The role of D-dimer and fibrinogen testing in catheter-directed thrombolysis with urokinase for deep venous thrombosis

BACKGROUND

During catheter-directed thrombolysis (CDT), D-dimer (D-D) are generated in large quantities and fibrinogen (FIB) is continuously consumed. Reduction of FIB increases the risk of bleeding. However, there are currently few studies on the relationship between D-D and FIB concentrations during CDT.

OBJECTIVES

To evaluate the relationship of D-D and FIB concentrations during CDT with urokinase for deep venous thrombosis (DVT).

METHOD

17 patients with lower limb DVT were enrolled and treated with CDT. The concentrations of plasma D-D and FIB were measured every 8 h during thrombolysis. The degree of thrombolysis was evaluated, the change rules of D-D and FIB concentrations were analyzed, and the change curve graphs were drawn. The "thrombus volume," "thrombolysis time," "thrombolysis ratio," "D-D peak," "D-D rising speed," "FIB falling speed," and "duration of D-D elevation" were calculated in each patient. The mixed model was used to simulate the time change trend of the plasma D-D and FIB concentrations. Pearson method and linear regression were used to analyze the correlation and linear relationship, respectively.

RESULTS

The D-D concentration first increased rapidly and then decreased gradually, and the FIB concentration continued to decrease during thrombolysis. The rate of the decline of FIB varies with the urokinase dose. The thrombus volume is positively correlated with D-D rising speed, duration of D-D elevation, D-D peak, and FIB falling speed; the D-D rising speed is positively correlated with the D-D peak and FIB falling speed; and the D-D peak is positively correlated with the FIB falling speed. The correlation coefficients were all statistically significant (p < 0.05). Efficacy reached level I-II in 76.5% patients. No major bleeding occurred in any of the patients.

CONCLUSION

During CDT with urokinase for DVT, the concentrations of D-D and FIB show specific changes, and there are some specific relationships between each other. Understanding these changes and relationships may be helpful to adjust the thrombolysis time and urokinase dose more rationally.

A new method of monitoring catheter-directed thrombolysis for deep venous thrombosis-application of D-dimer and fibrinogen testing

BACKGROUND

Catheter-directed thrombolysis (CDT) is one of the main treatment methods for acute deep venous thrombosis (DVT), which has the characteristics of long treatment time and large dosage of thrombolytic drugs. In the absence of good monitoring methods, problems such as low thrombolytic efficiency and high risk of bleeding are easy to occur.

OBJECTIVE

To evaluate the value of D-dimer (D-D) and fibrinogen (FIB) testing as a thrombolysis-monitoring method during CDT for acute DVT.

METHODS

Twenty patients with acute DVT were divided into group A and group B. During CDT, the D-D and FIB testing every 8 h were used in group A, and the venography and FIB testing every 24 h in group B. The thrombolysis rate, thrombolysis time, urokinase dosage, and X-ray radiation dose were compared.

RESULTS

The thrombolysis rate in group A was significantly higher than that in group B (p < 0.05), but the number of venography and radiation dose were significantly lower than those in group B (p < 0.05).

CONCLUSION

D-D and FIB testing can improve the thrombolysis rate, reduce the risk of bleeding, and decrease the number of angiograms and X-ray radiation dose during CDT.

Unexpected, isolated activated partial thromboplastin time prolongation: A practical mini-review

A common inquiry in coagulation laboratories is how to interpret an unexpected, isolated prolonged activated partial thromboplastin time (APTT). In this context, isolated means together with a normal prothrombin time (PT) and/or normal international normalized ratio (INR). This finding may lead to contact with laboratory doctors for further advice on a diagnostic strategy. Occasionally, the need for a diagnostic algorithm can be subacute, where surgery has to be postponed until an explanation for the isolated, prolonged APTT has been established. Activated partial thromboplastin time as a coagulation test was developed to monitor patients with hemophilia. Different APTT reagents display considerable differences in their sensitivity to deficiencies of coagulation factors. An isolated, prolonged APTT is seen in (a) individuals/patients with lupus anticoagulants, (b) patients in treatment with anticoagulants, mainly heparin, and (c) patients with deficiencies of specific coagulation factors. In this tutorial review, we summarize what may cause an isolated prolonged APTT and we present a simple diagnostic algorithm to differentiate between lupus anticoagulants (common) and factor deficiencies (rare). The identification of an isolated prolonged APTT as well as the underlying cause can be of the utmost importance in ensuring the correct therapeutic follow-up.

Comparison of Two Different Fibrinogen Concentrates in an in vitro Model of Dilutional Coagulopathy

Introduction

Fibrinogen concentrates are widely used to restore clot stability in situations of bleeding. Fibrinogen preparations are produced using different production methods, resulting in different compounds. Thus, different preparations might have a distinct impact on blood coagulation. We tested the effect of fibrinogen concentrates Haemocomplettan® (CSL Behring, Marburg, Germany) and fibryga® (Octapharma GmbH, Langenfeld, Germany) on the impairments induced by 60% dilutional coagulopathy in vitro.

Materials and Methods

The influence of the fibrinogen concentrates fibryga® and Haemocomplettan® on colloid (gelatine, hydroxyethyl starch [HES], albumin)-induced or crystalloid (Ringer's acetate)-induced dilutional coagulopathy was analysed using rotational thromboelastometry (ROTEM®) and standard laboratory tests. The following experimental conditions were analysed in vitro: whole blood, 60% dilution (40% blood and 60% diluent) ± 50 or 100 mg/kg^-1 fibryga® or Haemocomplettan®, respectively.

Results

Dilution with either diluent resulted in prolonged clotting time (CT) in an extrinsic activated test (CT_EXTEM) and decreased maximum clot firmness (MCF_FIBTEM) as expressed, e.g., by gelatine: (59.5 s [62/54.8] vs. 95 s [102.8/86.8]; p < 0.001 and 14 mm [16/10.5] vs. 3 mm [4-3]; p < 0.001). Substitution after 60% dilution with HES resulted in no difference between the preparations, except for shorter thrombin time with fibryga® (14 s [15/14] vs. 18 s [18.8/17]; p = 0.0093; low dose). CT_EXTEM was higher with Haemocomplettan® in a gelatine-induced dilution (51 s [54.5/47.5] vs. 63 s [71/60.3]; p = 0.0202; low dose) whereas thrombin time was lower with fibryga® (19.5 s [20.8/19] vs. 27 s [29/25.3]; p = 0.0017). In dilution with albumin, differences in CT_EXTEM (69 s [76.5/66] vs. 56 s [57/53.3]; p = 0.0114; low dose) and thrombin time (18 s [18/17] vs. 24.5 s [25.8/24]; p = 0.0202; low dose) were seen. In dilution with crystalloid solution, again differences in CT_EXTEM (53.5 s [57.8/53] vs. 45 s [47/43]; p = 0.035; low dose) and thrombin time (17 s [17/16] vs. 23.5 s [24/23]; p = 0.0014; low dose) were seen. Fibrinogen levels were more increased by high-dose substitution of both preparations.

