgery. !lectrosurgery, developed in the "%#$s, is the use of high-fre(uency Eeg, radio fre(uen-cyF alternating current for cutting, coagulating,and vaporiing tissues in both open and laparoscopic procedures."#,">

!lectrosurgical energy is delivered in t+o modesH monopolar and bipolar acompleteelectrical circuit is necessary for current to flo+ +hen using either


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of these modes, ho+ever, the cir-cuits are different." !lectrosurgical unitsare considered high-ris; e(uipment."

he potential ris;s of electrosurgery use include patient in*uries, userin*uries, fires, and electromag-netic interference +ith other medicale(uipment and internal electronic devices. !lectrosurgery safety isheightened by adhering to good practices, and adverse events Eeg, patientburns and firesF associated +ith electrosurgery use may be reduced byadhering to basic principles of electrosurgery safety. eriop-erative

personnel should follo+ the manufacturers instructions for the specificelectrosurgery system being used and follo+ current AORN Recommendedpractices for electrosurgery/" to promotepatient safety.

P 6onopolar electrosurgery. 6onopolar electrosurgery is the mostfre(uently used electrosurgical method of hemostasis."# )n a monopolarcircuit, electrical current flo+s from the generator through an activeelectrode to the patient E1igure #F." )f the electrical energy concentratesin a small area and the tissue provides increased resistance, controlledheat is produced, +hich resultsin either cutting or coagulation of thetissue. 9hen an electrosurgery unit is activated, electrical energy passesfrom the unit through the pencil to the patient and then to the dispersiveelec-


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trode placed on the patients body. he energy then returns to thegenerator to complete thecircuit. Because electricity +ill follo+ thepath of least resistance +hen returning to the genera-tor, if adispersive electrode is tented or only a small portion of it is in contact+ith the patientsbody, electrical energy can concentrate at that siteand result in a burn. he surface area of thedispersive electrode alsoshould be large enough to prevent the energy from becoming concen-trated enough at that area to generate significant heat."

6onopolar electrosurgery delivers current using different types of+aveforms or modes. hecoagulation mode produces an interrupted+aveform that creates heat, thereby coagulating a cell, also referred toas fulguration. he cutting mode is a continuous current at lo+erenergy,+hich produces a cutting effect to vaporie tissue +ith little orno hemostasis. he blend mode simultaneously cuts tissue andcoagulates bleeding.","

Figure - !onopolar Electrosurger# Circuit

P Bipolar electrosurgery. )n a bipolar electrosurgery circuit, current doesnot flo+ through the patient to complete the circuit. he circuit iscompleted bet+een the t+o tines Eor prongs or bladesF of the bipolarforceps. he distance bet+een the active and ground electrode is verysmall and current flo+s only bet+een the t+o tines E1igure IFtherefore, a dispersive electrode is not needed."As +ith monopolarelectrosurgery, heat is generated in the tissue as the currentflo+s fromone bipolar tip through the tissue and bac; to the other tip therefore,the electrode tips need to be near each other and the tissue should bein contact +ith the electrodes."

Figure / Bipolar Electrosurger# Circuit


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Bipolar electrosurgery +or;s +ell for procedures in +hich the surgeonneeds to limit thermal spread Eeg, delicate tissue and'or on smallanatomical structuresF."# Bipolar electrosurgery useslo+er voltage todeliver the current, ma;ing it a safer option +hen the potential forelectromag-

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netic interference +ith implanted medical devices Eeg, pacema;ers,internal cardioverter-defibril-latorsF e&ists."

P Bipolar electrosurgeryvessel sealing technology is an advancedelectrosurgical modality in +hich the intimal layers of a vessel are fusedand a permanent seal is formed."# his deviceE1igure >F applies heatover time +ith high compression. Other energy-based hemostatic meth-ods shrin; the vessel +alls and rely on the formation of a thrombus toocclude the vessel +ith bipolar sealing technology, the lumen of the

vessel is obliterated. hese systems are capable ofsimultaneouslysealing and transecting vessels up to mm in diameter, large tissuepedicles, and vascular bundles by using a combination of pressure andenergy."#

Figure 0 Bipolar essel Sealing Device

PArgon-enhanced coagulation technology."#Argon-enhancedelectrosurgery uses a stream of in-ert, noncombustible argon gas to

conduct the electrosurgical current. Argon gas is heavier than air anddisplaces nitrogen and o&ygen the electrosurgical current ionies theargon gas, +hich ma;es it more conductive than air and creates abridge bet+een the electrode and the tissue."#

L 2ltrasonic devices.","#An ultrasonic device converts electrical energy intomechanical energy that oscil-lates longitudinally at the point of contact

vibrating at >>,>$$ times per second, it simultaneously cutsand coagulatesand can seal vessels up to > mm in diameter and offers an alternative toelectrosurgeryfor some surgical procedures. Because this device generateslo+er temperatures and there is no dis-persed current, it cuts or coagulatesonly the tissue +ith +hich it is in contact and this limits thermal damage to

surrounding tissues. A dispersive electrode should not be used because noelectrical currententers the tissue and, therefore, does not need to bereturned to a generator through a dispersive elec-trode.","#

2ltrasonic devices should be used in a manner that minimies the potential forin*uries to patients

and staff members." )nhalation of aerosols generated by an ultrasonicelectrosurgical device should beminimied by the use of smo;e evacuationsystems and +all suction +ith an in-line, ultra-lo+ penetra-tion air filter.

(*asers. 3asers are a common heat-generating device used by surgeons toprovide hemostasis."# 3aser is an acronym that stands for light amplificationby stimulated emission of radiation, and describes the process in +hich


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laser light energy is produced." 3aser light differs from ordinary light inthatit is monochromatic Eie, composed of photons of the same +avelength or colorF it is

collimated Eie,

it consists of +aves parallel to each other that do not diverge significantlyF+hich minimies loss of po+er and allo+s light to be focused into a tiny spotof highly concentrated energy and it is coherentEie, all light +aves areorderly, in phase +ith each other, and travel in the same directionF." 3aser

energydelivered to a targeted site can be reflected, scattered, transmitted, orabsorbed. he e&tent of the tissue reaction depends on the laser +avelength,po+er settings, spot sie, length of contact time +ith the

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targeted tissue, and tissuecharacteristics./"Ep@@MF

P 3aser safety. 6edical laser systems Eeg, class # and class I lasersF areclassified by ho+ haard-ous they are and the controls re(uired. hedangers of using a class # laser are related to directe&posure ore&posure to mirror-li;e light reflection, also ;no+n as specularreflection. !yeand s;in e&posure to class I lasers may be haardous, and these lasers

may present a potential fire ris;. erioperative personnel shouldestablish a formal laser safety program and follo+ the current AORNsRecommended practices for laser safety in perioperative practice/"M

settings to promote patient safety during laser use.

Chemical !ethodsTopical "emostatic %roducts

7epending on the procedure and location of the bleeding tissue, it may beimpractical or impossible to ef-fectively control bleeding +ith mechanical orthermal hemostatic techni(ues. 1or e&ample, in bony surfaces,parenchymaltissues, inflamed or friable vessels, or tissues +ith multiple and diffuse capillaries,it is e&tremely difficult to maintain hemostasis +ith these methods./ #Ep4>F )n thesecases, using pharmacological methods to obtain hemostasis or an ad*unct to otherhemostatic methods may be helpful.

