Autologous fibrin glue: the last step in operative hemostasis.

BACKGROUND: Fibrin glue may be the perfect hemostatic agent for operative use as it seals in minutes, has no tissue toxicity, reabsorbs, and promotes local tissue growth and repair. Use in the United States has been limited because of lack of Food and Drug Administration approval of the commercial homologous products, lack of a concentrated source of fibrinogen, and because of the potential for viral transmission, particularly hepatitis, with pooled homologous plasma and cryoprecipitate-based methods. Autologous fibrin glue (AFG) obviates these problems. METHODS: During the past year, we obtained AFG through the same routine predonation procedure as with red blood cells before major elective surgery. Intraoperatively, we made AFG from the platelet-rich plasma derived from the Plasma-Saver. Our experience has been with 36 patients undergoing aortic, thoracoabdominal, and thoracic surgery, as well as patch graft angioplasty cases. RESULTS: Fibrin glue formation mimics the final stage in the coagulation cascade. The AFG from predonation acts more like an epoxy glue, while the AFG made during surgery is less viscous and acts more like a sealant because of the lesser concentration of fibrinogen in platelet-rich plasma. In emergencies, however, the intraoperative method is obviously the only choice available, and it is a useful adjunct to hemostasis at the end of the procedure. The technique will be described. CONCLUSION: This relatively new approach to hemostasis should gain popularity because it is easy and fairly inexpensive to produce, and because the patient's own blood is used.

Postoperative salvage: a technological advance in the 'washed' versus 'unwashed' blood controversy.

AT techniques are becoming the standard of care in surgery. Some controversy exists regarding the use of washed versus unwashed salvaged blood, as discussed. The literature concerning this unresolved problem has been reviewed. Because blood collected intraoperatively has undergone clotting and lysis, no beneficial coagulation effects can be expected with reinfusion of unwashed blood. If, additionally, potentially harmful effects may result, a strong argument can be made for washing the RBCs free of the activated clotting factors before reinfusion. Theoretically, this has strong appeal. In practice, it is recognized that patients who are in good health can tolerate small volume reinfusion of unwashed blood, particularly if they have been anticoagulated. In weighing the options and the risk/benefits equation, it would appear that washing the RBCs is generally the safest course. Now, it seems that there is a definite trend toward washing the red cells before reinfusion. Technological advances make this possible. The Haemolite 2 is a small, compact, portable autotransfusor that provides a safe, practical, and efficient means of recycling the patients own blood in the postoperative salvage setting.

Postoperative Salvage: Technological Advance in the "Washed vs Unwashed" Blood Controversy.

In the past decade, the standard of care for transfusion in major surgery has evolved in most modern hospitals to auto transfusion (AT) techniques. In several states, in fact, it has become a law of "informed consent". The surgeon must present the risks of homologous transfusion and discuss alternatives and options with the patient. Presently, three standard transfusion options are preoperative donation, intraoperative salvage, and postoperative salvage. This article will address aspects of the latter option - post-operative salvage. Present technology has made significant advances over older collection systems. The Haemolite® 2 is a compact, portable cell-saver well-suited for this purpose for reasons to be presented. Postoperative blood salvage is not a new concept. The Sorenson Device (Sorenson Research Co., Salt Lake City, UT) has been used extensively for many years to collect blood from mediastinal and chest tubes following cardiovascular and thoracic surgery. Similarly, the Soleotrans collection device (Solco-Basle, Rockland, Mass) has been used in vascular and orthopedic cases for blood salvage. Other devices such as the Pleura-Vac and Auto-Vac share the same features: collection of shed blood in low volume, filtration, and reinfusion without washing the RBC's. (Figure I) The omission of this processing step is the major difference in comparison with the Haemolite® 2 that separates the RBC's by centrifugal washing. (Figure 2) Presently this "washed vs unwashed" aspect is the source of controversy, which this article will attempt to clarify.

Avoiding coagulopathy in vascular surgery.

