Fibrin glue eliminates the need for packing after complex liver injuries.

Hemostasis after traumatic liver injury can be extremely difficult to obtain, particularly in coagulopathic patients who have suffered extensive liver damage. We determined the ability of a fibrin glue preparation (FG) to terminate ongoing bleeding using a new, clinically relevant porcine model of complex hepatic injury. Anesthetized swine (n = 6, 18 to 19 kg) received an external blast to the right upper abdomen and were immediately anticoagulated with intravenous heparin (200 u/kg). Uncontrolled hemorrhage from blast continued from time of injury (t = 0 minutes) to t = 15 minutes. Lactated Ringer's solution was infused to keep mean arterial pressure (MAP) > 80 mm Hg until the end of experiment (t = 90 minutes). Animals underwent routine surgical techniques to control bleeding, and FG was employed in the event these measures failed. Estimated blood loss and fluid resuscitation volume were measured. Serial MAP, arterial base excess, and temperature were recorded. Animals were severely injured with significant blood loss prior to laparotomy (26 +/- 6 cc/kg) and during routine surgical efforts to arrest hemorrhage (11 +/- 2 cc/kg). Bleeding could not be controlled with standard techniques in any animal. FG rapidly controlled hemorrhage and eliminated the need for packing. Re-bleeding was noted in only one animal (portal vein injury). FG can control severe hepatic hemorrhage when surgical techniques fail. Further work in the clinical arena is warranted to determine the potential benefits of FG in arresting hemorrhage in hemodynamically unstable coagulopathic patients with complex hepatic injuries.

Fibrin glue terminates massive bleeding after complex hepatic injury.

OBJECTIVE: We determined the ability of a packaged fibrin glue (FG) product to terminate severe bleeding in a new porcine model of complex hepatic injury. METHODS: Femoral arterial and venous catheters were placed in pentobarbital-anesthetized swine (n=7 per group, 16-18 kg). Pigs received an external blast to the right upper abdomen at 0 minutes, followed by uncontrolled hemorrhage at 0 to 30 minutes, with anticoagulation (heparin, 200 U/kg) at 10 minutes. Pigs were resuscitated with lactated Ringer's solution (20 mL/kg) beginning at 15 minutes and then underwent laparotomy to control bleeding at 30 minutes. Lactated Ringer's solution was infused to keep mean arterial pressure greater than 70 mm Hg until 120 minutes, when repeat laparotomy was performed. Control animals (group 1) underwent routine surgical procedures to terminate bleeding followed by packing if hepatic bleeding continued. The FG animals (group II) underwent routine surgical procedures plus application of FG. Avoidance of packing, estimated blood loss (EBL) during and after laparotomy, and fluid resuscitation volume were the primary end points studied. RESULTS: In both groups, mean arterial pressure varied significantly from baseline to 120 minutes (group I: 100+/-3 to 52+/-11 mm Hg; group II: 99+/-4 to 66+/-3 mm Hg). Temperature decreased at the end of each experiment (group I: 37+/-1 to 33+/-1 degrees C; group II: 37+/-1 to 34+/-1 degrees C). There were no group differences in EBL before laparotomy (0-30 minutes), but from initial laparotomy to repeat laparotomy (30-120 min), EBL (group I: 875+/-265 mL; group II: 300+/-59 mL) and total fluid resuscitation (group I: 2.9+/-0.4 L; group II: 1.9+/-0.3 L) were statistically significantly less in FG pigs. Of greatest importance, six of seven control pigs required packing, but none of the FG animals were packed and none bled at repeat laparotomy. CONCLUSION: FG stopped bleeding and eliminated the need for packing in a model of severe liver injury. Further work in the clinical arena is warranted to determine the potential benefits of FG in arresting hemorrhage in hypotensive, hypothermic, coagulopathic trauma patients with complex visceral injuries.