Chemical methods available today Eeg, pharmacological agents, various topicalhemostatic agentsF enhancethe natural coagulative mechanisms. )t is importantto note that the surgeon or licensed independent prac-titioner selects thehemostatic agent to be used and all of the agents and products discussed herere(uire a physicians order.

Lharmacological agents

P harmacological agents are used primarily to improve clot formationthrough several mecha-nisms including increasing platelet functionand reversing anticoagulation."% hese agents used during surgery to

control bleeding by enhancing the natural mechanisms of coagulationmayinclude use of the follo+ing agentsH#

L!pinephrine." his hormone causes direct vasoconstriction and actson the heart byincreasing the heart rate. his vasoconstrictiveproperty ma;es epinephrine useful duringsurgery, because it canbe applied topically or in*ected in combination +ith a local anes-thetic agent. 9hen combined +ith a local anesthetic, epinephrinereduces bleeding, slo+sthe absorption of the local anesthetic, andprolongs the analgesic effect.

L


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the previous four hours./@@ 0o+ever, protamine does not reverselo+-molecu-lar-+eight heparin. rotamine is associated +ithadverse events, including anaphyla&is,acute pulmonary

vasoconstriction, and right ventricular failure./"%Ep4"MF atients atris; for protamine reactions include diabetic patients, patients+ho have undergone a vasectomy,or those +ho have multiple drugallergies or have had previous protamine e&posure."%

L 7esmopressin."%,@# 7esmopressin is a synthetic analogue ofarginine vasopressin. )t stim-ulates the release of von 9illebrandfactor Ev91F from endothelial cells, +hich leads to an increase inplasma levels of v91 and enhances primary hemostasis.7esmopressin should be administered by slo+ )< infusion at adose of $.# Qg';g to prevent hypoten-sion./"%Ep4"MF 9hile it assists inreducing perioperative bleeding, the effect of desmopressin is toosmall to influence other, more clinically relevant outcomes, such asthe need for blood transfusion and repeat procedures."%

L3ysine analogues Eie, aminocaproic acid, trane&amic acidF."% 4yntheticlysine analogues

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are antifibrinolytic agents that competitively inhibit activation ofplasminogen, thereby reducing the conversion of plasminogen toplasmin, the enyme that degrades a fibrin clot./"%Ep4"F heseagents have variable effects in reduction of bleeding in addition,pub-lished safety data on these agents is limited.

3ysine analogues also may also be used for cardiac surgerypatients.@#A loading dose of "to "> grams of aminocaproic acid, fore&ample, is administered at induction of anesthesia,follo+ed by a

maintenance dose of " to @ grams per hour as a continuous infusionduringsurgery, +ith a total dose of "$ to #$ grams. rane&amicacid is administered as a loadingdose of @ to grams at inductionof anesthesia, follo+ed by a maintenance dose of @$ to @>$milligrams per hour as a continuous infusion during the procedure,+ith a total doseof # to "$ grams."%,@#

Lopical 0emostatic roducts

oday, there is a +ide range of topical hemostatic products available for usein the OR. o understand their mechanisms of action and use themappropriately and safely, the reader must understand theprocesses ofpassive and active hemostasis.

P assive versus active hemostasis.#,> opical hemostatic agents currentlyavailable for use in surgery can be divided into t+o primary categoriesHpassive and active. hese classifications refer to the mechanism ofaction provided by the agent during surgery. assive, or mechanical,agents act passively through contact +ith bleeding sites and promotionof platelet aggregationactive agents act biologically on the clotting cascade. assive topicalhemostatic products includecollagens, cellulose, gelatins, andpolysaccharide spheres. Active agents include thrombin and thoseproducts in +hich thrombin is combined +ith a passive agent to providean active overall product. +o other categories are flo+able agents and

sealants, +hich include fibrin sealants, polyethylene glycol E!:Fpolymers, albumin and glutaraldehyde, and cyanoacrylate.#,>

L assive hemostasis. assive or mechanical topical hemostatic agentsconserve blood by accelerating thecoagulation cascade and reducing bloodloss. he central mechanism of passive hemostatic agents is to form aphysical, lattice-li;e matri& that adheres to the bleeding site this matri&activates the e&trinsicclotting path+ay and provides a platform around+hich platelets can aggregate to form a clot. Becausepassive hemostats relyon fibrin production to achieve hemostasis, they are only appropriate for usein patients +ho have an intact coagulation cascade. 1or e&ample, ahemorrhaging patient +ith a signi-cant coagulopathy +ould not be an

appropriate candidate.#,>assive hemostatic agents used during surgery are available in many formsand methods of application Eeg, bovine collagen, cellulose, porcine gelatins,polysaccharide spheresF that integrate an absorbablesponge, foam, pad, orother material +ith a topical hemostatic agent, +hich is then applied to thebleeding site. assive hemostats are generally used as first-line agentsbecause they are immediately available, re(uire no special storage orpreparation, and are relatively ine&pensive.

hese agents can absorb several times their o+n +eight in fluid. 1ore&ample, o&idied cellulose can absorb seven times its o+n +eight in normalsaline, +hereas cotton-type collagen can absorb #@ timesits o+n +eight.

0o+ever, this e&pansion can result in complications, such as pressing nerves


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in thesurrounding tissue against bone or hard tissue. 1or e&ample,Broadbelt et al @I reported three cases ofpatients +ith paraplegia follo+ingthoracic surgery +here o&idied cellulose +as used for hemorrhage controland +hich +as later found to have passed through the intervertebralforamen causing spi-nal cord compression. herefore, +hen a passive topical hemostatic agent isused on or near bony or neural spaces, it is recommended that the surgeonuse the minimum amount of the agent re(uired to achieve hemostasis andremove as much of the agent as possible once hemostasis has beenachieved.",@Iassive topical hemostatic agents do not adhere strongly to +ettissue and thus have little effect on actively bleeding +ounds ho+ever, theycan be effective in the presence of heavier bleeding because oftheir largerabsorption capacity and the greater mass provided by their morefibrous'dense structures.@I

LActive hemostasis. Active hemostatic agents such as topical thrombins Eeg,bovine, pooled human plasma, recombinantF, have biological activity anddirectly participate at the end of the coagulation cascade to stimulatefibrinogen at the bleeding site to produce a fibrin clot.#,> Because thrombinacts at the end

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of the clotting cascade, its action is less affected by coagulopathies fromclotting factor deficiencies or platelet malfunction, and thrombin is a logicaland useful choice for patients +ho are receiving anti-platelet and'oranticoagulation medications. Because thrombin relies on the presence offibrinogen in the patients blood, ho+ever, it is ineffective in patients +hohave afibrinogenemia. )n addition, throm-bin itself does not need to beremoved from the site of bleeding before +ound closure. 7egeneration andreabsorption of the resulting fibrin clot occur during the normal +ound

healing process.

#,>

Active topical hemostatic agents typically provide hemostasis +ithin "$minutes in most patients. )n addition, they control local bleeding moreeffectively than passive hemostats, although they are usuallymore costly.

