Haemostatic technique in malignant gliomas.

INTRODUCTION: Haemostasis in brain surgery is mandatory to avoid postoperative re-bleeding and a poor outcome. Postoperative intra-cavity haemorrhage is a frequent complication, especially in surgery of malignant gliomas because of the fragility of pathological vessels. MATERIAL AND METHODS: In this technical note, we describe our 'compression' technique used to achieve haemostasis in adult patients who underwent surgery for supratentorial malignant gliomas (GBM) at our Institute from January 2019 to January 2022. Peri-operative work-up included clinical status, laboratory data and contrast brain CT, performed at 24 hours after surgery, or earlier for patients with neurological worsening. RESULTS: A total of 82 patients was included in this study, 46 males (57%) and 36 females (43%). A post-operative intra-cavity haemorrhage was documented by postoperative CT-scan in 3/82 patients (3.65%), and the mean surgical time was 3.66 hours. No late bleeding was observed 48 hours after surgery. CONCLUSIONS: We have documented the good results of our technique to achieve haemostasis in patients operated for malignant glioma (GBM). The technique described in this study seems to be safe and useful to avoid post-operative bleeding in the surgery of cerebral GBM.

Patients with haemophilia A with inhibitors in China: a national real-world analysis and follow-up.

The development of alloantibodies (inhibitors) against coagulation factor VIII (FVIII) is the most serious complication of FVIII replacement therapy in patients with haemophilia A (HA). We carried out a nationwide study focussing on patients with HA with inhibitors in China to evaluate the condition and management of this population. The study retrospectively analysed patient characteristics, clinical history, manifestation, treatment strategy as well as individual haemophilia care of 493 patients with inhibitors (466 with severe HA and 27 with non-severe HA) registered all over China. The median (interquartile range) age at diagnosis of FVIII inhibitors was 13 (5-28) years in patients with severe HA and 24 (10·5-39·5) years in patients with non-severe HA. Most patients (85%) had high-titre inhibitors. Prothrombin complex concentrate and recombinant activated coagulation factor VII were used respectively in 76·2% and 29·2% of patients for acute bleeding. Only 22·3% of patients underwent immune tolerance induction (ITI) treatment, of whom 64·9% achieved negative inhibitor titre. In patients who did not undergo ITI, the inhibitors turned negative in 17·7%, and patients with low peak inhibitor titre were more likely to acquire negative titre spontaneously (odds ratio 11·524, 95% confidence interval 5·222-25·432; P = 0·000). We recorded that 3·2% of the patients died from haemophilia-related life-threatening bleeding.

Analysing the effectiveness of topical bleeding care following tooth extraction in patients receiving dual antiplatelet therapy-retrospective observational study.

BACKGROUND: Patients using antiplatelet drugs following infarctions, acute coronary syndrome or stroke pose a significant clinical problem if it is necessary to perform surgery, including dental surgery, since they are at risk of prolonged or secondary post-extraction bleeding. Discontinuation of this therapy is associated with a high risk of serious thromboembolic complications. The purpose of this study was to assess the effectiveness of TachoSil fibrin-collagen patches in stopping and preventing of secondary post-extraction bleeding in patients undergoing chronic antiplatelet therapy. METHODS: The study was conducted through retrospective examination of the medical records of 153 patients using chronic antiplatelet therapy and those qualified for tooth extraction. The largest group comprised 74 patients using aspirin and clopidogrel as dual platelet antiaggregation therapy; in this group 75 tooth extractions were carried out. In all of the patients TachoSil fibrin-collagen patches and stiches were applied to the wounds resulting from tooth removal. RESULTS: Following tooth extraction, primary bleeding was stopped in all the patients and their wounds closed via coagulation within 20-30 min. In eight cases, accounting for 4.9% of the patients, secondary bleeding occurred and was successfully stopped only by applying a pressure dressing soaked in tranexamic acid. Secondary bleeding occurred in three patients on the second day and in five patients on the third day following tooth removal. CONCLUSION: Topical application of TachoSil patches following tooth removal in patients using single or dual antiplatelet therapy effectively stopped bleeding and prevented secondary bleeding after tooth extraction.