Conclusion

Based on this data it can be stated that both fibryga® and Haemocomplettan® had the same performance in our in vitro model except for CT_EXTEM and thrombin time.

Fibrinogen levels measured by the dry hematology method are lower than those measured by the Clauss method under a high concentration of heparin

The activity of fibrinogen has been reported to decrease soon after the onset of major bleeding and to be an important determinant of the final extent of bleeding and postoperative outcome. A device that measures the perioperative fibrinogen level using the dry hematology (DH) method has recently become available. The aim of this study was to compare perioperative fibrinogen levels measured by the DH method with those measured by the conventional Clauss method and to assess the effects of heparin on these measurements. The study included 206 samples from 36 patients undergoing major surgery who received high-dose heparin (HH group, 23 samples), low-dose heparin (LH group, 57 samples), or no heparin (C group, 126 control samples). Each sample was measured using the DH and Clauss methods. After excluding samples outside the effective measurement range, the three study groups (HH group, n=23; LH group, n=49; C group, n=115) were compared. The mean fibrinogen level measured by the DH method in the HH group (87.9 ± 3.1%) was significantly lower than that measured by the Clauss method. There were no significant differences between the fibrinogen measurements obtained by the two methods between the LH and C groups. In patients on high-dose heparin, the mean fibrinogen level measured by the DH method was significantly lower than that measured by the Clauss method. When hemorrhage requires emergency treatment, a method that can measure the fibrinogen level rapidly is important. The DH method may be useful for decision-making with regard to perioperative coagulation factor replacement.

Prospective validation of a new protocol with preperitoneal pelvic packing as the mainstay for the treatment of hemodynamically unstable pelvic trauma: a 5-year experience

PURPOSES

Hemodynamically unstable pelvic trauma has been a significant challenge even in most experienced Trauma Centres. In 2011 preperitoneal pelvic packing (PPP) was introduced in our Hospital as the first manoeuvre. This study aims to review overall mortality at 24 h from arrival in the emergency department.

METHODS

A retrospective review of our prospective database was performed considering patients with systolic blood pressure (SBP) < 90 mmHg or with the need for more than 2 Units of packed red blood cells (PRBC) on admission in the emergency department, (ED) and a pelvic fracture. Values were expressed as a median and interquartile range. Continuous variables were compared with the Mann-Whitney test.

RESULTS

Between September 2011 and December 2016, we treated 30 patients. Median age was 51 years (40-65) and Injury Severity Score 36 (34-42). SBP in the ED was 90 (67-99), heart rate was 115 (90-130), Base Excess - 8 (- 11.5/- 4.8), pH 7.23 (7.20-7.28). Median PRBC requirements during the first 24 h (from admission) were 13 Units (8-18.8). Time to emergency treatment was 63 min (51-113). 17 patients (56.6%) underwent angiography after PPP. Overall 24 h mortality was 30%. A comparison between survivors and non-survivors showed no statistically significant differences between groups.

CONCLUSIONS

In our experience, PPP resulted to be quick to perform and effective. No death occurred from direct pelvic bleeding.

Rapid paper diagnostic for plasma fibrinogen concentration

Fibrinogen is one of the first proteins to be depleted in heavily bleeding patients. In this study, we have developed a new paper-based diagnostic to quantify the fibrinogen concentration in blood at room temperature.

Quality of Evidence-Based Guidelines for Transfusion of Red Blood Cells and Plasma: A Systematic Review

Many transfusion guidelines are available, but little appraisal of their quality has been undertaken. The quality of guidelines may potentially influence adoption. Our aim was to determine the quality of evidence-based transfusion guidelines (EBG) for red cells and plasma, using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument, and assess duplication and consistency of recommendations. MEDLINE and EMBASE were systematically searched for EBG from 2005 to June 3, 2016. Citations were reviewed for inclusion in duplicate. A guideline was included if it had a specified clinical question, described a systematic search strategy, included critical appraisal of the literature and a description of how recommendations were developed. Four to six physicians used AGREE II to appraise each guideline. Median and scaled scores were calculated, with each item scored on a scale of one to seven, seven representing the highest score. Of 6174 citations, 30 guidelines met inclusion criteria. Twenty six guidelines had recommendations for red cells and 18 included recommendations for plasma use. The median score, the scaled score and the interquartile range of the scaled score were: scope and purpose: median score 5, scaled score 60%, IQR (49-74%); stakeholder involvement 4, 43%, (33-49%); rigor of development 4, 41%, (19-59%); clarity of presentation 5, 69%, (52-81%); applicability 1, 16%, (9-23%); editorial independence 3, 43%, (20-58%). Sixteen guidelines were evaluated to have a scaled domain score of 50% or less. Variations in recommendations were found for the use of hemoglobin triggers for red cell transfusion in patients with acute coronary syndromes and for plasma use for patients with bleeding. Our findings document, limited rigor in guideline development and duplication and inconsistencies in recommendations for the same topic. The process of developing guidelines for red cells and plasma transfusion can be enhanced to improve implementation.

Protection against cold - a survey of available equipment in Swedish pre-hospital services

BACKGROUND

The aim of this study was to survey the current equipment used for prevention, treatment and monitoring of accidental hypothermia in Swedish pre-hospital services.

METHODS

A questionnaire was sent to all road ambulance services (AS), the helicopter emergency medical services (HEMS), the national helicopter search and rescue service (SAR) and the municipal rescue services (RS) in Sweden to determine the availability of insulation, active warming, fluid heating, and low-reading thermometers.

RESULTS

The response rate was 77% (n = 255). All units carried woollen or polyester blankets for basic insulation. Specific windproof insulation materials were common in the HEMS, SAR and RS units but only present in about half of the AS units. Active warming equipment was present in all the SAR units, but only in about two-thirds of the HEMS units and about one-third of the AS units. About half of the RS units had the ability to provide a heated tent or container. Low-reading thermometers were present in less than half of the AS and HEMS units and were non-existent in the SAR units. Pre-warmed intravenous fluids were carried by almost all of the AS units and half of the HEMS units but infusion heaters were absent in most units.

