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Fibrin glue as a hemostatic agent in hepatic and splenic trauma.

Fibrin glue is a biologic hemostatic agent that coagulates and seals upon application. It is made by combining human fibrinogen concentrate with standard thrombin solutions containing calcium. Similar to epoxy glue, the two components are applied simultaneously in equal volumes resulting in an almost instantaneous formation of a coagulum. Fibrinogen concentrate is prepared in the blood bank from single donor plasma. Fibrin glue can be applied topically or injected into the parenchyma of solid organs. Twenty-six patients sustained hepatic or splenic trauma from May through August 1989--17 liver and nine splenic injuries. The glue was effective after one application in 21 patients and after a second in five. Hemostasis was achieved despite coagulopathy and thrombocytopenia in eight patients. There were no re-explorations for bleeding, and nine complications occurred in six patients. Our experience suggests fibrin glue is an effective, underutilized adjunctive hemostatic agent in trauma.

Fibrin Tissue Adhesive↗

The effect of burn wound size on hemostasis: a correlation of the hemostatic changes to the clinical state.

The effect of burn wound size on the activation of fibrinolysis, coagulation, and contact factors was analyzed in 60 thermal injury patients. Blood samples from 47 male patients and 13 female patients, (average age 37 years; range 1.5-70 years) were collected within the first 36 hours and at 5-7 days following injury. The patient population was categorized by percentage of burn (second degree and/or third degree): less than 20%, n = 22; 20%-40%, n = 18; greater than 40%, n = 20. The average percentage of burn was 32% (range, 4%-95%). The mechanism of injury was by flame (25), explosion and flame (19), scald (12), electric (3), or chemicals (1). An associated inhalation injury was present in 12 patients. The overall mortality rate was 13% (8). Sepsis or serious infection occurred in 23% (14) of the patients. On admission, 83% of the patients had normal prothrombin times (PT) and activated partial thromboplastin times (APTT). However, specific hemostatic variables showed marked changes. Admission hemostatic markers that correlated with the severity of injury were: tissue-plasminogen activator (tPA), plasminogen activator inhibitor (PAI), D-dimer (D-di), plasminogen (Plg), proteins C and S (PrC and PrS), antithrombin III (ATIII), thrombin-antithrombin complex (TAT), kallikrein (Kal:c), kinin (Kin), C1 esterase inhibitor (C1Inh), and factor VII clotting and antigen (FVII:c, FVII:ag). These data suggest that during the early course following burn injury, thrombogenicity is increased (TAT increases) because of a decrease in ATIII, PrC, and PrS; and fibrinolysis activation (D-di increases) occurs via an increase in tPA with a p value increase in PAI.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

A new, pluronic-based, bone hemostatic agent that does not impair osteogenesis.

OBJECTIVE: Intraoperative bone hemostasis can be accomplished using surgical beeswax (bone wax). However, bone wax locally interferes with osteogenesis, and its use is avoided when bone fusion is critical. We describe the use of a Pluronic copolymer blend as a biocompatible, absorbable, hemostatic agent. METHODS: A rat femur defect model and a femur gap nonunion model were used. For each surgical model, 24 rats were divided into three treatment groups, i.e., those receiving bone wax implants, Pluronic (90% Pluronic P85/10% Pluronic F88) implants, or no implants (control group). After 10, 21, or 42 days, animals were killed and femora were removed for radiographic analysis and hematoxylin and eosin staining. RESULTS: In the femur defect model, no differences were observed between the Pluronic-treated and control groups; hematoxylin and eosin staining demonstrated bone formation and osteocytes within the defect. In the femur gap nonunion model, no fusions occurred in any group. Development of an osseous callus at the gap site was observed for the control and Pluronic-treated groups. In both models, rats that received bone wax implants exhibited no osseous growth. CONCLUSION: The Pluronic blend exhibits handling properties similar to those of bone wax, readily achieves hemostasis, and does not inhibit bone regrowth. Pluronic compounds may serve as effective absorbable hemostatic agents for the treatment of bone bleeding in sites where fusion is critical. In addition, this copolymer blend may find use as a vehicle for the short-term release of pharmacological agents, which may further reduce the incidence of infections, reduce inflammation, and improve fusion rates.