Regenerated oxidised cellulose versus calcium alginate in controlling bleeding from malignant breast cancer wounds: randomised control trial study protocol.

OBJECTIVE: Malignant wounds due to breast cancer can present with recurrent episodes of bleeding in the tumour tissue. This study will compare the efficacy of a calcium alginate dressing (Biatain, Coloplast A/S, Denmark) and a regenerated oxidised cellulose dressing (Surgicel, Ethicon, LLC, Puerto Rico). PROTOCOL: A total of 24 patients with breast cancer and bleeding, malignant wounds will be enrolled in the randomised, controlled, open study, conducted at a hospital specialising in breast cancer treatment and at another hospital specialising in palliative care. Patients over 18 years old, with bleeding and willing to undergo venipuncture for blood collection will be included. All enrolled patients will be randomised for allocation to an experimental group (regenerated oxidised cellulose dressing) or a control group (calcium alginate dressing). The main intervention will consist of the application of the haemostatic product, assessment of digital pressure and estimation of the time required for haemostasis. OUTCOMES: Key outcome measures will be the percentage of patients with haemostasis within 20 minutes, observation of haemostasis after three, five and 10 minutes, in addition to recurrence of bleeding and the quantity of product used. DISCUSSION: To our knowledge, this is the first study to evaluate the effectiveness of haemostatic products in malignant wounds. This type of wound is poorly explored in the literature and, among its signs and symptoms, bleeding is poorly studied. The completion of this study will provide a more robust rationale for clinical decision-making related to the control of bleeding in malignant breast cancer wounds in the context of evidence-based nursing practices.

Elevated fibrinogen, von Willebrand factor, and Factor VIII confer resistance to dilutional coagulopathy and activated protein C in normal pregnant women.

BACKGROUND: Gestational changes in coagulation factor concentrations include elevations in fibrinogen, Factor VIII, and von Willebrand factor (vWF). We hypothesised that blood samples from term pregnant (TP) subjects are less prone to coagulation disturbances from haemodilution compared with those from non-pregnant (NP) females. METHODS: Blood samples were collected from 15 NP and 15 TP subjects. In vitro haemodilution with normal saline was assessed by modified Clauss fibrinogen assay, factor activity, flow-chamber assay, and thromboelastometry. The impact of human fibrinogen concentrate (hFC), cryoprecipitate, and vWF/Factor VIII (FVIII) concentrate replacement in diluted TP and NP blood was compared. Thrombin generation and activated protein C sensitivity were assessed. RESULTS: TP blood contained twice the concentrations of fibrinogen, FVIII, and vWF relative to NP blood (P<0.0001). Platelet thrombus formation (PTF) under flow was reduced by 99.2% and 69.2% in diluted NP and TP blood, respectively. Platelet thrombus formation was partially restored by adding vWF/FVIII, but not hFC or cryoprecipitate. Fibrin clot firmness approached the threshold of 10 mm in diluted NP blood, and clot firmness was effectively restored by hFC, but not by vWF/FVIII. In the presence of thrombomodulin, peak thrombin generation was decreased by 86.7% in NP plasma, but by 31.8% in TP plasma (P<0.0001 vs NP plasma), indicating reduced activated protein C sensitivity in TP plasma. Both elevated FVIII and haemodilution contributed to activated protein C insensitivity. CONCLUSIONS: Our in vitro model showed relative resistance of TP blood to dilutional coagulation changes with respect to platelet adhesion, fibrin polymerisation, and thrombin generation. Careful therapeutic monitoring for different pro-haemostatic agents in pregnant women is warranted.

[Use of topical haemostatic agents in cardiovascular surgery]. / Ispol'zovanie mestnykh gemostaticheskikh sredstv v serdechno-sosudistoi khirurgii.