CONCLUSION

Basic insulation capabilities are well established in the Swedish pre-hospital services. Specific wind and waterproof insulation materials, active warming devices, low-reading thermometers and IV fluid heating systems are less common. We suggest the development and implementation of national guidelines on accidental hypothermia that include basic recommendations on equipment requirements.

The effectiveness of 10 years of interventions to control postoperative bleeding in adult cardiac surgery

Objectives

Postoperative bleeding in cardiac surgery remains an important complication, leading to increased morbidity and mortality. Different interventions are possible to prevent/treat postoperative bleeding. The present study aims to investigate the effectiveness of these interventions in a real-world scenario.

Methods

This is a retrospective study based on 19 670 consecutive adult cardiac surgery patients operated from 2000 to 2015. During the study period, the following interventions have been applied and tested for effectiveness with a before versus after analysis: thromboelastography (TEG)-based diagnosis and treatment in actively bleeding patients; platelet function tests (PFTs); timing of surgery based on PFTs; fresh frozen plasma (FFP)-free strategy using prothrombin complex concentrate and fibrinogen concentrate.

Results

TEG-based diagnostic and therapeutic approach resulted in a significant (P = 0.006) reduction of postoperative bleeding and significant (P = 0.001) increase in platelet concentrate transfusion rate. Timing of surgery based on PFTs resulted in a significant reduction of postoperative bleeding (P = 0.001), surgical re-exploration rate (P = 0.002), FFP (P = 0.001) and platelet concentrate (P = 0.016) transfusion rate. FFP-free strategy was associated with a significant decrease in postoperative bleeding (P = 0.005) and FFP transfusions (P = 0.001). The combination of all the interventions was associated with a significant (P = 0.001) reduction in postoperative bleeding, surgical re-exploration rate and FFP transfusions, whereas platelet concentrate transfusion rate was significantly (P = 0.001) higher.

Conclusions

Despite a continuous increase in the bleeding risk profile, the application of a bundle of interventions is effective in controlling postoperative bleeding and related complications. Platelet transfusions remain unreplaceable in the present scenario.

Relative effects of plasma, fibrinogen concentrate, and factor XIII on ROTEM coagulation profiles in an in vitro model of massive transfusion in trauma

Massive traumatic haemorrhage is aggravated through the development of trauma-induced coagulopathy, which is managed by plasma transfusion and/or fibrinogen concentrate administration. It is yet unclear whether these treatments are equally potent in ensuring adequate haemostasis, and whether additional factor XIII (FXIII) administration provides further benefits. In this study, we compared ROTEM whole blood coagulation profiles after experimental massive transfusion with different transfusion regimens in an in vitro model of dilution- and transfusion-related coagulopathy. Healthy donor blood was mixed 1 + 1 with six different transfusion regimens. Each regimen contained RBC, platelet concentrate, and either fresh frozen plasma (FFP) or Ringer's acetate (RA). The regimens were further augmented through addition of a low- or medium-dose fibrinogen concentrate and FXIII. Transfusion with FFP alone was insufficient to maintain tissue-factor activated clot strength, coincidental with a deficiency in fibrin-based clot strength. Fibrinogen concentrate conserved, but did not improve coagulation kinetics and overall clot strength. Only combination therapy with FFP and low-dose fibrinogen concentrate improved both coagulation kinetics and fibrin-based clot strength. Administration of FXIII did not result in an improvement of clot strength. In conclusion, combination therapy with both FFP and low-dose fibrinogen concentrate improved clotting time and produced firm clots, representing a possible preferred first-line regimen to manage trauma-induced coagulopathy when RBC and platelets are also transfused. Further research is required to identify optimal first-line transfusion fluids for massive traumatic haemorrhage.

Age of blood and survival after massive transfusion

BACKGROUND

Massive transfusion is the clinical scenario where the presumed adverse effects of stored blood are expected to be more evident because the whole patient's blood volume is replaced by stored blood.

OBJECTIVE

To analyse the association between age of transfused red blood cells (RBC) and survival in massively transfused patients.

METHODS

In this retrospective study, clinical and transfusion data of all consecutive patients massively transfused between 2008 and 2014 in a large, tertiary-care hospital were electronically extracted from the Transfusion Service database and the patients' electronic medical records. Prognostic factors for in-hospital mortality were investigated by multivariate logistic regression.

RESULTS

A total of 689 consecutive patients were analysed (median age: 61 years; 65% males) and 272 died in-hospital. Projected mortality at 2, 30, and 90 days was 21%, 35% and 45%, respectively. The odds ratio (OR) for in-hospital mortality among patients who survived after the 2nd day increased with patient age (OR: 1.037, 95% CI: 1.021-1.054; per year P<0.001), with the number of RBC unit transfused in the first 48hours (OR: 1.060; 95% CI: 1.038-1.020 per unit; P<0.001), and the percentage of such RBC stored for more than 28 days (1.010, 95% CI: 1.005-1.018 per percent point; P=0.01).

CONCLUSION

Mortality after massive transfusion was associated with a higher proportion of old RBCs transfused in the first 48hours. Other factors associated with poor prognosis were older patient's age and larger volumes of transfused RBCs.

Definition of hemodynamic stability in blunt trauma patients: a systematic review and assessment amongst Dutch trauma team members

INTRODUCTION

Trauma is a great contributor to mortality worldwide. One of the challenges in trauma care is early identification and management of bleeding. The circulatory status of blunt trauma patients in the emergency room is evaluated using hemodynamic (HD) parameters. However, there is no consensus on which parameters to use. In this study, we evaluate the used terms and definitions in the literature for HD stability and compare those to the opinion of Dutch trauma team members.

METHOD

A systematic review was performed to collect the definitions used for HD stability. Studies describing the assessment and/or treatment of blunt trauma patients in the emergency room were included. In addition, an online survey was conducted amongst Dutch trauma team members.

RESULTS

Out of a total of 222, 67 articles were found to be eligible for inclusion. HD stability was defined in 70% of these articles. The most used parameters were systolic blood pressure and heart rate. Besides the variety of parameters, a broad range of corresponding cut-off points is noted. Despite some common ground, high inter- and intra-variability is seen for the physicians that are part of the Dutch trauma teams.