Active hemostatic agents are available in various forms and can be appliedusing pump or spray ;its +hen large +ound areas need to be evenly covered.he surgeon can also apply them directlyto the bleeding site using asaturated, ;neaded, absorbable gelatin sponge. )n many cases, the surgeonmay choose to combine an active agent +ith a passive agent to improve overallhemostasis.#,>

P :eneral considerations for the use of topical hemostatic agents.","#

opical hemostatic agents areused as an ad*unct method to controlbleeding +hen standard methods are ineffective or imprac-tical that is,if the use of direct pressure, suture, or electrosurgery can safely achieveand main-tain hemostasis, then one of these techni(ues should be thefirst choice for control of bleeding. Before using a chemical hemostaticagent, the surgeon or first assistant shouldH

Ldetermine the appropriateness of using a chemical agent in the areare(uiring hemostasis,

Levaluate the +ound classification because use of most topicalhemostatic agents is contra-indicated in contaminated +ounds,

Lunderstand that chemical agents are not intended to act to

tamponade or plug a bleedingsite, andL assess the patient for allergies to the agent being considered for

use or to the productsconstituents."#

9hen a topical hemostatic agent is selected to help manage surgicalbleeding, team members should follo+ AORNs Recommended practices formedication safety/ for safe management on the sterileeld.",@> hemanufacturers instructions for use Eie, the pac;age insert regardingapproved indicationsfor use level of bleeding contraindications specificstorage, preparation, and application instructions safety considerationsFshould al+ays be follo+ed. Before providing any topical hemostatic agent tothe sterile field, the perioperative RN should chec; its e&piration date,

inspect the product for sterility compromise, and transfer it to the sterile fieldusing aseptic techni(ue. he scrub person should label the syringe orcontainer, if applicable, and the surgeon or first assistant should verballyconfirm and ac;no+ledge the scrub persons announcement of the topicalagent provided for use.@>

!ach category of passive and active topical hemostatic products is described in

greater detail belo+.

%assive "emostatic Agents

he products in the passive or mechanical category of hemostatic agents act byforming a barrier to stop the flo+ of blood and by providing a surface that allo+s

blood to more rapidly clot.@

his category includescollagen-based products,


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o&idied regenerated cellulose, gelatin-based products, and polysaccharidehemo-spheres each of these product categories is described belo+.

7Collagen-3ased products. Collagen-based products are activated on contact+ith bleeding and provide a scaffold to +hich platelets can adhere. hisstimulates the bodys normal coagulation mechanism.hese products providea stable matri& for clot formation, but also enhance platelet aggregation, degranulation, and release of clotting factors, +hich further promotes clotformation.@ 0emostaticcollagen products are derived from either bovine

tendon or bovine dermal collagen and may be further divided intomicrofibrillar and absorbable collagen products.

P!icrofi3rillar collagen hemostat Eeg,Avitene8 andAvitene89ltrafoam8, S htt p H''++ + .d avo l .c o m 'products'srugical-specialties'hemostasis'avitene-ultrafoam-collagen-sponge'T @M,)nstatU6C0@%ShttpH''++ + .e t h ic o n # $ .c o m 'p r o d u c t s 'i n s t a t -m c h-m ic r o fib r ill a r - c o l la g e n -h e m o s t atTF",>,"#

his type of product is derived from purified bovine dermal collagen itis a fibrous, +ater-insol-uble partial hydrochloric salt. 6icrofibrillarcollagen hemostats are available in a loose fibrous

?AORN, )nc, @$"# "
http://www.davol.com/http://www.davol.com/http://www.ethicon360.com/products/instat-mch-microfibrillar-collagen-hemostathttp://www.ethicon360.com/products/instat-mch-microfibrillar-collagen-hemostathttp://www.ethicon360.com/products/instat-mch-microfibrillar-collagen-hemostathttp://www.davol.com/http://www.davol.com/http://www.ethicon360.com/products/instat-mch-microfibrillar-collagen-hemostathttp://www.ethicon360.com/products/instat-mch-microfibrillar-collagen-hemostat


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form and also as sheets or sponges. hese products are stored at roomtemperature, are imme-diately available for use, and should not beresterilied. 9hen a microfibrillar collagen hemostat comes in contact+ith a bleeding site, the platelets are attracted to it, adhere to thefibrils, and then aggregate, thus initiating the clotting cascade."#

6icrofibrillar collagen hemostats are effective agents +hen there iscapillary, venous, or small arterial bleeding.> Collagen inherentlyadheres to tissue, and +hen used as a hemostatic agent it should be

applied directly to the source of bleeding. Because moisture activatesmicrofibril- lar collagen products, they should be used dry Eie, notcombined +ith saline or thrombinF andapplied +ith dry, smooth forceps to the bleeding site. 4heets +or; beston flat surfaces or +hen +rapping vessels and anastomosis sites isneeded sponges should only be used in ophthalmic or urologicprocedures.> he presence of a firm, adherent coagulum +ith nobrea;through bleeding from the surface or edges indicates that thecollagen has been successfully applied. he surgeon or first assistantshould remove any e&cess product from the application site and irrigatebefore the +ound is closed. 6icrofibrillar collagen hemostat is a foreignsubstance, therefore, its pres-ence may potentiate +ound infections andabscess formation."#

6icrofibrillar collagen hemostats should not be usedH

Lin patients +ith ;no+n allergies or sensitivities to materials of bovineorigin

L+hen a blood scavenging system is used because fragments canpass through the systems filters. 4crubbed team members shouldnotify the RN circulator to discontinue the use of blood scavenginge(uipment after microfibrillar collagen hemostat is used

Lfor s;in closure, as it may interfere +ith healing of the s;in edges

Lon bony surfaces because it interferes +ith methyl methacrylate

adhesives by filling poros-ities of cancellous bone orLin any area +here it may e&ert pressure on ad*acent structures because of

fluid absorption

and e&pansion.",>,"#

hese products potential adverse effects includeH allergic reaction,adhesion formation, inflam-mation, foreign-body reaction, andpotentiation of +ound infections and abscess formation.",>,"#

P A3sor3a3le collagen hemostat sponge Eeg,$elistat:Sh t t p H''++ + . i n te g r a l i fe .c o m 'p r o d u ct s 'p d fs 'h e l i-

tene-helistat-sellsheetD@$finalS"TVI.pdf TF","#,#$

hese agents consist of collagen derived from purified and lyophili+edEie, freee driedF bovine fle&or tendon and is available as a lightly cross-lin;ed sponge-li;e pad or felt. hese products are supplied sterile andshould not be resterilied. 9hen the product comes in contact +ithblood, it activates the coagulation mechanism causing plateletaggregation and accelerating the formation of a clot +ithin t+o to fourminutes."#

3i;e microfibrillar collagen, moisture activates absorbable collagenhemostatic products there-fore, the surgeon should cut them to theappropriate sie and apply them dry to the bleeding surface using drygloves or instruments and only use the amount needed. !&cess product

should be removed before +ound closure. Because absorbable collagen
http://www.integralife.com/products/pdfs/heli-http://www.integralife.com/products/pdfs/heli-


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hemostatic sponges do notdisperse li;e microfibrillar collagen does,these products are easier to handle and place. he product should bepac;ed loosely in closed spaces or cavities because it s+ells as it absorbsfluid. he body absorbs collagen sponge in eight to "$ +ee;s.","#