The problem of haemostasis in cardiovascular surgery is of current concern. Recent trends are towards increased use of topical haemostatic agents. Tachocomb has been used for more than 30 years in abdominal surgery and oncology. The purpose of the present publication is to analyse the literature data and formulate the indications for the use of Tachocomb in cardiovascular surgery. Multicenter randomized and local studies have demonstrated efficacy of Tachocomb in treatment of surgical haemorrhage in operations on the heart, thoracic aorta, carotid arteries and lower-limb arteries, resulting in significantly decreased time to achieve haemostasis, decreased volume of blood loss and haemotrasfusion, as well as reduced frequency of complications. Also shown was economic efficacy, including a shortened length of patients' hospital stay. This is followed by describing a wide spectrum of examples of alternative use of Tachocomb, including its use for seamless closure of defects of cardiac chamber walls, aero- and lymphostasis, prevention of formation of commissures. Convincing experimental and clinical results make it possible to formulate a series of indications for the use of Tachocomb in cardiovascular surgery.

Design of New-Generation Usable Forms of Topical Haemostatic Agents Containing Chitosan.

Designing usable forms of topical haemostatic agents is the most important activity during the design process, resulting in strengthened functional properties of the final medical devices. This study aimed to propose indications for a research programme based on risk management supporting the development of two usable forms of a topical haemostatic agent: chitosan/alginate lyophilized foam and chitosan/alginate impregnated gauze. Both of the usable forms of the topical haemostatic agent, being the main part of the modified combat gauze, were fabricated using the chitosan/alginate complex. Risk analysis is helpful in developing an appropriate research programme, significantly reducing the risk to an acceptable level.

Beneficial effects of Ankaferd Blood Stopper on dermal wound healing: an experimental study.

Ankaferd Blood Stopper(®) (ABS) is a folkloric medicinal plant extract used as a haemostatic agent in traditional Turkish medicine. The aim of this study was to investigate the efficacy of ABS on the healing of dermal wounds in a rat model. Twenty Wistar albino rats were divided into two groups. Standard full-thickness skin defects were created on the back of the rats. In the control group (group 1), dressings moisturised with saline were changed daily. In the study group (group 2), the wounds were cleaned daily with saline, Ankaferd solution was applied, then the wounds were covered with moisturised dressings. The contraction percentage of wound areas were calculated on the 3rd, 7th, 10th and 14th days using a planimetric programme. On day 14, the wound areas were excised for histopathological examination, inflammatory scoring and evaluation of collagen deposition. The study group was superior to the control group in terms of inflammatory scoring, type I/type III collagen ratio and wound contraction rates. ABS(®) may be used effectively and safely on full-thickness wounds as a natural product.

Development of novel waxy bone haemostatic agents composed of biodegradable polymers with osteogenic-enhancing peptides in rabbit models.

OBJECTIVES: The use of bone wax (BW) is controversial for sternal haemostasis because it increases the risk of wound infection and inhibits bone healing. We developed new waxy bone haemostatic agents made from biodegradable polymers containing peptides and evaluated them using rabbit models. METHODS: We designed 2 types of waxy bone haemostatic agents: peptide wax (PW) and non-peptide wax (NPW), which used poly(ε-caprolactone)-based biodegradable polymers with or without an osteogenesis-enhancing peptide, respectively. Rabbits were randomly divided into 4 groups based on treatment with BW, NPW, PW or no treatment. In a tibial defect model, the bleeding amount was measured and bone healing was evaluated by micro-computed tomography over 16 weeks. Bone healing in a median sternotomy model was assessed for 2 weeks using X-ray, micro-computed tomography, histological examination and flexural strength testing. RESULTS: The textures of PW and NPW (n = 12 each) were similar to that of BW and achieved a comparable degree of haemostasis. The crevice area of the sternal fracture line in the BW group was significantly larger than that in other groups (n = 10 each). The PW group demonstrated the strongest sternal flexural strength (n = 10), with complete tibial healing at 16 weeks. No groups exhibited wound infection, including osteomyelitis. CONCLUSIONS: Waxy biodegradable haemostatic agents showed satisfactory results in haemostasis and bone healing in rabbit models and may be an effective alternative to BW.