Absorbable Implants↗

Work stress and metabolic and hemostatic risk factors.

OBJECTIVE: A high level of work stress has been associated with cardiovascular disease. However, the pathophysiological mechanisms underlying this association remain unclear. This study examined the effect of work stress on a cluster of metabolic and hemostatic risk factors. METHODS: Blood was collected three times, on the first, third, and fifth day of a work week, from 124 middle-aged, white-collar workers. Metabolic measures were insulin, glucose, triglycerides, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and total cholesterol. Hemostatic measures were fibrinogen, tissue-type plasminogen activator activity, tissue-type plasminogen activator antigen, and type 1 plasminogen activator inhibitor antigen. Chronic work stress was defined according to Siegrist's model as 1) a combination of high effort and low reward at work (effort-reward imbalance) or 2) high overcommitment (an exhaustive work-related coping style). RESULTS: Overcommitment, but not imbalance or the imbalance-overcommitment interaction, was associated with an impaired fibrinolytic system, as reflected in decreased tissue-type plasminogen activator activity levels and increased type 1 plasminogen activator inhibitor antigen levels on all three measurement occasions. After controlling for body mass index, total cholesterol, triglycerides, high-density lipoprotein/low-density lipoprotein cholesterol ratio, glucose, and insulin, the relation between overcom-mitment and the fibrinolytic factors was attenuated but remained significant. CONCLUSIONS: The results suggest that individuals with an exhaustive coping style at work have an impaired fibrinolytic capacity that is possibly due to the effects of chronic stress on insulin resistance.

Adaptation, Psychological↗

Hemostatic parameters in sepsis patients treated with anti-TNF alpha-monoclonal antibodies.

Tumor necrosis factor-alpha (TNF alpha) is a central mediator in the pathogenesis of sepsis. It also interferes with the hemostatic system and exerts and a net procoagulant effect. Since TNF alpha may contribute to thrombotic complications in sepsis patients, we determined markers of thrombin activation, parameters of the fibrinolytic system (D-dimer, tissue plasminogen activator antigen (tPA) urinary type plasminogen activator antigen (uPA), plasminogen activator inhibitor antigen (PAI-1) and von Willebrand factor antigen (vWF) in 30 patients with sepsis or septic shock. All patients were treated with standard therapy, but 14 patients were treated additionally with an anti-TNF alpha monoclonal antibody (MAK 195F); 16 patients served as historical controls. No significant effect of the antibody on the parameters of the hemostatic system could be determined. Our data speak against a modulation of coagulation or the fibrinolytic system by the monoclonal anti-TNF alpha antibody MAK 195F in this cohort of sepsis patients.

Adult↗

Transfusion-sparing hemostatic agents.

A variety of agents are available to improve hemostasis and reduce blood loss in multiple clinical settings. These agents are most commonly used to reduce bleeding when an underlying hemostatic defect is present. Some new agents offer the potential to decrease blood loss even in the absence of an obvious underlying hemostatic defect. The authors discuss the use of a variety of products to reduce bleeding and minimize transfusion of blood products in the setting of clotting factor deficiency or inhibition, platelet deficiency and/or dysfunction, increased fibrinolysis, therapeutic anticoagulation, and coagulopathies caused by dilution and consumption in the setting of trauma and surgery. The authors primarily focus on the available pharmaceuticals.

Antifibrinolytic Agents↗

Immunoglobulin preparations attenuate organ dysfunction and hemostatic abnormality by suppressing the production of cytokines in lipopolysaccharide-induced disseminated intravascular coagulation in rats.