The possibility of coagulopathy can be minimized by attending to certain general perioperative details to avoid hypothermia, hypotension-shock, and multiple transfusions. In this paper, we present our protocol for avoiding coagulopathy in vascular surgery. In the past 1 1/2 years, we have used perioperative plasmapheresis in 204 patients undergoing cardiac or aortic peripheral vascular surgery. Autologous platelet-rich plasma is transfused at the completion of the operation after heparin reversal. Our data show an approximate 50% reduction in homologous blood product requirement. Seventy-five percent of patients having aortic surgery received no homologous blood products during their hospital stay. For those undergoing cardiac surgery, there has been about a 45% reduction in the use of homologous blood products. In our experience, autologous platelet-rich plasma not only decreases the risk of transmittable disease, but promotes hemostasis.

The plasma collection system: a new concept in autotransfusion.

We have used the Haemonetics Cell-Saver autotransfusion technique in over 6,500 cases since 1979, salvaging more than 11,000 units of packed red blood cells. Major utilization has been in cardiac, vascular, and orthopedic cases. Coagulopathy associated with hypothermia, shock, multiple transfusions, and the autotransfusion technique, which removes clotting factors and platelets, often necessitated use of fresh-frozen plasma and platelet packs postoperatively to control bleeding and clotting problems. However, this defeats the prevention of disease transmission, transfusion reaction, and autoimmunization. Haemonetics has recently developed a plasma collection system which salvages up to 1,000 cc of platelet-rich plasma. Early experience suggests this technique will not only decrease the incidence of postoperative bleeding but further decrease the use of homologous (bank) blood and components. A step-by-step guide to the plasma collection system is discussed. The plasma collection system augments the present autotransfusion technique that conserves red blood cells, thus making complete autologous blood transfusion a reality.

The cell-saver and autologous transfusion: an underutilized resource in vascular surgery.

The vascular surgeon's best resource for blood transfusion is the patient's own blood. It is readily available for recycling, already precisely typed and crossmatched, and without the risk of transfusion-related diseases such as hepatitis and AIDS. The relative ease, safety, and cost-effectiveness of autologous blood transfusions, intraoperative autotransfusions, and postoperative autotransfusions has been shown in our hospital experience with 320 cases and in the literature. We predict that autologous donor blood and autotransfusion will soon be widely accepted and utilized as the best and safest method of blood replacement.

Arterial thromboembolism. A 20-year perspective.

Our experience with 739 patients with lower extremity thromboembolism since the advent of the balloon catheter has led us to several important observations: As the etiology has shifted from rheumatic to atherosclerotic, we treat a more complex group of patients, one fourth of whom have severe, preexisting peripheral occlusive disease. Early diagnosis and treatment is essential to decrease the mortality and morbidity, which has ranged about 25% +/- 10%. Anticoagulation must be continued in the postoperative period, accepting wound hematomas as a fair "trade-off" to prevent recurrent embolus and distal thrombosis in areas inaccessible to the catheter. Postoperative use of heparin "buys time" to further assess marginal results of embolectomy allowing arteriography and careful planning of secondary operations to assure not only a viable but a functional limb. There is little mention in the literature to emphasize this approach, which we think is essential for long-term salvage. Early in the series, patients were treated with heparin or embolectomy alone. There were 161 secondary operations in 135 patients following embolectomy consisting of repeated thromboembolectomy, popliteal exploration, sympathectomy, bypass graft(s), angioplasty, and endarterectomy. Additionally, 44 patients had a direct attack correcting the cardiac source of their embolism. Our overall mortality (12%) and limb salvage (95%) shows marked improvement compared with earlier reports. Therefore, we recommend combined embolectomy and heparin as the primary choice of therapy.

The treatment of the expectant mother with deep venous thrombosis.

Experience with 12 expectant mothers with DVT from 1978 to 1983 supports heparin therapy. After early experience with four patients with various doses of intravenous and subcutaneous mini-heparin both in and out of the hospital, we have selected a program of outpatient, self-administered adjusted subcutaneous heparin. There has been no maternal or fetal mortality. There have been no serious bleeding or post-phlebitic complications, although two patients have had flare-ups of superficial phlebitis during the follow-up over the last four-and-a-half years. There have been three subsequent pregnancies, two of which were first trimester miscarriages and one uneventful term delivery of a normal infant.

Polytetrafluoroethylene vein composite grafts across the knee.