CONCLUSION

All authors acknowledge HD stability as the most important factor in the assessment and management of blunt trauma patients. There is, however, no consensus in the literature as well as none-to-fair consensus amongst Dutch trauma team members in the definition of HD stability. A trauma team ready to co-operate with consensus-based opinions together with a valid scoring system is in our opinion the best method to assess and treat seriously injured trauma patients.

Do male and female trauma patients receive the same prehospital care?: an observational follow-up study

BACKGROUND

Trauma-related mortality can be lowered by efficient prehospital care. Less is known about whether gender influences the prehospital trauma care provided. The aim of this study was to explore gender-related differences in prehospital trauma care of severely injured trauma patients, with a special focus on triage, transportation, and interventions.

METHODS

We performed a retrospective observational study based on local trauma registries and hospital and ambulance records in Stockholm County, Sweden. A total of 383 trauma patients (279 males and 104 females) > 15 years of age with an Injury Severity Score (ISS) of > 15 transported to emergency care hospitals in the Stockholm area were included.

RESULTS

Male patients had a 2.75 higher odds ratio (95 % CI, 1.2-6.2) for receiving the highest prehospital priority compared to females on controlling for injury mechanism and vital signs on scene. No significant difference between genders was detected regarding other aspects of the prehospital care provided.

CONCLUSIONS

This study indicated that prehospital prioritization among severely injured late adolescent and adult trauma patients differs between genders. Knowledge of a more diffuse presentation of symptoms in female trauma patients despite severe injury may help to adapt and improve prehospital trauma care for this group.

Can the Viscoelastic Parameter α-Angle Distinguish Fibrinogen from Platelet Deficiency and Guide Fibrinogen Supplementation?

Viscoelastic tests such as thrombelastography (TEG, Haemoscope Inc., Niles, IL) and thromboelastometry (ROTEM, Tem International GmbH, Munich, Germany), performed in whole blood, are increasingly used at the point-of-care to characterize coagulopathic states and guide hemostatic therapy. An algorithm, based on a mono-analysis (kaolin-activated assay) approach, was proposed in the TEG patent (issued in 2004) where the α-angle and the maximum amplitude parameters are used to guide fibrinogen supplementation and platelet administration, respectively. Although multiple assays for both the TEG and ROTEM devices are now available, algorithms based on TEG mono-analysis are still used in many institutions. In light of more recent findings, we discuss here the limitations and inaccuracies of the mono-analysis approach. Research shows that both α-angle and maximum amplitude parameters reflect the combined contribution of fibrinogen and platelets to clot strength. Therefore, although TEG mono-analysis is useful for identifying a coagulopathic state, it cannot be used to discriminate between fibrin/fibrinogen and/or platelet deficits, respectively. Conversely, the use of viscoelastic methods where 2 assays can be run simultaneously, one with platelet inhibitors and one without, can effectively allow for the identification of specific coagulopathic states, such as insufficient fibrin formation or an insufficient contribution of platelets to clot strength. Such information is critical for making the appropriate choice of hemostatic therapy.

Detection of acute traumatic coagulopathy and massive transfusion requirements by means of rotational thromboelastometry: an international prospective validation study

Introduction

The purpose of this study was to re-evaluate the findings of a smaller cohort study on the functional definition and characteristics of acute traumatic coagulopathy (ATC). We also aimed to identify the threshold values for the most accurate identification of ATC and prediction of massive transfusion (MT) using rotational thromboelastometry (ROTEM) assays.

Methods

In this prospective international multicentre cohort study, adult trauma patients who met the local criteria for full trauma team activation from four major trauma centres were included. Blood was collected on arrival to the emergency department and analyzed with laboratory international normalized ratio (INR), fibrinogen concentration and two ROTEM assays (EXTEM and FIBTEM). ATC was defined as laboratory INR >1.2. Transfusion requirements of ≥10 units of packed red blood cells within 24 hours were defined as MT. Performance of the tests were evaluated by receiver operating characteristic curves, and calculation of area under the curve (AUC). Optimal cutoff points were estimated based on Youden index.

Results

In total, 808 patients were included in the study. Among the ROTEM parameters, the largest AUCs were found for the clot amplitude (CA) 5 value in both the EXTEM and FIBTEM assays. EXTEM CA5 threshold value of ≤37 mm had a detection rate of 66.3% for ATC. An EXTEM CA5 threshold value of ≤40 mm predicted MT in 72.7%. FIBTEM CA5 threshold value of ≤8 mm detected ATC in 67.5%, and a FIBTEM CA5 threshold value ≤9 mm predicted MT in 77.5%. Fibrinogen concentration ≤1.6 g/L detected ATC in 73.6% and a fibrinogen concentration ≤1.90 g/L predicted MT in 77.8%. Patients with either an EXTEM or FIBTEM CA5 below the optimum detection threshold for ATC received significantly more packed red blood cells and plasma.

Conclusions

This study confirms previous findings of ROTEM CA5 as a valid marker for ATC and predictor for MT. With optimum threshold for EXTEM CA5 ≤ 40 mm and FIBTEM CA5 ≤ 9 mm, sensitivity is 72.7% and 77.5% respectively. Future investigations should evaluate the role of repeated viscoelastic testing in guiding haemostatic resuscitation in trauma.

Hemostatic resuscitation in postpartum hemorrhage - a supplement to surgery

BACKGROUND

Postpartum hemorrhage is a potentially life-threatening albeit preventable condition that persists as a leading cause of maternal death. Identification of safe and cost-effective hemostatic treatment options remains crucial as a supplement to surgery and uterotonic agents.

OBJECTIVE

This review summarizes the background, current evidence and recommendations with regard to the role of fibrinogen, tranexamic acid, prothrombin complex concentrate, desmopressin, and recombinant factor VIIa in the treatment of patients with postpartum hemorrhage. The benefits and evidence behind traditional standard laboratory tests and viscoelastic hemostatic assays, i.e. thromboelastography TEG(®) and thromboelastometry ROTEM(®) , are discussed. In addition we assess and elaborate on the current paradigm and evidence for transfusion of these patients.

DATA SOURCES

Publications between 1994 and 2014 were identified from PubMed, EMBASE, Cochrane Library databases, and ClinicalTrial.gov.

RESULTS

Viscoelastic hemostatic assays were found to provide a real-time continuum of coagulation and fibrinolysis when introduced as a supplement in transfusion management of postpartum hemorrhage. Fibrinogen should be considered when hypofibrinogenemia is identified. Early administration of 1-2 g tranexamic acid is recommended, followed by an additional dose in cases of ongoing bleeding. Uncontrolled hemorrhage requires early balanced transfusion.