OBJECTIVE: We attempted to clarify the effect of immunoglobulin concentrates on the rat lipopolysaccharide (LPS)-induced disseminated intravascular coagulation (DIC) model. DESIGN: Prospective, comparative, experimental study. SETTING: Laboratory at a university hospital. SUBJECTS: Male Wistar rats, aged 6 to 7 wks and weighing 160 to 170 g. INTERVENTIONS: Two kinds of experiments were performed. In the first, experimental DIC was induced by sustained infusion of 30 mg/kg LPS for 4 hrs via the tail vein, and two doses of immunoglobulin (25 or 100 mg/kg/4.5 hrs) were administered to rats 30 mins before infusion of LPS, after which immunoglobulin infusion was continued for a further 4 hrs. In the second, experimental DIC was induced by sustained infusion (5 mg/kg/1 hr) of LPS for 1 hr, and one dose of immunoglobulin (100 mg/kg/4 hrs) was administered to rats after LPS induction. The parameters were estimated at 4 hrs and 8 hrs in the first experiment and at 1, 5, and 10 hrs in the second one. MEASUREMENT AND MAIN RESULTS: Similar results were observed in the two experiments. Consumption coagulopathy and hemostatic activation were attenuated, especially when immunoglobulin was administered before LPS infusion. Plasma levels of creatinine and alanine aminotransferase were significantly depressed by coadministration of immunoglobulin. Marked glomerular fibrin deposition was observed in the LPS-induced DIC model, but this deposition was reduced by immunoglobulin. In the first stage of the experiment, plasma levels of tumor necrosis factor (TNF) and interleukin (IL)-6 were suppressed by coadministration of immunoglobulin. In the second, plasma levels of IL-6 were significantly suppressed by immunoglobulin. CONCLUSION: It was concluded that plasma levels of TNF and IL-6 could be significantly suppressed by immunoglobulin in the LPS-induced DIC model. Moreover, hemostatic abnormality, organ dysfunction, and glomerular fibrin deposition in this model were all ameliorated by immunoglobulin.

Alanine Transaminase↗

Clinical and hemostatic responses to treatment in ventilator-associated pneumonia: role of bacterial pathogens.

OBJECTIVE: To determine pathogen-specific kinetic changes in the alveolar procoagulant (PC) activity, tissue factor (TF), and tissue factor pathway inhibitor (TFPI) expression during the course of ventilator-associated pneumonia (VAP) and to assess the relationship between clinical resolution, intra-alveolar bacterial eradication, and restoration of hemostatic balance. DESIGN: Prospective, multiple-center study in a cohort of VAP patients. SETTING: Two university-affiliated intensive care units. PATIENTS: Thirty-five patients with microbiologically documented VAP who received adequate antimicrobial coverage and 13 controls. INTERVENTIONS: Nonbronchoscopic bronchoalveolar lavage was performed at the onset of VAP and on days 4 and 8 after initiation of antibiotic therapy. Samples were assayed for PC, TF, TFPI, and thrombin-antithrombin complex (TATc). The corresponding Clinical Pulmonary Infection Score (CPIS) was collected simultaneously. MEASUREMENTS AND MAIN RESULTS: Isolated pathogens included Pseudomonas aeruginosa (n=13), methicillin-resistant Staphylococcus aureus (MRSA) (n=8), methicillin-sensitive S. aureus (MSSA) (n=7), and Escherichia coli (n=7). Although PC activity and TF were increased among the various pathogens at the onset of VAP, the levels of those with P. aeruginosa remained elevated at the end of treatment compared with controls and other etiological agents. TFPI levels were elevated for the duration of the study for all pathogens. A universal increase in TATc was noted at the onset of VAP, but the difference among the group of pathogens was significant at days 4 and 8 posttherapy. Despite the persisting hemostatic imbalance and incomplete intra-alveolar eradication of P. aeruginosa at end of therapy, the CPIS fell comparably at each time point irrespective of the etiological agents. CONCLUSIONS: Alveolar activation of the TF-dependent pathway may be species-specific in VAP and may not be adequately balanced by TFPI. The disparity between clinical response and eradication of P. aeruginosa from the intra-alveolar space suggests the need for biological markers to guide response to therapy.

Aged↗

Pregnancy-associated changes in the hemostatic system.

Pregnancy, from implantation to parturition, presents unique and profound challenges to a women's hemostatic system. During pregnancy, potentially catastrophic bleeding can occur during implantation and endovascular trophoblast invasion of the maternal spiral arteries. The risk of hemorrhage reaches a peak during the third stage of labor when the placenta is shorn from the decidua basalis exposing 120 spiral arteries largely denuded of their smooth muscle, and thus, their ability to constrict in response to injury. These challenges are met by dramatic changes in the local uterine, and systemic hemostatic systems. The net effect of these changes is to increase the efficiency of clotting and to impair fibrinolysis. Unfortunately, they also lead to an increase in the prevalence of venous thromboembolism, which is otherwise uncommon in reproductive age women.