Biomaterials as Haemostatic Agents in Cardiovascular Surgery: Review of Current Situation and Future Trends.

Intraoperative haemostasis is of paramount importance in the practice of cardiovascular surgery. Over the past 70 years, topical haemostatic methods have advanced significantly and today we deal with various haemostatic agents with different properties and different mechanisms of action. The particularity of coagulation mechanisms after extracorporeal circulation, has encouraged the introduction of new types of topic agents to achieve haemostasis, where conventional methods prove their limits. These products have an important role in cardiac, as well as in vascular, surgery, mainly in major vascular procedures, like aortic dissections and aortic aneurysms. This article presents those agents used for topical application and the mechanism of haemostasis and offers general recommendations for their use in the operating room.

The use of state-of-the-art haemostatic materials in gastrointestinal surgery.

Haemostatic materials such as: gelatine sponges, oxygenated cellulose meshes, tissue sealants, collagen matrices with human thrombin and fibrinogen are gaining on popularity in gastrointestinal surgery, especially in colorectal surgery. We searched for available scientific publications in the Pubmed and Cochrane database on the use of individual hemostatic materials in the field of gastrointestinal surgery. The analysis focused on the assessment of the safety of the use of individual materials in terms of the rate of bleeding complications and the rate of anastomotic leakage cases. The use of haemostatic materials has for years been a recognized method of reducing the rate of intra- and postoperative complications, both in gastrointestinal surgery and in other surgical specialties. Based on the available studies, it can be concluded that the use of hemostatic materials such as matrices, sponges and adhesives in gastrointestinal surgery, even in patients at high risk of anastomotic leakage and bleeding complications, reduces the incidence of complications. The growing popularity of haemostatics and sealants in surgery means that they are currently used in a wide range of indications, and surgeons are more and more willing to use them even in case of standard surgical procedures, which is reflected in the available studies. Choosing a haemostat should be a conscious decision, taking into account the site and type of bleeding, mechanism of action, ease of use, efficacy, safety, and price, among others.

Effects of haemostatic agents on bond strength - An In Vitro study.

AIM: To evaluate and compare the effect of contamination with haemostatic agents like Tranexamic Acid (TA) and Ethamsylate, on the shear bond strength. MATERIALS AND METHODS: There are about 100 extracted human premolars randomly segregated into four groups each consisting of 25 samples. Group I was bonded with Transbond, Group II was bonded with Transbond after blood contamination, while groups III and IV were bonded with Transbond after contamination with Tranexamic acid and the shear bond strength was measured. The data were compared by One- way ANOVA and Tukey (HSD) tests. RESULTS: Group I had the highest shear bond strength (SBS) while Group II, where the teeth were contaminated with blood showed the least SBS values ANOVA indicated significant differences between the four groups (P < .05). Tukey HSD revealed that contamination with TA (Group III) had a statistically higher SBS that contamination with Ethamsylate (Group IV) (P < .05). CONCLUSION: Since tranexamic acid and ethamsylate reduces the bleeding when used during surgery, these haemostatic agents may be considered in bonding situations where blood contamination is anticipated.

Surgicel mimicking early onset prosthetic valve endocarditis: case report.

