Hemostatic agents

DR. ASHOK PRADHAN
DU, TU

1. Hemostatic instruments and agents in surgical practise Dr. A shok Pradhan 2 nd YR Surgery JR UCMS,TH

2. INTRODUCTION Hemostasis is the process of forming clots in the walls of damaged blood vessels

3. Events Vascular constriction Platelet plug Blood clot Growth of fibrous tissue into the clot

4. Platelet adhesion

5. Clotting factors Factor i (fibrinogen) Factor ii( prothrombin ) Factoriii (tissue factor) Factor Iv(calcium) Factor v(labile factor) Factor vii(stable factor) Factor viii( antihemophilic factor) Factor ix ( christmas factor) Factor x ( stuart power factor) Factor xi( plasma thromboplastin acntecedent ) Factor xii ( hageman factor) Factor xiii ( fibrin stabilizing factor)

6. C ont

7. Adverse effects of surgical bleeding Visual obstruction of surgical field Need for blood transfusion Reduction of core temperature Thrombocytopenia Hypovolemic shock

8. Methods of hemostasis Mechanical Thermal Chemical Topical

9. Characteristics of an ideal hemostatic agent Capability to stop large vessel (arterial and venous bleeding) within minutes of application No requirement for mixing Light weight and durable Safe to use with no risk of injury to tissues Cost effective

10. Methods of hemostasis Mechanical T hermal Direct pressure gauge pads/sponges Sutures/ staples/ ligating clips Electrosurgery monopolar Bipolar Bipolar vessels sealing device Argon enhanced coagulation Ultrasonic device laser

11. chemical Epinephrine Vitamin k Protamine Desmopressin Lysine analogue

12. Cont. Topical agent Passive Active others Collagens based agent Cellulose Gelatin Polysaccharide spheres Thrombin products Sealants Glutaraldehyde cynoacrylate

13. Mechanical method 1 Direct pressure Simplest & fastest Arterial bleeding better controlled than venous 2 G auzes pads/sponges Application of direct pressure Packing of body cavity Temproary method 3 Sutures/staples/ligation clips Sutures and ties used as ligatures to tie off blood vessels Nonabsorbable sutures are used, c hances of foreign body reaction For staples-stapling device used, faster than suture application Ligation clips –quick and easy to apply

14. Thermal or energy based Mono-polar most frequently used, composed of generator, electrode for application and electrode for returning current to complete the circuit Grounding pad used to function properly and prevent thermal burn Bipolar short circuit between the tips of instrument without grounding pad Mechanical advantage of compression of tissue between tips of instrument to thermal coagulation better on delicate tissues/small anatomical structures Bipolar vessels sealing device and transecting vessels upto 7mm diameter. Monopolar electrosurgery can be used for several modalities including cut, blend, desiccation, and fulguration. Using a pencil instrument, the active electrode is placed in the entry site and can be used to cut tissue and coagulate bleeding. The return electrode pad is attached to the patient, so the electrical current flows from the generator to the electrode through the target tissue, to the patient return pad and back to the generator. Monopolar electrosurgery is the most commonly used because of its versatility and effectiveness.

15. Monopolar Monopolar electrosurgery can be used for several modalities including cut , desiccation, and fulguration Using a pencil instrument, the active electrode is placed in the entry site and can be used to cut tissue and coagulate bleeding. The return electrode pad is attached to the patient, so the electrical current flows from the generator to the electrode through the target tissue, to the patient return pad and back to the generator.

16. Bipolar Bipolar electrosurgery uses lower voltages so less energy is required Because it has limited ability to cut and coagulate large bleeding areas, it is more ideally used for those procedures where tissues can be easily grabbed on both sides by the forceps electrode. Electrosurgical current in the patient is restricted to just the tissue between the arms of the forceps electrode. This gives better control over the area being targeted, and helps prevent damage to other sensitive tissues.