Decidua↗

Nerve sparing radical prostatectomy: effects of hemostatic energy sources on the recovery of cavernous nerve function in a canine model.

PURPOSE: To preserve sexual function following radical prostatectomy, one must avoid injury to the neurovascular bundles (NVBs). In the conventional open surgical technique, the use of energy sources for hemostasis is avoided to prevent damage to the cavernous nerves. In contrast, during laparoscopic radical prostatectomy, electrosurgical and ultrasonic energy sources are frequently used for hemostasis during dissection of the prostate. In this study, we evaluated the acute and chronic physiological effects of various hemostatic energy sources on cavernous nerve function in the canine model. MATERIALS AND METHODS: A total of 12 dogs were divided into 4 groups based on the type of energy source used for hemostasis during unilateral dissection of the NVB. The groups included conventional dissection with suture ligatures (group 1), monopolar (group 2) or bipolar (group 3) electrosurgery and ultrasonic shears (group 4). The contralateral NVB was left undissected as a control. Erectile function was assessed acutely and after 2 weeks of survival by measuring peak intracavernous pressures in response to cavernous nerve stimulation. RESULTS: Following conventional techniques of nerve sparing, the erectile response to nerve stimulation was unaffected. In contrast, the use of energy sources in proximity to the NVB during nerve preservation was associated with a substantial decrease in erectile response both acutely (74% to 91% decrease compared to controls) and after 2 weeks (93% to 96% decrease). CONCLUSIONS: In the chronic canine model, use of hemostatic energy sources in proximity to the prostate during dissection of the neurovascular bundle is associated with a significantly decreased erectile response to cavernous nerve stimulation.

Animals↗

Psychosocial, hemostatic, and inflammatory correlates of delayed poststress blood pressure recovery.

OBJECTIVE: Delayed poststress cardiovascular recovery has been associated with cardiovascular disease risk. This study assessed relationships between systolic blood pressure (BP) recovery, psychosocial risk factors, and delayed recovery of inflammatory and hemostatic variables. METHOD: Data were analyzed from 228 middle-aged men and women from the Whitehall Psychobiology study who performed color/word and mirror-tracing tasks. Systolic BP recovery was assessed as the difference between baseline and levels recorded 40 to 45 minutes poststress. Associations were analyzed with socioeconomic markers (grade of employment, education, income), psychosocial factors (social isolation, hostility, mental health, financial strain), and recovery of heart rate, heart rate variability, von Willebrand factor, factor VIII clotting activity, plasma fibrinogen, and plasma viscosity. RESULTS: Systolic BP was on average 6.19 +/- 9.6 mm Hg higher on recovery than baseline. Delayed BP recovery was associated with lower grade of employment, lower education and lower income independently of age, gender, and systolic BP stress reactivity. Delayed BP recovery was related to social isolation and poor mental health independently of age, gender, socioeconomic position, and task reactivity. Delayed systolic BP recovery was also associated with delayed recovery in diastolic BP, heart rate, factor VIII, and plasma viscosity but not delayed heart rate variability recovery, independently of age, gender, body mass, and task reactivity. CONCLUSION: Socioeconomic and psychosocial risk factors for cardiovascular disease are related to delays in poststress recovery. Delayed systolic BP recovery may be a marker for prolonged responses in hemostatic variables that have a direct influence on cardiovascular disease pathogenesis.

Biomarkers↗

Association between the severity of sepsis and the changes in hemostatic molecular markers and vascular endothelial damage markers.

It is well known that disorders of coagulation and fibrinolysis play a major role in the development of organ dysfunction during sepsis. Furthermore, the importance of the early initiation of anticoagulation therapy for severe cases has been emphasized based on the success of recent clinical trials. The purpose of this study is to search for useful markers for predicting organ dysfunction. Plasma samples were prospectively collected from 78 patients within 48 h after the onset of sepsis. Hemostatic markers and endothelial damage markers were compared between the patients with and without organ dysfunction. The WBC and platelet counts were not different between the groups. In contrast, fibrin/fibrinogen degradation products, D-dimer, thrombin-antithrombin complex, plasmin alpha2-antiplasmin complex, soluble fibrin, and total plasminogen activator inhibitor-1 were significantly higher, and the antithrombin activity and protein C levels were lower in the patients with organ dysfunction. Thus, the changes in the hemostatic molecular markers were associated with organ dysfunction from an early stage of sepsis, and antithrombin and protein C activities were found to be the most reliable markers.