CONCLUSION

Despite the lack of conclusive evidence for optimal hemostatic resuscitation in postpartum hemorrhage, the use of viscoelastic hemostatic assays, fibrinogen, tranexamic acid and balanced transfusion therapy may prove to be potentially pivotal in the treatment of postpartum hemorrhage.

Damage control resuscitation

The early recognition and management of hemorrhage shock are among the most difficult tasks challenging the clinician during primary assessment of the acutely bleeding patient. Often with little time, within a chaotic setting, and without sufficient clinical data, a decision must be reached to begin transfusion of blood components in massive amounts. The practice of massive transfusion has advanced considerably and is now a more complete and, arguably, more effective process. This new therapeutic paradigm, referred to as damage control resuscitation (DCR), differs considerably in many important respects from previous management strategies for catastrophic blood loss. We review several important elements of DCR including immediate correction of specific coagulopathies induced by hemorrhage and management of several extreme homeostatic imbalances that may appear in the aftermath of resuscitation. We also emphasize that the foremost objective in managing exsanguinating hemorrhage is always expedient and definitive control of the source of bleeding.

Viscoelastic guidance of resuscitation

PURPOSE OF REVIEW

Bleeding in trauma carries a high mortality and is increased in case of coagulopathy. Our understanding of hemostasis and coagulopathy has improved, leading to a change in the protocols for hemostatic monitoring. This review describes the current state of evidence supporting the use of viscoelastic hemostatic assays to guide trauma resuscitation.

RECENT FINDINGS

Viscoelastic hemostatic assays such as thrombelastography and rotational thrombelastometry have shown to reduce bleeding, transfusion of fresh frozen plasma and platelets, and possibly mortality in different surgical populations. In trauma care, viscoelastic hemostatic assays allows for rapid and timely identification of coagulopathy and individualized, goal-directed transfusion therapy. As part of the resuscitation concept, viscoelastic hemostatic assays seem to improve outcome also in trauma; however, there is a need for randomized clinical trials to confirm this.

SUMMARY

We are moving toward avoiding coagulopathy by individualized, goal-directed transfusion therapy, using viscoelastic hemostatic assays to guide ongoing resuscitation of actively bleeding patients in a goal-directed manner.

Usefulness of standard plasma coagulation tests in the management of perioperative coagulopathic bleeding: is there any evidence?

Standard laboratory coagulation tests (SLTs) such as prothrombin time/international normalized ratio or partial thromboplastin time are frequently used to assess coagulopathy and to guide haemostatic interventions. However, this has been challenged by numerous reports, including the current European guidelines for perioperative bleeding management, which question the utility and reliability of SLTs in this setting. Furthermore, the arbitrary definition of coagulopathy (i.e. SLTs are prolonged by more than 1.5-fold) has been questioned. The present study aims to review the evidence for the usefulness of SLTs to assess coagulopathy and to guide bleeding management in the perioperative and massive bleeding setting. Medline was searched for investigations using results of SLTs as a means to determine coagulopathy or to guide bleeding management, and the outcomes (i.e. blood loss, transfusion requirements, mortality) were reported. A total of 11 guidelines for management of massive bleeding or perioperative bleeding and 64 studies investigating the usefulness of SLTs in this setting were identified and were included for final data synthesis. Referenced evidence for the usefulness of SLTs was found in only three prospective trials, investigating a total of 108 patients (whereby microvascular bleeding was a rare finding). Furthermore, no data from randomized controlled trials support the use of SLTs. In contrast, numerous investigations have challenged the reliability of SLTs to assess coagulopathy or guide bleeding management. There is actually no sound evidence from well-designed studies that confirm the usefulness of SLTs for diagnosis of coagulopathy or to guide haemostatic therapy.

Prehospital detection of traumatic coagulopathy

Increased focus on traumatic coagulopathy over the last decade has led to more aggressive use of hemostatic agents in resuscitation of the massively bleeding patient. Novel formulations of plasma factors and other therapeutics have opened for early intervention to prevent coagulopathy and may even be utilized in the prehospital setting. Careful selection of patients to receive hemostatic agents early during the resuscitation is of great importance due to the potential detrimental effects of this treatment. Several studies have identified coagulation parameters as reliable predictors of massive transfusion, even very early after trauma. Prothrombin time international normalized ratio (PT/INR), activated partial thromboplastin time (aPTT), fibrinogen concentration, and viscoelastic tests such as thrombelastography (TEG) and rotational thrombelastometry (RoTEM) have proved to be of value in predicting massive transfusion when performed in-hospital. PT/INR appears to be slightly more accurate than the other parameters, with a reported sensitivity of 84.8% and an area under the receiver operating curve of 0.87. Comparison studies on PT/INR, aPTT, and viscoelastic assays do suggest that caution should be taken when point-of-care (POC) methods, as opposed to conventional laboratory analyses, are used. Novel techniques for POC measurement of fibrinogen levels are currently being developed, and preclinical data suggest acceptable agreement with conventional methods. A number of factors should be considered regarding the feasibility of POC tests in the prehospital environment. In addition to environmental factors such as temperature, altitude, and humidity, electromagnetic interference issues and operators' skills must be taken into account. Coagulation parameters appear to be a useful tool in identifying patients with increased risk of massive bleeding at an early stage. Further studies are needed to determine if prehospital intervention based on POC analyses improves outcome.

Angiographic embolization in the treatment of arterial pelvic hemorrhage: evaluation of prognostic mortality-related factors

Purpose

The control of arterial bleeding associated with pelvic ring and acetabular fractures (PRAF) remains a challenge for emergency trauma care. The aim of the present study was to uncover early prognostic mortality-related factors in PRAF-related arterial bleedings treated with transcatheter angiographic embolization (TAE).

Methods

Forty-nine PRAF patients (46 pelvic ring and three acetabular fractures) with arterial pelvic bleeding controlled with TAE (within 24 h) were evaluated.

Results

All large arterial disruptions (n = 7) were seen in type C pelvic ring injuries. The 30-day mortality in large vessel (iliac artery) bleeding was higher (57 %) than in medium- or small-size artery bleeding (24 %). Overall 30-day mortality was 29 %. No statistically significant difference in the first laboratory values between the survivors and nonsurvivors was found. However, after excluding patients dying of head injuries (n = 5), a reasonable cut-off value was identified for the base excess (BE; lower than −10 mmol/l) obtained on admission.