BACKGROUND: Surgicel is one of the commercial forms of oxidized regenerated cellulose used as a bioabsorbable topical haemostatic agent during surgical procedures. However, its presence can mimic an abscess, tumour, lymph node or retained foreign body on imaging studies. The challenge in cardiac surgery is to differentiate the haemostatic material from an abscess that might be mistaken for an early onset prosthetic valve endocarditis. CASE SUMMARY: A 56-year-old woman was admitted to our department for a suspicion of early onset prosthetic valve endocarditis after an aortic valve replacement. An early clinical and biological improvement, features on a chest computed tomography scan, as well as a surgical correlation were able to rectify the diagnosis. The acute fever was linked to urinary tract infection, whereas the periaortic echogenic mass shown at the transoesophageal echocardiography corresponded to Surgicel. DISCUSSION: Oxidized regenerated cellulose can mimic an abscess on cardiac imaging, especially when used in excess during cardiac surgery. Fortunately, some radiographic features can help differentiate the haemostatic material from an abscess. Hence, sharing the use and location of Surgicel between the surgeon, radiologist, and cardiologist is very important and necessary to make the correct diagnosis.

Feasibility of a novel, synthetic, self-assembling peptide for suture-line haemostasis in cardiac surgery.

BACKGROUD: To assess the feasibility and efficacy of PuraStat®, a novel haemostatic agent, in achieving suture line haemostasis in a wide range of cardiac surgical procedures and surgery of the thoracic aorta. METHODS: A prospective, non-randomised study was conducted at our institution. Operative data on fifty consecutive patients undergoing cardiac surgery where PuraStat® was utilised in cases of intraoperative suture line bleeding was prospectively collected. Questionnaires encompassing multiple aspects of the ease of use and efficacy of PuraStat® were completed by ten surgeons (five consultants and five senior registrars) and analysed to gauge the performance of the product. RESULTS: No major adverse cardiac events were reported in this cohort. Complications such as atrial fibrillation, pacemaker requirement and pleural effusions were comparable to the national average. Mean blood product use of packed red cells, platelets, fresh-frozen plasma (FFP) and cryoprecipitate was below the national average. There was one incidence of re-exploration, however this was due to pericardial constriction rather than bleeding. Analysis of questionnaire responses revealed that surgeons consistently rated PuraStat® highly (between a score of 7 and 10 in the various subcategories). The transparent nature or PuraStat® allowed unobscured visualisation of suture sites and possessed excellent qualities in terms of adherence to site of application. The application of PuraStat® did not interfere with the use of other haemostatic agents or manipulation of the suture site by the surgeon. CONCLUSION: PuraStat® is an easy-to-use and effective haemostatic agent in a wide range of cardiac and aortic surgical procedures.

An update on topical haemostatic agents in liver surgery: systematic review and meta analysis.

Mortality and morbidity in hepatic surgery are affected by blood loss and transfusion. Topical haemostatic agents (THA) are composed by a matrix and/or fibrin sealants, and their association known as "carrier-bound fibrin sealant" (CBFS): despite widely used for secondary haemostasis, the level of evidence remains low. To realize a meta-analysis on the results of CBFS on haemostasis and postoperative complications. Searches in PubMed, PubMed Central, Cochrane and Google Scholar using keywords: "topical_haemostasis" OR "haemostatic_agents" OR "sealant_patch" OR "fibrin_sealant" OR "collagen_sealant" AND "liver_surgery" OR "hepatic_surgery" OR "liver_transplantation". Randomized clinical trials, large retrospective cohort studies, case control studies evaluating THA on open/laparoscopic liver surgery and transplantation. From 1993 to 2016 were found 22 studies for qualitative synthesis and 13 for quantitative meta-analysis. The time to haemostasis was lower in the CBFS group (mean difference -2.33 min; P = 0.00001). The risk of receiving blood transfusion, developing collections and bile leak was not influenced by the use of CBFS (OR 0.75; P = 0.25), (OR 0.72; P = 0.52), (OR 0.74; P = 0.30) respectively. The use of CBFS in liver surgery significantly reduce the time to haemostasis, but does not decrease transfusion, postoperative collection and bile leak.