Absorbable collagen hemostats should not be usedH

L in patients +ith ;no+n allergy or sensitivity to materials of bovine origin

L in areas that are infected or contaminated

Lfor s;in incision closure, because they +ill create a mechanical barrier to

healingLin areas +here blood or other body fluids have pooled

Lon bony surfaces +here methyl methacrylate adhesives +ill beneeded, as it may substan-tially decrease the bonding strength ofthe methyl methacrylate or

Lin urological, neurological, or ophthalmological procedures because theproduct absorbs

fluid and may e&pand and e&ert pressure on ad*acent structures.","#,#$

otential adverse reactions include allergic reaction, adhesionformation, foreign body reaction,and hematoma. ","#,#$

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7 O;idized regenerated cellulose Eeg, Surgicel:( Surgicel Nu-0nit: ,"#,#"

An ORC product can absorb seven to "$ times its o+n +eight ho+ever, therate at +hich the bodyabsorbs it depends on the amount used, the e&tent ofblood saturation, and the tissue bed. As ORC reacts +ith the blood, itincreases in sie and forms a gelatinous mass, +hich aids in the formation ofa clot. Adding thrombin for additional hemostasis does not affect the actionof o&idied cellulose ho+-ever, the activity of thrombin is destroyed by thelo+ p0 of o&idied cellulose."# he hemostatic effectof ORC also is reduced ifit is moistened +ith saline, +ater, other hemostatic agents, or anti-infective agents therefore these products should be used dry and not in combination

+ith saline or throm-bin.",>,"#,#"

hese products are used to control capillary, venous, and small arterialbleeding. he surgeon can cutthe product into sheets, smaller pieces, orstrips for placement and smaller pieces can be easily manip-ulated intoplace. !&cess product should be removed +ith irrigation before closure, butsmall amountsmay be left in place. )f used around the optic nerve or spinalcord, the surgeon must remove e&cessproduct because of the potential harmthat can be caused from the product s+elling and placing pres-sure onnerves.",>,"#,#"

4imilar to other hemostatic agents discussed, ORC products should not be used

Lin closed spaces because of s+ellingLon bony defects Eeg, fracturesF, as it may interfere +ith boneregeneration unless it is re-moved after hemostasis is achieved

Lfor control of hemorrhage from large arteries

Lon surfaces ooing serous nonhemorrhagic fluid, because body fluidsother than +hole

blood Eeg, serumF do not react +ell +ith the product to achievehemostasis or

L for adhesion prevention.",>,"#,#"

he potential adverse reactions include

Lencapsulation of fluid and foreign body reaction, if the product is left inthe +ound

Lstenosis of vascular structures if ORC is used to +rap a vessel tightly

Lburning or stinging sensations, headaches, and sneeing +henused as a pac;ing for epi-sta&is because of its lo+ p0 and

L burning or stinging +hen used after nasal polypectomy orhemorrhoidectomy, or +hen applied to open +ound surfaces Eeg,donor sites, venous stasis ulcerations, dermabra-sionsF."",>,"#,#"

7>elatins Eeg, >elfoam:, >elfoam: 4lus elfoam: sponges com3ined 5iththrom3in=, Surgifoam:",>,"#,#@ ShttpH''++ + .b a & t e r.c o m 'h e a lt h c a r e V p r o fe s s io n a l s 'p r o d u c t s ': e l fo a m.h tm lTF
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Absorbable porcine gelatin hemostatic agents are prepared from apurified gelatin solution that has been +hipped into foam, dried, andthen sterilied./"Ep"M%F his type of product is available as a sponge orpo+der and is stored at room temperature as a single-use product thatis im-mediately available. he product should not be resterilied. )t ispliable and can absorb several times its +eight. )t assists +ithhemostasis by providing a matri& for clot formation, by creating amechanical barrier to bleeding, and is generally used in cases ofminimal bleeding. Clotting isinitiated by contact +ith bleeding. 9henthe surgeon places it on areas of capillary bleeding, theproduct absorbsfibrin into its interstices and then s+ells. he s+ollen gelatin particlesrestrict blood flo+ and provide a stable matri& for clot formation.",>,"#,#@

A surgeon can apply a gelatin sponge dry or can moisten it +ith sterilesaline before application. 1re(uently surgeons add thrombin orepinephrine to the saline they soa; the gelatin foam in to augment itshemostatic effect. :elatin conforms easily to +ounds ma;ing it suitablefor use in

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irregular +ounds. )t li(uefies +ithin t+o to ve days after applicationand is absorbed complete-ly in four to si& +ee;s. Absorbable gelatinsponges do not need to be removed before +ound closure, ho+ever,surgeons often remove them +hen possible to prevent compression ofad*acentstructures from the gelatins s+elling.",>,"","#,#@

Absorbable gelatin hemostatic products should not be used

Lfor patients +ith ;no+n allergies or sensitivities to porcine products

L for s;in incision closureLin intravascular compartments because of emboliation ris;

Lin the presence of infection or areas of gross contaminationbecause bacteria can becomeenmeshed in the sponge, leading tothe formation of an abscess or

L around nerves because of the ris; of s+elling and nervecompression.",>,"#,#@

otential adverse reactions to absorbable gelatin hemostatic products includeabscess formation,

foreign body reactions, encapsulation of fluid, hematoma, and localiedinfection.",>,"#,#@

P Polysaccharide Hemospheres )eg, Arista:A$##

Sh t t p H''m e d a for.c o m 'pr o d u ct s - a n d -t e c h n o lo g y ' arista-ahT $emostase!4$:#I ShttpH'' ++ + .p l a n n e d . hu 'u s e r fi le s 'fi le '0 e m o s t a s e D @ $ D @ $ B io -:lueD@$erfectD@$artnershipD@$BrochureD@$-D@$!uropaD@$-D@$63$@MV$$$.pdf T 2itasure8#>

Sh t t p H''++ + .o r t h o v it a .c o m 'v it a s u r e 'p d f'ap p l ic a t o r ) 1 2 .p d f TF",>

his is a relatively ne+ type of topical hemostatic agent derived fromvegetable starch and con-tains no human or animal components. )t isavailable in po+der form +ith a bello+s applicator E1igure F.

Figure 2 Bello*s applicator

)t has a fle&ible storage temperature E- I$. C S- I" 1T to $ C S"I$1TF and is immediately available for use, as it re(uires no additionalcomponents or mi&ing. he product should not beresterilied.",>,##-#>

olysaccharide hemospheres are used to control capillary, venous, andsmall arterial bleeding byproducing a hydrophilic effect, dehydrating theblood, and concentrating its solid componentsthereby increasing barrierformation. Because the hemospheres are composed of sugars, theamount
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used should not e&ceed >$ g in patients +ith diabetes. !&cess productshould be re-moved +ith irrigation.",>,##-#>

his type of product should not be used in closed spaces Eeg, neurologic,urologic, ophthalmicareasF because of s+elling. his type of agentpresents little ris; to the patient because it containsno human or animalcomponents ho+ever, pressure from s+elling may be e&erted onad*acentstructures.",>,##-#>

he efficacy of passive hemostats varies among products.> Research found that

microfibrillar

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collagen +as the most effective of the passive topical hemostatic agents,follo+ed by collagen sponge, gelatin sponge, and then o&idiedregenerated cellulose."$,# olysaccharide hemosphereshave alsodemonstrated efficacy. )n a recent preliminary study of "$ patientsundergoing cere-bral procedures, the direct application of absorbablehemospheres helped to effectively managesuperficial cerebral bleeding,reducing the use of bipolar coagulation and shortening surgical time.#

0o+ever, researchers have not been able to conduct surgeon-blinded

trials therefore,studies comparing the efficacies of the various topicalhemostatic agents in situ are open to bias and should be evaluated +ithcaution.#

Active "emostatic Agents

Active hemostatic agents are those that contain thrombin. hrombin is a naturallyderived enyme that plays a role in hemostasis, inflammation, and cell signaling.#M

hrombin is formed from prothrombin as a result ofactivation of the intrinsic ande&trinsic coagulation path+ays it forms the basis of a fibrin clot by promoting theconversion of fibrinogen to fibrin.