Conclusions

PRAF patients with exsanguinating bleeding from the large pelvic artery have the worst prognosis. Very low BE values (<−10.0 mmol/l) on admission for exsanguinating patients have a negative predictive value for survival, thus anticipating a poor outcome in bleeding controlled with TAE only and an increased risk of death. In critical cases, an aggressive bleeding control protocol prompts extraperitoneal pelvic packing prior to TAE. PRAF-related rupture of the external iliac artery is rare and indicates surgical techniques in controlling and restoring blood supply to the lower leg.

Current management of massive hemorrhage in trauma

Hemorrhage remains a major cause of potentially preventable deaths. Trauma and massive transfusion are associated with coagulopathy secondary to tissue injury, hypoperfusion, dilution, and consumption of clotting factors and platelets. Concepts of damage control surgery have evolved prioritizing early control of the cause of bleeding by non-definitive means, while hemostatic control resuscitation seeks early control of coagulopathy.Hemostatic resuscitation provides transfusions with plasma and platelets in addition to red blood cells in an immediate and sustained manner as part of the transfusion protocol for massively bleeding patients. Although early and effective reversal of coagulopathy is documented, the most effective means of preventing coagulopathy of massive transfusion remains debated and randomized controlled studies are lacking. Viscoelastical whole blood assays, like TEG and ROTEM however appear advantageous for identifying coagulopathy in patients with severe hemorrhage as opposed the conventional coagulation assays.In our view, patients with uncontrolled bleeding, regardless of it's cause, should be treated with hemostatic control resuscitation involving early administration of plasma and platelets and earliest possible goal-directed, based on the results of TEG/ROTEM analysis. The aim of the goal-directed therapy should be to maintain a normal hemostatic competence until surgical hemostasis is achieved, as this appears to be associated with reduced mortality.

Simulation of survivorship bias in observational studies on plasma to red blood cell ratios in massive transfusion for trauma

BACKGROUND

Observational studies on injured patients requiring massive transfusion have found a survival advantage associated with use of equivalent number of units of fresh frozen plasma (FFP) and packed red blood cells (RBCs) compared with use of FFP based on conventional guidelines. However, a survivorship bias might have favoured the higher use of FFP because patients who died early never had the chance to receive sufficient FFP to match the number of RBC units transfused.

METHODS

A Markov model using trauma data from local hospitals was constructed and various FFP transfusion scenarios were applied in Monte Carlo simulations in which the relative risk of death associated with exposure to high FFP transfusion was set at 1.00, so that the FFP : RBC ratio had no influence on mortality outcome.

RESULTS

Simulation results showed that the relative risk associated with exposure to high FFP transfusion was less than 1.00 (0.33-0.56 based on programmed delays in achieving an FFP : RBC ratio of 1 : 1-2), thus demonstrating a survivorship bias in favour of FFP : RBC equal to or more than 1 : 1-2 in certain observational trauma studies. This bias was directly proportional to the delay in achieving a FFP : RBC ratio of 1 : 1-2 during resuscitation.

CONCLUSION

Some observational studies comparing low and high FFP administration in injured patients requiring massive transfusion probably involve survivorship bias that inflates or creates a survival advantage in favour of a higher FFP : RBC ratio.

A review of the clinical utility of INR to monitor and guide administration of prothrombin complex concentrate to orally anticoagulated patients

Background and objectives

The number of patients treated with oral anticoagulation (OAC) is increasing and these patients are monitored by International Normalized Ratio (INR). Bleeding complications are common and we speculate if this is related to the limitation of INR only reflecting the initiation steps of the haemostatic process. The objective of the present review was to reassess the evidence for using INR as a tool to guide administration of prothrombin complex concentrates (PCC) to OAC patients. A Medline and Cochrane database search was conducted using the following keywords: prothrombin complex concentrate, reversal of oral anticoagulation and international normalized ratio (INR). Thirty-three articles were contracted and a total of ten studies were eligible after applying inclusion and exclusion criteria encompassing only 339 patients. No consensus regarding optimal target INR value to aim for when reversing OAC was found. In three of the studies it was reported that patients reaching their target INR continued to bleed, whereas three studies reviewed reported good haemostatic response also in patients that did not reach their target INR. The present review found limited evidence for the usefulness of INR as a tool to monitor and guide reversal of OAC induced coagulopathy in patients with PCC, which is expected given that it is a plasma-based assay only reflecting a limited part of the haemostatic process.

Can RoTEM® analysis be applied for haemostatic monitoring in paediatric congenital heart surgery?

BACKGROUND

Successful management of bleeding disorders after congenital heart surgery requires detection of specific coagulation disturbances. Whole-blood rotation thromboelastometry (RoTEM®) provides continuous qualitative haemostatic profiles, and the technique has shown promising results in adult cardiac surgery.

SETTING

To compare the performance of RoTEM® with that of conventional coagulation tests in children, we conducted a descriptive study in children undergoing congenital cardiac surgery. For that purpose, 60 children were enrolled and had blood samples taken before, immediately after, and 1 day after surgery. Conventional coagulation tests included: activated partial thromboplastin time, prothrombin time, fibrinogen, fibrin D-dimer, thrombin clotting time, factor XIII, and platelet count.

RESULTS

Post-surgical haemostatic impairment was present to some degree in all children, as seen by pronounced changes in activated partial thromboplastin time, prothrombin time, thrombin clotting time, and platelet count, as well as RoTEM® analysis. RoTEM® showed marked changes in clotting time - prolonged by 7-18% - clot formation time - prolonged by 46-71% - maximum clot firmness - reduced by 10-19%, and maximum velocity - reduced by 29-39%. Comparison of the two techniques showed that conventional coagulation tests and RoTEM® performed equally well with regard to negative predictive values for excessive post-operative drain production - more than 20 millilitres per kilogram per 24 hours after surgery - with an area under the curve of approximately 0.65.

CONCLUSION

RoTEM® can detect haemostatic impairments in children undergoing cardiac surgery and the method should be considered as a supplement in the perioperative care of the children where targeted transfusion therapy is necessary to avoid volume overload.

Monitoring patients at risk of massive transfusion with Thrombelastography or Thromboelastometry: a systematic review

BACKGROUND

Thrombelastography (TEG) and Thrombelastometry (ROTEM) are viscoelastic whole-blood assays evaluating the haemostatic capacity of blood. These devices are used in algorithms to guide transfusion of haemostatic blood components.