Agentes hemostáticos tópicos de uso quirúrgico / Topical hemostatic agents for surgical use

Introducción: La morbilidad, mortalidad y costes tras la cirugía se hallan influenciados en gran medida por la pérdida hemática o hemorragia y las consecuencias derivadas de la misma. Para controlar la hemorragia, es frecuente el uso de agentes hemostáticos tópicos en combinación o en adyuvancia a otras técnicas hemostáticas, cuando éstas resultan ineficaces o impracticables. Material y métodos: Se realizó una revisión sistemática en Cochrane y MEDLINE desde el año 2000 a 2017 para identificar las publicaciones relacionadas con el uso de hemostáticos pasivos, activos y sellantes en comparación con otros agentes hemostáticos en todos los tipos de intervenciones quirúrgicas. Resultados: Se seleccionaron 20 ensayos clínicos. La variable principal de eficacia en el 95% fue el tiempo hasta la hemostasia y en el 5% la disminución del sangrado. Las intervenciones quirúrgicas más frecuentes fueron; cirugía hepática (30%), vascular (20%), cardíaca (10%), espinal (10%), general (5%), plástica (5%), y otros tipos de cirugía (20%).Los estudios se dividieron en 7 grupos, en función del tipo de agente hemostático a estudio y el comparador: a) hemostáticos mixtos versus pasivos (10%), b) sellantes de fibrina versus hemostáticos activos (5%), c) sellantes de fibrina versus hemostáticos pasivos (50%), d) hemostáticos mixtos entre sí (15%), e) sellantes de fibrina entre sí (5%), f) hemostáticos pasivos entre sí (5%), g) hemostáticos activos entre sí (10%).Conclusiones: Los hemostáticos activos, mixtos y sellantes de fibrina demuestran superioridad frente a los pasivos en términos de eficacia clínica, con un coste superior y un perfil de efectos adversos similar. (AU)

Introduction: Morbidity, mortality, and costs after surgery are greatly influenced by blood loss or bleeding and the consequences of it.To control bleeding, the use of topical hemostatic agents in combination or adjuvant to other hemostatic techniques is frequent, when these are ineffective or impractical.Method: A systematic review was conducted in Cochrane and PubMed from 2000 to 2017 to identify publications related to the use of passive, active and sealant hemostatics compared to other hemostatic agents in all types of surgical interventions.Results: Twenty clinical trials were selected. The main variable of efficacy in 95% was the time to hemostasis and in 5% the decrease in bleeding.The most frequent surgical interventions were; liver surgery (30%), vascular (20%), cardiac (10%), spinal (10%), general (5%), plastic (5%), and other types of surgery (20%).The studies were divided into 7 groups, depending on the type of hemostatic agent under study and the comparator: a) mixed hemostatic versus passive (10%), b) fibrin sealants versus active hemostatic agents (5%), c) fibrin sealants versus passive hemostatic (50%), d) mixed hemostatic with each other (15%), e) fibrin sealants with each other (5%), f) passive hemostatic with each other (5%), g) active hemostatic with each other (10%).Conclusions: Active and mixed hemostatics and fibrin sealants showed superiority over the passive hemostatics in terms of clinical efficacy, with a higher cost and a similar profile of side effects. (AU)

A hybrid simulator model for the control of catastrophic external junctional haemorrhage in the military environment.

Catastrophic haemorrhage from extremity injuries has for a long time been the single most common cause of preventable death in the military environment. The effective use of extremity tourniquets has increased the survival of combat casualties, and exsanguination from isolated limb injuries is no longer the most common cause of death. Today, the most common cause of potentially preventable death is haemorrhage from the junctional zones, i.e. the most proximal part of the extremities, not amenable to standard tourniquets. Different training techniques to control catastrophic haemorrhage have been used by the Swedish Armed Forces in the pre-deployment training of physicians, nurses and medics for many years. The training techniques include different types of human patient simulators such as moulage patients and manikins. Preferred training conditions for the control of catastrophic haemorrhage include a high degree of realism, in combination with multiple training attempts. This report presents a new hybrid training model for catastrophic external junctional haemorrhage control. It offers a readily reproducible, simple and inexpensive opportunity to train personnel to deal with life threatening catastrophic junctional haemorrhage. In particular, this model offers an opportunity for non-medical military personnel in Sweden to practice control of realistic catastrophic haemorrhage, with multiple training attempts.