)n the late "%$s, the 24 1ood and 7rug Administration E17AF approved topicalbovine thrombin as an aid to hemostasis in surgery.# 4ince then, thrombin has

demonstrated a long history of clinical efficacy and safety in various surgicalprocedures.#,#% hrombin has been purified from numerous sources and used as aclinical aid for topical hemostasis for more than $ years.#MAlthough thrombin hasbeen effective in the control ofbleeding, bovine-derived thrombin has been sho+nto induce an immune response follo+ing human e&po-sure numerous reportshave documented a number of clinical events that follo+ bovine thrombine&posure,including the development of antibodies against thrombin, prothrombin,factor D of patients in eachtreatment group. Overall complications, including mortal-ity, adverse events, andlaboratory abnormalities, +ere similar bet+een groups. 1orty-three patientsE@".>DFreceiving bovine thrombin developed antibodies to the product. Onlythree patients E".>DF in the recombi-nant human thrombin group developed

antibodies to the product none of the three patients had abnormal coagulationlaboratory results or bleeding, thromboembolic, or hypersensitivity events. heresults of thistrial suggest that recombinant human thrombin has comparableefficacy, a similar safety profile, and is con-siderably less immunogenic thanbovine thrombin +hen used for surgical hemostasis.I#

P Clinical Considerations",#,>,"#

hrombin re(uires no intermediate physiological agent for its actions,but it does re(uire thepresence of circulating fibrinogen to activelyconvert fibrinogen to fibrin at the bleeding site to produce a clot.#,>

opical thrombin products are indicated for broad surgical use to helpcontrol minor bleeding from accessible capillaries and small venules. As

previously discussed, thrombin is commonly used in combination +ith


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certain passive topical hemostatic agents Eeg, a gelatin spongeF toincrease both the usefulness and effectiveness of the final product. )nneurosurgical procedures, thrombin is applied to small cottonoidsponges that are placed on the brain and'or nerve structures for theirprotection.#,>

he surgeon must assess the use of thrombin to provide hemostasis.7epending on the productused any patient allergy or sensitivity tobovine materials or human blood product allergies mustbe verified.

Before applying thrombin, the surgeon should remove any e&cess bloodfrom the operative site by suctioning or sponging the area. 0e or shecan then use a spray or flood the surface +ith a syringe containing thehemostatic agent. )f absorbable gelatin sponges soa;edin thrombin are used, it is important for the surgeon to s(ueee thesponge gently to remove any trapped air and completely saturate thesponge +ith thrombin to promote more effective hemostasis. 9henusing thrombin in con*unction +ith an absorbable gelatin sponge,periop-

?AORN, )nc, @$"# @$


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erative personnel should ensure that the concentration of the thrombinproduct is appropriateand that the sponge is held in place for "$ to ">seconds +ith a gaue sponge. After an area has been treated, scrubbedteam members should not sponge it to avoid removing or dislodging the

clots.",#,>,"#

hrombin should never be in*ected into the bloodstream or allo+ed toenter the bloodstreamthrough large, open blood vessels, because it cancause e&tensive intravascular clotting, +hich can be fatal. Repeatedsurgical applications of thrombin increase the li;elihood that the patientmay form antibodies against thrombin and'or factor ,"#

P Throm3in 4roducts",@

here are three forms of thrombin products each of +hich function byproviding concentrated thrombin that rapidly converts fibrinogen into afibrin clot, +ith the rate of clot formation being proportional to thethrombin concentration. hese products are differentiated based on the

typeof plasma used to create them Eeg, bovine, human, recombinantF.No thrombin product should ever be in*ected intravascularly.

7/ovine throm3in Eeg, hrombin-W6)UII ShttpH''++ + .pf i e rin*e c t ab les .c o 'fa c t sh ee t s ' h r o m -bin-W6)VallD@$4W2s.pdfTF is available as a po+der in vial form that can be used dry orreconstituted +ith sterile saline. )t should be used +ithin threehours of reconstitution, and it is applied using a pump or spray ;it,or in a saturated, ;neaded, absorbable gelatin sponge. he productshould be stored at room temperature.II

Bovine thrombin is available in several concentrationsH

L>,$$$ )2 per vial +ith >m3 diluent

L@$,$$$ )2 per vial +ith @$ m3 diluentsL@$,$$$ )2 per vial +ith @$ m3 diluent, spray pump, and actuator and

L@$,$$$ )2 per vial +ith @$ m3 diluent, spray tip, and syringe.

he perioperative RN should verify +ith the scrub person and thesurgeon that the cor-rect concentration of the product has beenprepared, and follo+ safe medication practicesby verballyconfirming the prepared concentration +ith the scrub assistant andthe sur-geon by reading the solution label.@>

9hen spraying bovine thrombin, the surgeon should flood thesurface +ith the product. 0e or she should not suction or sponge the

area dry because thrombin is most effective+hen it mi&es +ith
http://www.pfizerinjectables.co/factsheets/Throm-http://www.pfizerinjectables.co/factsheets/Throm-http://www.pfizerinjectables.co/factsheets/Throm-http://www.pfizerinjectables.co/factsheets/Throm-


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blood. 9hen using thrombin-soa;ed sponges, the surgeon orassistantshould use dry forceps to apply the appropriately-siedpiece of sponge and hold it in place +ith a surgical sponge Eeg,gaue sponge, cottonoidF for "$ to "> seconds.II

Antibody formation associated +ith the use of bovine thrombincan potentially resultin coagulopathy and, in rare cases, death.his has resulted in a blac; bo& +arning, the17As highest level of concern, being placed on the materials

pac;age insert. As a result,use of bovine thrombin iscontraindicated in patients +ith allergies or ;no+n sensitivitiestocomponents or materials of bovine origin, because fever or allergic-type reactions mayoccur. Bovine thrombin product should not beused in patients +ho have developed coag-ulopathies from previouse&posure to bovine thrombin.II

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74ooled human plasma throm3in Eeg, !vithromUI>

Sh t t p H''++ + .e t h ic o n # $ .co m 'pr o d u ct s '!vithrom-thrombin-topical-humanTF is available as a froen li(uid in vial form. )t may bestored froen E-"M C S-I$ 1TF for t+o years refrigerated E@ C toM C S#>. 1 to I.I 1TF for #$ days or stored at roomtemperature E@$ C to @> C SM 1 to 1TFfor @I hours orstored at # C E%M. 1F for one hour. he product must be used+ithin @I hours of reconstitution. he product is delivered via a

saturated, ;neaded, absorbablegelatin sponge.