METHODS

The methods used for this study were systematic reviews with meta-analyses and trial sequential analyses of randomised clinical trials (RCTs) of TEG/ROTEM-based algorithm compared with standard treatment in patients with bleeding. Primary outcome was all-cause mortality. We searched the literature in seven databases (up to 31 October 2010), reference lists, registers of ongoing trials, and contacted authors and experts. We extracted data from included studies related to study methods, interventions, outcomes, bias risk and adverse events using Cochrane methodology. All trials irrespective of blinding or language status were included.

RESULTS

Nine trials involving 776 participants were included. Eight trials involved cardiac surgery with an average blood loss of 390-960  ml, and one trial investigated liver transplantations. One trial was classified as low-risk-of-bias trial. We found two ongoing trials. No impact was identified on mortality, amount of blood transfused, incidence of surgical reinterventions, time to extubation, or length of stay in hospital and intensive care unit. We identified a significant reduction in blood loss favouring the use of TEG/ROTEM {85  ml [95% confidence interval (CI) 29.4-140.7]} and in the proportion of patients receiving freshly frozen plasma and platelets [relative risk 0.39 (95%CI 0.27-0.57)].

CONCLUSION

There is currently weak evidence to support the use of TEG/ROTEM as a tool to guide transfusion in patients with severe bleeding. Further studies need to address other clinical settings and with larger blood losses.

Fibrinogen concentrates for bleeding trauma patients: what is the evidence?

INTRODUCTION

A balanced transfusion of red blood cells, fresh frozen plasma and platelets are recommended for massively bleeding trauma patients. Fibrinogen concentrates could potentially lessen or replace the need for fresh frozen plasma and/or platelet transfusions.

OBJECTIVE

To provide a review of the literature covering the application of fibrinogen concentrates in trauma care.

METHODS

PubMed and Cochrane database search, 'fibrinogen' and ('concentrate' or 'trauma'), not 'congenital', 10 years.

RESULTS

Only four papers were identified. None were randomized controlled trials. The main conclusion of these papers was that administration of fibrinogen sometimes together with prothrombin complex concentrate might improve haemostasis in trauma patients resuscitated with synthetic colloids.

CONCLUSION

Evidence for the use of fibrinogen concentrate to trauma patients with massive bleeding is lacking. Well-designed prospective, randomized, double-blinded studies evaluating the effect of fibrinogen concentrate, as the only intervention, are urgently needed.

Clinical and cellular effects of hypothermia, acidosis and coagulopathy in major injury

BACKGROUND

Hypothermia, acidosis and coagulopathy have long been considered critical combinations after severe injury. The aim of this review was to give a clinical update on this triad in severely injured patients.

METHODS

A non-systematic literature search on hypothermia, acidosis and coagulopathy after major injury was undertaken, with a focus on clinical data from the past 5 years.

RESULTS

Hypothermia (less than 35 °C) is reported in 1·6-13·3 per cent of injured patients. The occurrence of acidosis is difficult to estimate, but usually follows other physiological disturbances. Trauma-induced coagulopathy (TIC) has both endogenous and exogenous components. Endogenous acute traumatic coagulopathy is associated with shock and hypoperfusion. Exogenous effects of dilution from fluid resuscitation and consumption through bleeding and loss of coagulation factors further add to TIC. TIC is present in 10-34 per cent of injured patients, depending on injury severity, acidosis, hypothermia and hypoperfusion. More expedient detection of coagulopathy is needed. Thromboelastography may be a useful point-of-care measurement. Management of TIC is controversial, with conflicting reports on blood component therapy in terms of both outcome and ratios of blood products to other fluids, particularly in the context of civilian trauma.

CONCLUSION

The triad of hypothermia, acidosis and coagulopathy after severe trauma appears to be fairly rare but does carry a poor prognosis. Future research should define modes of early detection and targeted therapy.

Trends in transfusion of trauma victims--evaluation of changes in clinical practice

Background

The present study was performed to compare blood product consumption and clinical results in consecutive, unselected trauma patients during the first 6 months of year 2002, 2004 and 2007.

Methods

Clinical data, blood product consumption, lowest haemoglobin values on day 1-10 after admission, and 30-day mortality were extracted from in-hospital trauma registry and the blood bank data base. The subpopulation of massively transfused patients was identified and analysed separately.

Results

The total number of admitted trauma patients increased by 48% from 2002 to 2007, but the clinical data remained essentially unchanged. The mean number of erythrocyte units given day 1-10 decreased insignificantly from 9.4 in 2002 to 6.8 in 2007. New Injury Severity Score (NISS) increased in transfused and massively transfused patients, but not significantly. The number of patients transfused with plasma increased and the mean ratio of erythrocyte to plasma units transfused decreased by about 50%. The mean haemoglobin value in transfused patients on day 2 after admittance was significantly lower in 2007 than in 2002, while that on day 10 was significantly higher in 2007 than in 2002 and 2004. There was no change of 30-day survival from 2002 to 2007.

Conclusions

Significant changes of transfusion practice occurred during the past decade, probably as a result of increased focus on haemostasis and more precise criteria for transfusion. Despite a lower consumption of erythrocytes in 2007 than in 2002 and 2004, the mean haemoglobin level of transfused patients was higher on day 10 in 2007. The low number of transfused patients in this material makes evaluation of effect on survival difficult. Larger studies with strict control of all influencing factors are needed.

A retrospective quality assessment of pre-hospital emergency medical documentation in motor vehicle accidents in south-eastern Norway

Background

Few studies have evaluated pre-hospital documentation quality. We retrospectively assessed emergency medical service (EMS) documentation of key logistic, physiologic, and mechanistic variables in motor vehicle accidents (MVAs).

Methods

Records from police, Emergency Medical Communication Centers (EMCC), ground and air ambulances were retrospectively collected for 189 MVAs involving 392 patients. Documentation of Glasgow Coma Scale (GCS), respiratory rate (RR), and systolic blood pressure (SBP) was classified as exact values, RTS categories, clinical descriptions enabling post-hoc inference of RTS categories, or missing. The distribution of values of exact versus inferred RTS categories were compared (Chi-square test for trend).