Fifteen Gore-tex vein composite femoral-popliteal artery bypass procedures were performed during the four year period of December 1975 to December 1979. Nine were performed for salvage of the limb and six, for incapacitating claudication. Preoperatively, all patients had an arteriographic evaluation of the outflow tract. CPR by the life-table method was 63 per cent at six years. Early failures were three occlusions within two months in patients with poor outflow. One late occlusion occurred at 16 months, and the limb was salvaged with a femoral tibial bypass graft. Another late occlusion was treated by thrombectomy at 24 months with continued patency. Late revision was carried out in one patient at seven months. This consisted of repair of a stenosis of the distal popliteal artery with salvage of the graft. Only two of ten grafts available for evaluation beyond one year have become occluded. All patients operated upon for claudication or with good runoff have patent grafts. On the contrary, none of the grafts to an isolated popliteal segment remained patent. When there is not sufficient autogenous saphenous vein available for femoral-popliteal bypass, the ready availability of a synthetic graft makes it an attractive choice. Nevertheless, our 63 per cent CPR at six years strongly suggests that the composite graft is a durable option.

Value of postoperative heparin therapy in peripheral arterial thromboembolism.

The experience with 359 patients with arterial thromboembolism from 1963 to 1982 has been reported. Combined operative and anticoagulant therapy appears the most beneficial form of treatment. Treatment with heparin after catheter embolectomy was associated with a decrease in mortality (7.6 percent), number of amputations (5 percent), and recurrent emboli (6 percent). Serious wound complications occurred less frequently than anticipated (8 percent). We advocate prompt arteriography and revascularization procedures to ensure long-term limb function after initial embolectomy for salvage, if the result is less than optimal or expected. Postoperative heparin seems to buy time in marginal cases, enabling secondary operations to ensure a satisfactory outcome in most patients.

Management of deep venous thrombosis and pulmonary embolism during pregnancy.

Despite venous stasis and a hypercoagulable state during pregnancy, the reported incidences of deep venous thrombosis and pulmonary embolism are remarkably low, about 1 in 2,000 and 1 in 10,000 cases, respectively. Mortality from antepartum thromboembolism has been reported in about 15 percent of untreated patients and less than 1 percent of treated patients. Adequate anticoagulant therapy significantly reduces maternal mortality and decreases postpartum morbidity. The proper anticoagulant agent for use during pregnancy has been widely debated. Coumarin compounds pass through the placenta and into the fetus. Hemorrhagic complications in the fetus are uncommon if prothrombin times are carefully controlled and if the drug is discontinued before delivery. However, coumarin during the first trimester has the teratogenic hazard of producing chondrodysplasia punctata. Heparin, in contrast, does not cross the placental barrier and is considered more effective treatment for deep venous thrombosis; however, long-term intravenous administration during pregnancy has been considered both impractical and possibly hazardous due to the risk of osteoporosis after 6 months of therapy. In our study, a combined regimen of intravenous and subcutaneous heparin was used successfully in four women with deep venous thrombosis. One patient who had recurrent embolization while on adequate intravenous heparin underwent vena caval clipping and had an uneventful Cesarian section at term with a normal infant. Another patient also underwent Caesarian section with a normal infant, while the other two women had normal vaginal deliveries at term. Miniheparin therapy was continued for 3 months postpartum, followed by long-term aspirin and Ascriptin therapy. Carefully controlled heparin therapy in a pregnant woman with deep venous thrombosis both safe and beneficial for mother and fetus.

Coagulopathy associated with peritoneovenous shunting.

Le Veen shunts successfully alleviated ascites in 19 of 24 patients (79 percent). Clinical clotting typical of disseminated intravenous coagulation occurred in nine of these patients (37 percent) and was fatal in seven (78 percent). Laboratory findings suggesting disseminated intravenous clotting were present in five other patients (21 percent) but were not associated with troublesome bleeding. Coagulopathy was reversed in 7 of 14 patients (50 percent), if the shunt was ligated and supportive measures were taken early in the postoperative course. Failure to recognize or take immediate action resulted in progressive disseminated intravenous clotting associated with a mortality of 50 percent (7 of 14 patients).