Spleen hydatidosis treated by hemi-splenectomy: A low-morbidity, cost-effective management by a recently improved surgical technique.

BACKGROUND: Splenic hydatidosis is a rare condition and is usually managed by total splenectomy, which is associated to various complications, including overwhelming post-splenectomy sepsis and thrombosis. Probably due to supposed technical difficulties, the partial splenectomy is rarely performed being often unknown to physicians, infectious disease specialists and surgeons. METHODS: Demographic, clinical and surgical data were collected of four consecutive patients undergoing partial (or hemi-) splenectomy using an original, recently improved technique as a treatment for polar splenic hydatid cyst. The procedure implies a selective vascular ligation, a mechanical stapler-assisted section and haemostatic agents (Surgicel(®)) application on the cutting surface. Three patients were treated by laparotomy (including one affected by both liver and spleen localizations) whereas the last one was approached laparoscopically. RESULTS: Partial splenectomy operative time reached 74 min (range: 60-94 min) and blood loss was 8 ml (range: 5-10 ml). Hospital stay was 5.6 days (range: 5-7 days). At a mean follow-up of 20 months (range: 12-36 months), outcomes were uneventful. CONCLUSIONS: Partial splenectomy for hydatidosis is effective and safe. Physicians and surgeons should be aware of such an easy-to-catch option when dealing with benign splenic conditions, such as parasitic cysts. Cost-effectiveness, low morbidity and the possible prevention of splenectomy-related infectious complications should plead in favor of this technique in developing countries, where hydatidosis is endemic and post-splenectomy drugs and vaccines may be lacking.

Use of local pro-coagulant haemostatic agents for intra-cavity control of haemorrhage after trauma.

INTRODUCTION: Uncontrolled haemorrhage as a result of trauma remains a significant surgical challenge, accounting for approximately 25-40% of trauma-related mortality. A wide range of local internal haemostatic agents have been developed to help achieve intra-cavity control of bleeding, with choice of agent influenced by the circumstances and nature of the haemorrhage. Trauma patients are frequently coagulopathic, so products that incorporate pro-coagulant technology and thereby act independently of the clotting cascade may be more effective in these settings. A range of products that utilise thrombin and fibrinogen to promote local haemostasis at intra-cavity bleeding points are available or in development, including fibrin glues (e.g. Tisseel®/Tissucol® and Evicel®/Crosseal®/Quixil®), fibrin sealant patches (e.g. TachoSil®) and products based on a gelatin-thrombin haemostatic matrix (e.g. FloSeal®). MATERIALS AND METHODS: This systematic review was performed to assess all peer-reviewed evidence of product efficacy. RESULTS: Fibrin sealant patches have shown haemostatic efficacy in a variety of surgical procedures and appear to offer practical advantages over liquid fibrin glues. Existing evidence suggests that patch products enable delivery of pro-coagulants to defined areas with less chance of dilution and/or displacement by blood flow, but they require a pressure buttress for a suitable amount of time to achieve good results after trauma. CONCLUSIONS: Our experience, supported by other reports in the literature, suggests the use of such fibrin patches may provide an effective option in helping to control haemorrhage after trauma. However, there is a general paucity of clinical data for intra-cavity haemostatic agent use, with the majority of data being based on animal models and case reports. Further clinical evidence, ideally including comparative studies between different agents, would be beneficial in helping guide surgeon choice to the most appropriate products to use in trauma settings.

A novel sutureless technique for the repair of coronary sinus injuries.

Coronary Sinus injury related to cardioplegia catheter insertion is a rare complication associated with significant morbidity and mortality risk. We describe a simple, safe and effective sutureless technique for the management of coronary sinus injury. This technique was developed in a porcine haemostatic workshop in Hamburg, Germany.