Results

25% of ground and 11% of air ambulance records were unretrieveable. Patient name, birth date, and transport destination was documented in >96% of ambulance records and 81% of EMCC reports. Only 54% of patient encounter times were transmitted to the EMCC, but 77% were documented in ground and 96% in air ambulance records. Ground ambulance records documented exact values of GCS in 48% and SBP in 53% of cases, exact RR in 10%, and RR RTS categories in 54%. Clinical descriptions made post-hoc inference of RTS categories possible in another 49% of cases for GCS, 26% for RR, and 20% for SBP. Air ambulance records documented exact values of GCS in 89% and SBP in 84% of cases, exact RR in 7% and RR RTS categories in 80%. Overall, for lower RTS categories of GCS, RR and SBP the proportion of actual documented values to inferred values increased (All: p < 0.001). Also, documentation of repeated assessment was more frequent for low RTS categories of GCS, RR, and SBP (All: p < 0.001). Mechanism of injury was documented in 80% of cases by ground and 92% of cases by air ambulance.

Conclusion

EMS documentation of logistic and mechanistic variables was adequate. Patient physiology was frequently documented only as descriptive text. Our finding indicates a need for improved procedures, training, and tools for EMS documentation. Documentation is in itself a quality criterion for appropriate care and is crucial to trauma research.

The contemporary role of blood products and components used in trauma resuscitation

INTRODUCTION

There is renewed interest in blood product use for resuscitation stimulated by recent military experience and growing recognition of the limitations of large-volume crystalloid resuscitation.

METHODS

An editorial review of recent reports published by investigators from the United States and Europe is presented. There is little prospective data in this area.

RESULTS

Despite increasing sophistication of trauma care systems, hemorrhage remains the major cause of early death after injury. In patients receiving massive transfusion, defined as 10 or more units of packed red blood cells in the first 24 hours after injury, administration of plasma and platelets in a ratio equivalent to packed red blood cells is becoming more common. There is a clear possibility of time dependent enrollment bias. The early use of multiple types of blood products is stimulated by the recognition of coagulopathy after reinjury which may occur as many as 25% of patients. These patients typically have large-volume tissue injury and are acidotic. Despite early enthusiasm, the value of administration of recombinant factor VIIa is now in question. Another dilemma is monitoring of appropriate component administration to control coagulopathy.

CONCLUSION

In patients requiring large volumes of blood products or displaying coagulopathy after injury, it appears that early and aggressive administration of blood component therapy may actually reduce the aggregate amount of blood required. If recombinant factor VIIa is given, it should be utilized in the fully resuscitated patient. Thrombelastography is seeing increased application for real-time assessment of coagulation changes after injury and directed replacement of components of the clotting mechanism.

Trauma systems and early management of severe injuries in Scandinavia: review of the current state

INTRODUCTION

Scandinavian countries face common challenges in trauma care. It has been suggested that Scandinavian trauma system development is immature compared to that of other regions. We wanted to assess the current status of Scandinavian trauma management and system development.

METHODS

An extensive search of the Medline/Pubmed, EMBASE and SweMed+ databases was conducted. Wide coverage was prioritized over systematic search strategies. Scandinavian publications from the last decade pertaining to trauma epidemiology, trauma systems and early trauma management were included.

RESULTS

The incidence of severe injury ranged from 30 to 52 per 100,000 inhabitants annually, with about 90% due to blunt trauma. Parts of Scandinavia are sparsely populated with long pre-hospital distances. In accordance with other European countries, pre-hospital physicians are widely employed and studies indicate that this practice imparts a survival benefit to trauma patients. More than 200 Scandinavian hospitals receive injured patients, increasingly via multidisciplinary trauma teams. Challenges remain concerning pre-hospital identification of the severely injured. Improved triage allows for a better match between patient needs and the level of resources available. Trauma management is threatened by the increasing sub-specialisation of professions and institutions. Scandinavian research is leading the development of team- and simulation-based trauma training. Several pan-Scandinavian efforts have facilitated research and provided guidelines for clinical management.

CONCLUSION

Scandinavian trauma research is characterised by an active collaboration across countries. The current challenges require a focus on the role of traumatology within an increasingly fragmented health care system. Regional networks of predictable and accountable pre- and in-hospital resources are needed for efficient trauma systems. Successful development requires both novel research and scientific assessment of imported principles of trauma care.

Correction of coagulation in dilutional coagulopathy: use of kinetic and capacitive coagulation assays to improve hemostasis

The management of dilutional coagulopathy due to fluid infusion and massive blood loss is a topic that deserves a biochemical approach. In this review article, we provide an overview of current guidelines and recommendations on diagnosis and on management of transfusion in acquired coagulopathy. We discuss the biochemical differences between kinetic clotting assays (clotting times) and new capacitive coagulation measurements that provide time-dependent information on thrombin generation and fibrin clot formation. The available evidence suggests that a combination of assay types is required for evaluating new transfusion protocols aimed to optimize hemostasis and stop bleeding. Although there is current consensus on the application of fresh frozen plasma to revert coagulopathy, factor concentrates may appear to be useful in the future.

Hemostatic effectiveness of Fibrin pad after partial nephrectomy in swine

BACKGROUND

Current management of severe surgical or traumatic bleeding is often achieved by manual tamponade or occlusion using devices such as tourniquets or ligatures. There are some clinical scenarios where these options are either marginally effective or impractical. The present study evaluates a new combination device (Fibrin pad) consisting of biologically active components (human thrombin and fibrinogen) delivered to the targeted site by an absorbable synthetic matrix (oxidized regenerated cellulose and polyglactin 910) in a swine severe bleeding model. In this model, severe bleeding can be managed by concurrent use of several currently available treatments, or a more convenient option that offers performance and safety advantages.

MATERIALS AND METHODS

Partial nephrectomies were performed on swine and treated with either Fibrin pad (FP) or conventional therapy (CTR)-temporary occlusion of renal artery, electrocautery, SURGIFLO, EVITHROM, SURGICEL NU-KNIT, and PDS II suture). After intraoperative hemostasis was confirmed, the animals were closed and recovered, then survived for 2, 14, or 56 d.

RESULTS

Hemostasis was achieved at surgery and maintained in all FP and CTR treated animals. FP was as effective as CTR at establishing durable hemostasis. Treatment with FP did not require temporary occlusion of the renal artery and decreased the total treatment time by half. No animals in either group had complications related to postoperative bleeding at any time during the study. There was no evidence of pulmonary thrombi or evidence of thrombotic complications. No biologically significant adverse local tissue response was present in association with the Fibrin pad at any study interval, and no biologically relevant or consistent changes in blood parameters were identified.

CONCLUSIONS

Fibrin pad was as effective as CTR for the primary management of severe bleeding without occlusion of the renal artery and a shorter surgical time. No evidence of a systemic or local adverse response was identified due to exposure to the Fibrin pad.