I>

ooled human plasma thrombin has a potential ris; of viral or prion Eeg,the agent respon-

sible for Creutfeldt-Wa;ob diseaseF disease transmission becausemultiple units of blood are used to manufacture of each lot ofproduct. ooled human plasma thrombin productsarecontraindicated in patients +ith human blood product allergies,and they should notbe used in combination +ith blood salvage orcardiopulmonary bypass systems.I>

7Recom3inant throm3in Eeg,Recothrom:I ShttpH''++ + . r e c o n t h r o m .c o m 'a b ou t V r e c o t h r o m 'default.asp&F. :enetically

engineered recombinant products are relatively ne+ hemostaticoptions on the 24 mar;et. Recombinant thrombin is a lyophiliedpo+der in vial form and can be stored at room temperature. heproduct is reconstituted +ith sterile salineand should be used+ithin @I hours of reconstitution. )t is applied either by using apump or spray ;it, or it also comes as a saturated, ;neaded,absorbable gelatin sponge.I

he use of genetic engineering to produce the product reduces theris;s of antibody for-mation and eliminates the ris; of ;no+n viral orprion disease transmission. Recombinantthrombin use iscontraindicated in patients +ith hypersensitivity to hamster and

sna;eproteins and should not be used in combination +ith bloodsalvage or cardiopulmonarybypass systems.I

Flo*able "emostatic Agents1'0'11'(2

he flo+able hemostatic agents combine a passive and active hemostatic agentinto a single application prod-uct. As a result, these products +or; by bloc;ingblood flo+ and actively converting fibrinogen in blood into fibrin at the site ofbleeding.@ his category includes t+o types of products a combination ofabsorbable bo-vine gelatin particles and pooled human thrombin E1lo4ealUhemostatic matri& I ShttpH''++ + .flos e a l .c o m 'us'preparation.htmlTF and a productthat consists of absorbable porcine gelatin particles that may be com-bined +ith

any of the three stand-alone thrombins described above E4urgifloUIM

ShttpH''+++.ethicon#$.com'products'4urgiflo-hemostatic-matri&TF.",>,"",@

9hen combined +ith a gelatin, human plasma thrombin is typically reconstitutedas a li(uid and can run offa bleeding surface. )t has a solid or pasty consistency.1or this reason, flo+able hemostatic agents remain in place more effectively thandoes the li(uid thrombin alone, and this allo+s the surgeon to more accurately administer it. )n addition, both of these products only re(uire t+o to threeminutes of preparation time and are applied +ith a syringe-li;e applicator. Aspreviously noted, perioperative RNs should refer to the pac;ageinsert forproduct-specific instructions regarding proper preparation, application, anduse.",>,"",@
http://www.ethicon360.com/products/http://www.reconthrom.com/about_recothrom/http://www.floseal.com/http://www.ethicon360.com/products/http://www.reconthrom.com/about_recothrom/http://www.floseal.com/


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Because these products contain thrombin +ithout fibrinogen, they re(uire directcontact +ith blood as a fibrinogen source for conversion into fibrin. ressure maybe rapidly placed directly onto the flo+able at the bleeding site by the surgeonusing a moist saline EnonbloodyF gaue or pad for a period of @ minutes./ @EpI%%Fheproduct does not stic; to the nonbloody saline-soa;ed gaue or pad thereforeremoval of the gaue or pad +ill not disrupt the clot. Because these products mays+ell, e&cess product should be removed, especiallyfrom confined spaces Eeg,spinal cord, optic chiasm, foramina in boneF.

roducts composed of bovine gelatin are approved for use in all surgicalspecialties e&cept ophthalmic sur-gery.I hey can be used in irregular +oundsor bleeding cavities.> his type of product should not beH

Lused in patients +ith allergies or ;no+n sensitivities to materials of bovine origin

Lin*ected or compressed in to blood vessels or tissue

Lapplied in the absence of active blood flo+ Eeg, to clamped or bypassedvesselsF because e&tensive intra-vascular clotting resulting in death mayoccur

Lused in combination +ith blood salvage or cardiopulmonary bypass systems or

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L used for closure of s;in incisions because it may interfere +ith the healing of thes;in edges.>,"",@

roducts composed of porcine gelatin are approved for use in all surgicalspecialties e&cept ophthalmic itssafety and efficacy for use in urology have notbeen established.IM hey can be used in irregular +ounds or bleeding cavities.>

Obviously, this type of product should not be used on patients +ith allergies or;no+n sensitivities to materials of porcine origin.>,"",@

Adverse reactions to flo+able hemostatic agents include anemia, arrhythmia,arterial thrombosis, atelectasis, atrial fibrillation, confusion, edema, fever,hemorrhage, hypotension, infection, pleural effusion, respiratory distress, and rightheart failure.>,"",@

Clinical trials have demonstrated the efficacy of flo+able hemostatic agents.Researchers conducted a multi-center, prospective, single-arm study to evaluatethe clinical performance of 4urgifloU in achieving hemosta-sis +ithin "$ minutesof application in patients undergoing endoscopic sinus surgery and to evaluatepatientsatisfaction and postoperative healing.I% Researchers report that theproduct achieved hemostasis +ithin "$minutes of product application in %.D ofpatients.I% he results of a multicenter trial of %# cardiac surgery patients

demonstrated that the efficacy of 1lo4ealU +as superior to that of :elfoamU plusthrombin. 1lo4ealU stopped bleeding in %ID of the patients Eat the first bleedingsite onlyF +ithin "$ minutes, com-pared to $D in the patients receiving:elfoamU plus thrombin.>$

Sealants

4ealants +or; by forming a barrier that is impervious to the flo+ of most li(uids.@

here are four types ofmaterials approved for use as sealants to manage surgicalhemostasisH fibrin sealants !: polymers albumin +ith glutaraldehyde and thene+ cyanoacrylate sealant.@,>"

L 1ibrin sealants. 1ibrin sealants consist of concentrated fibrinogen andthrombin +hich, upon mi&ing +ith blood, create a stable fibrin clot.@,#M

1ibrin sealants increase the rate of blood clot formation byproviding higherconcentrations of both fibrinogen and thrombin at a bleeding site than+ould nor-mally occur. he concentration of fibrinogen is proportional toclot strength, +hile the concentration of thrombin is proportional to the rateof clot formation.@,#M

here are three types of fibrin sealants availableH@,>"

P pooled human plasma Eeg, isseelU>@ ShttpH''tisseel.com'us'pdf'@$"@-$"@>V)V)44!!3V.

pdf T, !vicelU># ShttpH''++ + .e t h ic o n # $ .c o m 'p r o d u c t s 'e v ic e l-fib rin - s e a l a n t -

h u m a nF

P individual human plasma +ith bovine collagen and bovine thrombin Eeg,I ShttpH''++ + .o r t h o v it a .c o m 'p d fs ' < it a g e l V B r oc h u r e .p d f TF the patients plasmaprovides the source of fibrinogen that combines +ith bovine collagenand bovine thrombin to create a collagen-enhanced sealant and

P pooled human plasma and e(uine collagen Eeg, acho4ilU>>

S htt p H''++ + .t a c h o s i l .c o mTF pooled

human plasma fibrinogen and thrombin are embedded in an e(uine collagen patch.