17. Bipolar vessel sealing device(LIGASURE) LigaSure Atlas is a surgical endoscopic device (diameter: 10 mm, length: 37 cm) that seals and divides vessels up to 7 mm in diameter LigaSure V is a single-use endoscopic instrument (diameter: 5 mm, length: 37 cm) able to seal and divide LigaSure Lap is a single-use endoscopic instrument (diameter: 5 mm, length: 32 cm LigaSure Precise is a single-use instrument (length: 16.5 cm) for open procedures specifically designed to provide permanent vessel occlusion

18. Cont. T echnique is different from the conventional coagulating methods that it achieve vessel sealing by tissue carbonization H eat generated from the bipolar energy determines the fusion of collagen and elastin in the walls of the vessel with the creation of a permanent sealed zone. The system detects the thickness of tissue to be coagulated and automatically defines the amount of energy required and the delivering time. An acoustic signal informs the surgeon when the vessel obliteration is complete and its division is possible. The seal zone shows a translucent appearance that is easy to recognize. Furthermore, this sealing system has a minimal thermal effect on the tissues surrounding the sealing line.

19. Argon based coagulation Argon based coagulator creates monopolar electric circuit between hand held probe and target tissue by establishing a steady flow of electrons through a channel of electrically activated and ionised argon gas High flow argon gas conducts electric current to the target tissue and generates thermal coagulation Paranchymal hemorrhage, especially lungs

20. Cont. Ultrasonic devices Converts electrical energy to mechanical energy Simultaneously cuts and coagulates Less thermal damaged to tissues Lasers Use photons to excite chromophore molecule within target tissue and generate kinetic energy that is released as heat, cause protein denaturation and coagulation Laser effect can be enhanced by photosensitizing agent Argon, carbondioxide , and Nd -YAG laser

21. Chemical method Ephinephrine Causes direct vasoconstriction Vitamin k Administer pre operatively to reverse the effect of warfarin Loading dose(0.75mg/kg) Protamine Reverse the action of heparin(1mg /100U)

22. Cont. Desmopressin Stimulates release of von willebrand factor and enhance primary hemostasis Lysine analogues Aminocaproic acid, tranexamic acid Antifibrinolytic

23. Topical hemostatic agent Passive Acts passively through contact with bleeding sites and promotion of platelets aggregation Intact coagulation cascade Absorb several time its weight in fluid Eg : Collagen, Cellulose, Gelatins and Polysaccharide spheres active Acts biologically on clotting cascade Not affected by deficiency in clotting factor and platelet Activated within 10minutes of application Eg : thrombin and its products

24. Collagen based products Micro- fibrillar collagen hemostat ( avitene / hemotene ) derived from purified bovine dermal collagen Sprayed into wounds and anastomoses,in area difficult to reach Effective against when there is capillary, venous and small arterial bleeding Potential adverse events: allergic reaction, foreign body reaction, infection and abscess formation Collagen hemostat sponge( helistat ) Derived from purified bovine tendon Collagen sponge gets absorbed into 8-10 weeks(slowly) Foreign body reaction

25. Cont. Oxidised regenerated cellulose( surgicel ) Knitted fabric of cellulose ORC reacts with blood, increase in size and forms a gelatinous mass and promotes clot formation AD s : FB reaction, stenosis of vascular structures, burning or stinging sensation Gelatin sponge Absorbs many times of whole blood by capillary action No significant inflammatory reaction Ploysacchride hemospheres Derived from vagetables starch Contains no human or animals component

26. Thrombin products Bovine thrombin Supplied as lyophilized powder Applied directly to the dressing, dissolved in saline or sprayed onto wound Results in formation of inhibitors to thrombin or factor v AE S : coagulopathy, allergic reaction and death Pooled human thrombin( floseal ) Used in combination with gelatin matrix Thrombin sprayed over matrix AE: Viral or prion related disease Recombinant thrombin Reduced risk of antibody formation and eliminates risk of viral or prion disease transmssion

27. Sealants( tiseel / evicel ) Consist of conc human fibrinogen and human thrombin Fibrin sealants can be used in patient with coagulopathies Clinical concerns: difficulty of reconstruction, time taken for surgeon to learn Ad s : viral or prion disease transmission

28. Albumin G lutaraldehyde Contain 10%glutaraldehyde sol and 45% bovine serum albumin Glutaraldehyde cross links the residual proteins in albumin to cell proteins at wound site and forms a tough scaffold to which clot can adhere Commonly used for sealing holes around suture or staples lines AE s : M uscle necrosis, delayed pseudo-aneurysm formation

29. Cyano -acrylates(surgical adhesive) Consists of 2 cyanoacrylate monomers 2octyl cyanoacrylate Butyl lactoyl cyanoacrylate Product to be used as sealant or plug ( forms viscous semiliquid tissue glue) applied over suture lines, fistula tract or cavity, prevent lymphatic leakage, adapt to seal terminal bronchial

30. Thank you