Adult↗

Does the genotype predict the phenotype? Evaluations of the hemostatic proteome.

In this review, the complexity arising from the heterogeneity of the human hemostatic proteome is introduced and discussed with respect to impact on the diagnosis, prophylaxis and therapeutic interventions in thrombotic and hemorrhagic diseases. In the 'healthy' population, coagulation factor levels extend over a 2-4-fold range in concentration. In addition, the qualitative performance of these proteins is governed by many molecular events which are influenced both by genetic instructions which influence post-translational modification and by environmental processes that alter coagulation proteins during circulation. As a consequence, the stimulus-response coupling which follows tissue factor presentation to blood and the subsequent expression of thrombin activity is highly variable even in the 'normal' population. The consequences of this molecular heterogeneity and its potential influence on the diagnosis, prophylaxis and ultimate therapy of coagulation diseases are illustrated. It is the intention of the authors to be provocative; encouraging further investigations to understand the clinical significance of the heterogeneity of the human hemostatic proteome.

Blood Coagulation Factors↗

Effects of older age on fibrin D-dimer, C-reactive protein, and other hemostatic and inflammatory variables in men aged 60-79 years.

BACKGROUND: Previous studies have suggested that several hemostatic and inflammatory variables, which are risk predictors for arterial or venous thrombosis, increase with age. However, there is a lack of data from large population studies for reliable estimates of reference ranges. OBJECTIVES: To establish reliable reference ranges of hemostatic and inflammatory variables for 5-year age groups in older men and their implications for pathogenesis and diagnosis. PATIENTS AND METHODS: A total of 3861 men aged 60-79 years at the 20 years follow-up of the British Regional Heart Study. RESULTS: Several variables increased with age. The greatest median increases between 60-64 and 75-79 years age groups were observed for fibrin D-dimer (91%) and C-reactive protein (CRP) (57%). Significant median increases were also observed for von Willebrand factor antigen (23%), tissue plasminogen activator antigen (11%), factor VIII (10%), and fibrinogen (8%). In contrast, levels of classical cardiovascular risk factors neither decreased nor increased substantially with age, with the exception of systolic blood pressure (median increase 10%). CONCLUSIONS: The exponential increases in risk of arterial and venous thrombotic events in men between age 60 and 79 years (when most such events occur) may be related in part to increasing activation of blood coagulation, fibrinolysis, and inflammation; possibly related to the increasing inflammatory burden of both atherosclerotic and non-vascular disease. These increases also have implications for diagnosis of suspected acute venous thromboembolism (D-dimer), and recently proposed screening for prediction of coronary heart disease risk and detection of occult disease (CRP).

Aged↗

Thrombolysis vs. bleeding from hemostatic sites by a prourokinase mutant compared with tissue plasminogen activator.

BACKGROUND: A single site mutant (M5) of prourokinase (proUK) was developed to make proUK less vulnerable to spontaneous activation in plasma. This was a problem that seriously compromised proUK in clinical trials, as it precluded proUK-mediated fibrinolysis at therapeutic concentrations. METHODS AND RESULTS: After completing dose-finding studies, 12 anesthetized dogs with femoral artery thrombosis were given either M5 (2.0 mg kg(-1)) or tissue plasminogen activator (t-PA) (1.4 mg kg(-1)) by i.v. infusion over 60 min (20% administered as a bolus). Two pairs of standardized injuries were inflicted at which hemostasis was completed prior to drug administration. Blood loss was quantified by measuring the hemoglobin in blood absorbed from these sites. Thrombolysis was evaluated at 90 min and was comparably effective by both activators. Rethrombosis developed in one t-PA dog. The principal difference found was that blood loss was 10-fold higher with t-PA (mean approximately 40 mL) than with M5 (mean approximately 4 mL) (P = 0.026) and occurred at more multiple sites (mean 2.7 vs. 1.2). This effect was postulated to be related to differences in the mechanism of plasminogen activation by t-PA and M5 in which the latter is promoted by degraded rather than intact (hemostatic) fibrin. In addition, two-chain M5 was efficiently inactivated by plasma C1 inactivator, an exceptional property which helped contain its non-specific proteolytic effect. CONCLUSIONS: Intravascular thrombolysis by M5 was accompanied by significantly less bleeding from hemostatic sites than by t-PA. This was attributed to the proUK paradigm of fibrinolysis being retained at therapeutic concentrations by the mutation.