Clinical Considerations"",@,#M,>"

1ibrin sealants control local as +ell as diffuse bleeding, ho+ever, they do not

control vigorous bleed-ing. hese products can be applied using a syringe-
http://www.ethicon360.com/products/evicel-fibrin-sealant-human)%3Bhttp://www.ethicon360.com/products/evicel-fibrin-sealant-human)%3Bhttp://www.ethicon360.com/products/evicel-fibrin-sealant-human)%3Bhttp://www.orthovita.com/pdfs/Vitagel_Brochure.pdfhttp://www.tachosil.com/http://www.tachosil.com/http://www.ethicon360.com/products/evicel-fibrin-sealant-human)%3Bhttp://www.ethicon360.com/products/evicel-fibrin-sealant-human)%3Bhttp://www.orthovita.com/pdfs/Vitagel_Brochure.pdfhttp://www.tachosil.com/http://www.tachosil.com/


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li;e applicator or sprayed over a larger area using a gas-drivendevice."",@,#M,>"

1ibrin sealants can be used in patients +ith coagulopathies +ho haveinsufficient fibrinogen to form a clot, and can also be used on patients +hoare receiving heparin. hey can be used for s;in grafting,dural sealing, bonerepair, splenic in*uries, closure of colostomies, and in re-operative cardiacsurgery as +ell as during urologic procedures. he t+o pooled humanplasma products Eie, isseelU, !vicelUFare useful for controlling venous

ooing from ra+ surfaces. he surgeon should clean +ounds of anti-septicscontaining alcohol, iodine, or heavy metal ions that can denature appliedthrombin and fibrino-gen before applying these products."",@,#M,>"

he fibrin sealant product containing e(uine collagen Eie, acho4ilUF isapproved for hemostasis in cardiac surgical procedures. Because thisproduct is derived from human blood, the transmission ofinfectious agentsmay be a ris;. he ris; of disease transmission is reduced through donorscreening for viral disease ris; factors serologic and nucleic acid testingfor viral antigens and antibodies and pathogen reduction usingpasteuriation Eie, heating to inactivate virusF, precipitation Eie, chemical

?AORN, )nc, @$"# @#


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clumping of virusesF, and specialied filtering of plasma. 2se of e&cessivelytight pac;ing or the use of too many sponges of this product, may causetissue compression leading to in*ury. his product should not be usedintravascularly, in neurosurgical procedures, or for procedures on the renalpelvis or ure-ter, for the closure of s;in incisions it should not be left ininfected spaces.>> he number of patchesthat can be used on each patientmay be limited, based on +hich sie patch is used. he entire patch isdesigned to be left in place as it becomes firmly incorporated into the ne+ly

formed clot at the point of application. )t biodegrades +ithin "# +ee;s.

"",@,#M,>"

Clinical concerns about fibrin sealants use primarily concern the difficulty ofreconstitution, as +ell as the time it ta;es for the surgeon to learnapplication techni(ues. 1or e&ample, pooled human plasma fibrin sealantsmay re(uire tha+ing or mi&ing and individual human plasma productsre(uire process-ing the patients o+n blood."",@,#M,>"

Adverse reactions and safety concerns associated +ith fibrin sealants includeviral or prion disease transmission +ith pooled human plasma derivativesantibody formation +ith bovine thrombins+elling associated +ith collagenuse the need for the patient to have a functional coagulation sys-tem andthe need to avoid using any type of anticoagulant +ith individual human

plasma. roductsderived from pooled human plasma should not be used inpatients +ho have e&perienced anaphylacticor severe systemic reactions tohuman blood products, and products derived from bovine componentsshouldnot be used in patients +ith allergies or ;no+n sensitivities to materials ofbovine origin."",@,#M,>"

P Clinical ?vidence

he safety and effectiveness of fibrin sealants have been demonstratedin clinical trials. A pro-spective randomied controlled trial comparedthe hemostatic effectiveness of a fibrin sealantE!vicelUF in > patientsto manual compression in @ patients undergoing the insertion ofpolytet-rafluoroethylene E1!F arterial anastomoses.> he results of

this study demonstrated that ahigher percentage of patients +horeceived fibrin sealant achieved hemostasis at four minutes Eie,M>D

versus #%D respectivelyF versus patients upon +hom manualcompression +as used li;e+ise,a higher percentage of patients +horeceived the fibrin sealant achieved hemostasis at seven and"$ minutes. reatment failure +as lo+er in the fibrin sealant group,+hile the rate of complications potentially related to bleeding +assimilar ID of patients +ho received fibrin sealant e&periencedat leastone adverse event, compared +ith D in the manual compressiongroup.>

Researchers conducted a prospective study of M patients to evaluate

and compare the efficacy of topical autologous platelet-enriched plasmacombined +ith bovine collagen and thrombin to :elfoam'thrombinregarding hemostatic control'blood transfusion re(uirements andsubse-(uent outcome. hese outcomes +ere measured by the patientslength of stay in the )C2 and the hospital, as +ell as mortality rates. >

atients +ho received :elfoam'thrombin had a signi-cantly greater number of early postoperative transfusions and longer )C2and hospital lengths ofstay there +as no difference in mortalitybet+een the t+o groups. he authors concluded thatC is a rapidlyavailable topical hemostat that is associated +ith a significant decreasein the need for postoperative blood transfusions and )C2 and hospital


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length of stay.>A randomied prospective trial to confirm these results is+arranted.

Another clinical trial evaluated the efficacy and safety of a pooledhuman plasma and e(uine collagen patch Eacho4ilUF in comparison tothe use of standard hemostatic fleece for the con-trol of bleeding in"@$ patients undergoing cardiovascular surgery.>M he resultsdemonstrated that acho4ilU +as significantly superior to standardhemostatic fleece in controlling bleeding after insufficient primary

hemostasis Eie, >D of the acho4ilU patients achieved hemostasisat three minutes, compared +ith only ##D of the standard treatmentgroupF. his differencepersisted at si& minutes, +ith %>D of patientsachieving hemostasis in the acho4ilU group compared +ith @D in thestandard treatment group. Only three acho4ilU patients E>DF com-pared +ith " standard treatment patients E@MDF failed to achievehemostasis at si& minutes and received rescue treatment. acho4ilU+as +ell tolerated +ith adverse events generally similar in the t+otreatment groups.>M

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Lolyethylene glycol polymers Co4ealX"",@,#M,>",>%

Sh t t p H''++ + .b a &te rb ios u r g e r y .co m 'u s 'p r o d u ct s 'c o -seal'mechanism.htmlT

here are three types of products in this categoryH

P Co4ealX is a combination of t+o !: polymers that can be sprayed ontissue to form a syn-thetic, hydrogel matri&. he polymers cross-lin;to each other and to the contact tissue. hiscross-lin;ed net+or; thenforms a sealant to tissue fluids as +ell as a barrier to cell ingro+th andadhesion formation. his product is approved for vascular sealing and

is an effective agentfor vascular and cardiac procedures in +hichs+elling and e&pansion are not concerns."",@,#M,>",>%