Animals↗

The fat mouse. A powerful genetic model to study hemostatic gene expression in obesity/NIDDM.

In this chapter, we summarize our studies on plasminogen activator inhibitor 1 (PAI-1), tissue factor, and transforming growth factor beta (TGF-beta) expression in obesity, using genetically obese mice as a model. These studies emphasize the key role played by the adipocyte, a cell whose numbers, size, and metabolic activity are grossly altered in obesity/NIDDM. They also implicate multiple cytokines, hormones, and growth factors in the abnormal expression of these and perhaps other hemostatic genes by adipocytes in obesity/NIDDM. These studies demonstrate that tumor necrosis factor alpha (TNF-alpha) plays a central role in the expression of hemostatic genes in this disorder.

Adipocytes↗

Hemostatic abnormalities in dogs with hemangiosarcoma.

The hemostasis profiles of 24 dogs with histologically confirmed hemangiosarcoma were prospectively evaluated. Microangiopathic hemolysis was defined as the presence of schistocytes; disseminated intravascular coagulation was defined as 1) thrombocytopenia, 2) fibrin(ogen) degradation products greater than 10 micrograms/mL, 3) prolongation of one or more coagulation times (activated partial thromboplastin time or one-stage prothrombin time) by greater than 25% of the control, 4) fragmented red blood cells (greater than or equal to 1+ based on a semiquantitative grading scale), and 5) fibrinogen less than or equal to 80 mg/dL. Three of the five criteria listed above had to be met for disseminated intravascular coagulation to be diagnosed. Fifty percent of the dogs were considered to have disseminated intravascular coagulation at presentation. Thrombocytopenia was present in 75% of the dogs and was the most common abnormality. The mean platelet count was 137,800/microL. Twenty-five percent of the dogs died as a result of the hemostatic abnormalities. Only 12% of the dogs had microangiopathic hemolysis without other evidence of disseminated intravascular coagulation. Hemostatic abnormalities are present in many dogs with hemangiosarcoma at the initial clinical presentation and represent an important clinical finding.

Animals↗

Hemostatic disorders in feline immunodeficiency virus-seropositive cats.

The hemostatic function of 40 feline immunodeficiency virus (FIV) seropositive and 8 FIV and feline leukemia virus (FeLV) seropositive cats was evaluated and compared with reference values from 30 clinically healthy cats. The FIV-positive cats were divided into 3 groups: group I included asymptomatic carriers; group II comprised sick FIV-infected cats with illnesses not likely to influence the hemostatic system; and group III included FIV-positive cats with diseases potentially associated with coagulopathies. Platelet counts in FIV/FeLV-infected cats were significantly lower than in healthy cats (P < .003), whereas the differences in the 3 groups of FIV-positive cats were variable (group I, P = .009; II, P = .05; III, P = .09). Thrombocytopenia (< 145,000 platelets/microL) was present in 4 FIV-positive and 3 FIV/FeLV-positive cats. Platelet aggregation induced by collagen (0.5 and 0.25 micrograms/mL), adenosine diphosphate (ADP) (1 and 0.6 mumol/L), and thrombin (0.4 and 0.25 IU/mL) was not significantly different from that of healthy cats. The plasma coagulation system was evaluated by measuring one-stage prothrombin time (OSPT), activated partial thromboplastin time (APTT), thrombin time, fibrinogen concentration, coagulation factor assays, fibrinogen and fibrin degradation products (FDP), and plasma exchange test. The OSPT was similar in FIV-seropositive cats and in the healthy control group. Cats with FIV infection, however, had markedly shorter clotting times than healthy cats when using a modified test system (P < .05).(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