Co4ealX is stored at room temperature E1 @>CF and must bereconstituted by mi&ing itsli(uid and po+der components in theapplicator system, +hich is designed to assure proper mi&ing of theappropriate components. After reconstitution, the product is stable fort+o hours.he surgeon should use the dual-syringe spray applicatorsystem from a distance of appro&i-mately # cm in the presence ofpro&imal and distal vascular control so that the field is dry. Afterapplication, he or she should not place pressure on the blood vessel forat least $ seconds so that the !: can fully polymerie. he product

may be reapplied, but the applicator tip mustbe cleaned after each use to prevent clogging. )f the sealant fails to gelafter #$ seconds, thesurgeon should irrigate the site and remove thecomponents +ith suction and then discard thesuction tip."",@,#M,>",>%

P 7ura4ealX$ ShttpH''+++.covidien.come'covidien'pages.asp&YpageZ)nnovation'7etail-seal-antT is a combination of a !: polymer,trilysine amine, and blue dye +hen combined, thesecomponents form ahydrogel that can help +ith dural closure because it forms a +ater tightseal.7ura4ealX can be stored at room temperature 1 E@>CF and isprovided in a dual-syringeapplicator system. 9ith this product, thesurgeon reconstitutes the !: component po+der and its li(uid before

attaching the reconstituted !: and the trilysine amine solutions to oneofthree spray heads.$ 7ura4eal 5actX, a ne+ synthetic absorbable spinalsealant recently been ap-proved by the 17A, is based on modifications ofthe original 7ura4ealX. 2sed to seal sutured dural repair, it provides+atertight closure during spinal surgery. 7ura4ealX also contains abluedye, +hich assists the surgeon +ith accurate product placement.0o+ever, the molecular +eightof the !: has been reduced to minimies+elling the polymeri+ation time has also been re-duced to threeseconds. hese ne+ characteristics are designed to improve safety byminimiing the possibility of spinal nerve compression from product

s+elling and provide rapid polymeria-tion to reduce the ris; ofcerebrospinal fluid lea;age.$

P ro:elU" Sh t t p H''++ + . n e om e n d .c o m 'pr o g e l .pr o d u ct s 'pr o g e l- p le u r a l- a i r -le a ; - s e a l a nt 'T rep-resents a ne+ class of !: polymer combined +ithhuman serum albumin. )t provides a strong,fle&ible barrier and hasbeen approved for use on the visceral pleura to close air lea;s of [ @ mmduring pulmonary surgery and is the only product approved by the 17Aspecifically for lung sealing. he product should be refrigerated E@-MCS#-I1TF, and it re(uires reconstitution ofthe !: polymer po+der+ith saline no sooner than @$ minutes before use. he applicator,+hichdelivers the product in a stream or spray depending on the plunger

pressure applied Eie,less pressure creates a stream, more creates a
http://www.baxterbiosurgery.com/us/products/co-http://www.neomend.com/progel.products/progel-pleural-air-leak-sealant/http://www.neomend.com/progel.products/progel-pleural-air-leak-sealant/http://www.baxterbiosurgery.com/us/products/co-http://www.neomend.com/progel.products/progel-pleural-air-leak-sealant/http://www.neomend.com/progel.products/progel-pleural-air-leak-sealant/


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sprayF, contains syringes of the !: polymer and human serum albumin.he applicator produces I m3 of the final product. he t+o compo-nentsshould not be allo+ed to come into contact +ith each other until readyfor use, as this may cause clogging of the applicator. he surgeonshould apply the product from a distanceof @ inches E> cmF to a non-ventilated lung. )f this is not possible, theanesthesia professional should inflate the patients lung +ith reducedtidal volumes so the surgeon can apply the prod-uct. Recently, ne+longer fle&ible applicators have been approved E inches S" cmT ""inchesS@% cmTF, +hich may permit easier application, including using theproduct during thoracoscopy.After application, the surgeon shouldallo+ the product to cure for "> to #$ seconds ma&imumstrength isachieved at appro&imately t+o minutes. he material biodegrades+ithin @M days."ro:elU should not to be used in patients +ho areallergic to human albumin or +ho haveinsufficient renal function toclear the !: polymer. )t should not be applied to the main stem orlobar bronchi because of a possible increased incidence ofbronchopleural stulae formation.

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he safety of this agent in contaminated or infected spaces or incon*unction +ith the use ofother hemostats, sealants, or adhesiveshas not been established."

hese !: polymers are used most effectively +hen the surgical teamensures that the tissues to besealed are as dry and free of blood or fluid aspossible. he location and position of the tissue the product is applied toshould be assessed because these agents are applied as li(uids. heypolymerie (uic;ly, but may still tend to drip a+ay from the intended

application site."",@,#M,>",>%-"he primary safety concern +ith all of these products is s+elling and theneed to be used +ith cau-tion in closed spaces to avoid the adverse effects ofpressure, including nerve compression. Co4ealX should not be in*ected orused in place of sutures, staples, or other mechanical closure it has demonstrated s;in sensitiation in animals and its safety in doses larger than "m3 has not been validated. he blue dye in 7ura4ealX may be associated+ith allergic responses, and it has also been associated +ith +oundinfections, cerebrospinal fluid lea;s, renal or neurologic compromise,inflammatory reactions, and delayed +ound healing.@Absorption of thisproduct occurs +ithin four to eight +ee;sand it is cleared from the body by

the ;idneys. )t should be used +ith caution in patients +ith compro-misedrenal, hepatic, or immune function and +hen used in pro&imity to air sinusesor in combination +ith other hemostats and sealants.

he safety of 7ura4eal 5actX# is similar to Co4ealX and 7ura4ealX, butproduces less s+elling. he material is e&creted by the ;idneys. 4urgeonsare cautioned not to use this product as spacefillers in spinal proceduresbecause there is some potential for s+elling and nerve compression. )tssafety in patients +ith allergy to the blue dye used in 7ura4ealX and7ura4eal 5actX has not been established, nor has its use +ith thesimultaneous use of nonautologous dural patches. 9arnings andprecautions include that the product should not be used in patients younger

than "M years of age or in pregnant or breastfeeding +omen, untilhemostasis has been achieved, or bet+een tissue planes to beappro&imatedsuch as muscle or s;in.# he product biodegrades in four to eight+ee;s."",@,#M,>",>%-"

)n a randomied controlled trial of >I patients undergoing aorticreconstruction of nonruptured aneu-rysms, the effectiveness of Co4ealX +ascompared to :elfoam'thrombin for managing anastomoticbleeding.I hesurgeons applied each product directly to the suture line after confirming thepresence ofanastomotic bleeding. he study demonstrated that asignificantly greater proportion Eie, M"DF of bleed-ing suture line sitestreated +ith Co4ealX achieved immediate sealing follo+ing the

reestablishment ofblood flo+ compared +ith #D of the control sites treated+ith :elfoam'thrombin. After ve minutes,M>D of the sites treated +ithCo4ealX +ere sealed, as opposed to slightly more than half E>@DF of thecontrol sites. Additionally, researchers reported no adverse events related tothe use of Co4eal.I

A multicenter, prospective randomied study of @# patients undergoingelective cranial surgery demonstrated that a !: hydrogel E7ura4ealXF +assimilarly safe +hen used +ith common dural sealing techni(ues Eeg, sutures,autologous grafts, gelatin or collagen sponges, fibrin gluesF or +hen used asdural closure augmentation

Documents

Management of Surgical Hemostasis