Autologous fibrin glue with growth factors in reconstructive maxillofacial surgery.

The aim of this paper was to describe a method for the preparation of autologous fibrin glue with platelet growth factors and to report its use with particulate cancellous bone in reconstructive maxillofacial surgery. The fibrin glue is a two-component glue, where the one component is a concentrated fibrinogen solution with platelet growth factors and the other component is a thrombin solution. Both components were produced from the patients own blood, thus making the glue entirely autologous. The glue was prepared from platelet rich plasma separated from 200 ml of the patient's blood prior to the operation. The fibrinogen in the glue was precipitated from the platelet rich plasma by ethanol precipitation at low temperature and separated together with the platelets by centrifugation. Raising the temperature to 37 degrees C redissolved the precipitate. The thrombin solution in the glue was produced from prothrombin precipitated from 10 ml of the platelet rich plasma by lowering the pH and the ionic strength. The precipitate was separated by centrifugation and dissolved in a calcium ion solution. Increasing the pH to neutral value induced activation to thrombin. Preparation of the fibrin glue was performed in the blood bank within 60 to 90 min with the use of standard equipment. The outcome from 200 ml of blood was approximately 8 ml of fibrin glue: 6 ml fibrinogen to be coagulated with 2 ml of thrombin. The glue had a fibrinogen concentration of approximately 12 times the value in platelet rich plasma and the concentration of growth factors was approximately eight times the value in platelet rich plasma. We have used this glue successfully with particulate bone grafts for reconstructive purposes within the oral and maxillofacial field. It might as well be applied to other surgical areas. Whenever larger amount of the glue will be needed, a whole unit of blood may be taken from the patient, and the red cells re-transfused to the patient during or after the operation.

Prevention of air leakage by spraying vivostat fibrin sealant after lung resection in pigs.

STUDY OBJECTIVES: To evaluate Vivostat fibrin sealant in the prevention of air leakage after experimental lung resection in pigs. DESIGN: Randomized study. SETTING: University laboratory. METHODS: Six Landrace pigs were operated on in both lungs through a median sternotomy. Five different resection sites were created in each lung. INTERVENTION: Randomization was performed to either application of Vivostat fibrin sealant (ConvaTec; Skillman NJ) or human albumin 20% (control) at the resection sites. The lung parenchyma was occluded with a soft clamp for either 1, 2, 5, or 10 min in the treatment group and 10 min in the control group. After removal of the clamp, the lung was ventilated with an increasing intrabronchial pressure of 20, 30, and 45 cm H(2)O for 2 min at each step. RESULTS: At inspiratory pressures of 20 and 30 cm H(2)O air leaks were found in the control group but not in the Vivostat group (p < 0.001). At an inspiratory pressure of 45 cm H(2)O, there were two small air leaks in the Vivostat group at each clamping time (four at 5 min), compared with five small and seven large leaks in the control group. Analysis of the data after 10 min of clamping showed that the Vivostat group was superior to the human albumin group (p = 0.002). CONCLUSIONS: This randomized study shows that Vivostat fibrin sealant is effective in preventing air leakage after small lung resections in pigs, even at high inspiratory pressures.

Repair of experimental atrial rupture with fibrin glue.

Ten cases of experimental atrial rupture were created in five pigs by cutting into both atria. The defects measured approximately 3.0 x 1.0 cm. Bleeding was stopped by applying a tangential clamp and the defect in the atrium was sealed with fibrin glue (mean volume 2.0 ml, range 1.5-2.5 ml) with a mean fibrin concentration of 23 mg/ml. The mean pressures in the atria were 11 cmH2O in the left and 10 cmH2O in the right atrium. The clamp was released after 5 min and the atria were observed for bleeding for 30 min. In four animals, immediate haemostasis was obtained. In one animal, both atria leaked after release of the clamp because too little fibrin glue was applied, but complete haemostasis was obtained at a second attempt. All experimental atrial defects could be sealed with fibrin glue (P = 0.03), and we believe, based on our experimental results, that fibrin glue may have a place in emergency cases to improve the management of atrial injury. In conclusion successful repair of experimental atrial rupture was performed by the use of fibrin glue.

Autologous fibrin glue for sealing vascular prostheses of high porosity.

Thirty high-porosity double-Velour vascular prostheses were sealed with fibrin glue, the fibrinogen in the glue being prepared from citrated plasma by ethanol precipitation. After such preparation the prostheses were blood-tight at a pressure > 300 mmHg. Using a fibrin concentration of 13 mg/ml (obtained by dilution of the fibrinogen solution) the prostheses were blood-tight at a minimum pressure of 150 mmHg, which is suitable for clinical use. Sufficient fibrin glue can be prepared from 44-88 ml of the patient's blood to seal most types of high-porosity vascular prosthesis used clinically. The fibrin-sealed grafts have good handling characteristics because they are soft, pliable and non-sticky. The use of autologous fibrin glue has obvious safety advantages by preventing both transmission of viral diseases and immunological reactions.

Important factors influencing the strength of autologous fibrin glue; the fibrin concentration and reaction time--comparison of strength with commercial fibrin glue.

Fibrin glue was prepared from citrated plasma of human donors by means of ethanol. The outcome was a fibrinogen concentrate with a mean concentration of 43 mg/ml. The fibrinogen was converted to fibrin by the addition of 0.3 part of thrombin solution, 150 NIH U/ml, containing 100 mM calcium chloride. In a rat model full-thickness skin grafts were sealed with the glue, and the adhesive strength was measured at different fibrin concentrations, and after a variable reaction time, and compared to commercial fibrin glue (Tisseel). The strength of ethanol-prepared glue was directly proportional to the fibrin concentration, and increased rapidly within the first minutes of the reaction time. The strength of the commercial glue could be obtained with autologous fibrin glue at the same fibrin concentration.

Preparation of autologous fibrin glue from pericardial blood.

To salvage patients' blood and improve hemostasis in cardiac operations, autologous fibrin glue was prepared in a new way by means of ethanol from pericardial blood. The yield from 44 mL of blood was 2.1 +/- 0.7 mL (mean +/- standard deviation) of fibrinogen concentrate with a concentration of 25.1 +/- 7.5 mg/mL; 2.7 mL of two-component glue was obtained after the addition of thrombin solution. The glue has the advantages of safety from transmission of viral diseases and from immunologic reactions.

Histomorphological evaluation of wound healing of rabbit oviduct after microsurgical reanastomosis with the use of autologous fibrin adhesive, human fibrin adhesive or poly-glycolic acid suture.

The morphology of the healing process of microsurgical reanastomosis of the rabbit oviduct with the use of fibrin adhesive, autologous and heterologous, and conventional sutures is described. Both oviducts in 48 rabbits were cut and reanastomosis were performed. The rabbits were killed at different intervals after the operations, ranging from 2 h to 28 days, and the anastomoses were evaluated by histomorphological examination. The autologous fibrin adhesive was absorbed after a week and an uncomplicated healing was observed. Heterologous fibrin adhesive caused a granulomatous inflammation interpreted as an immune reaction of the host to the foreign protein, and conventional suturing resulted in severe tissue damage with an intensive inflammatory reaction.

A simple method of preparation of autologous fibrin glue by means of ethanol.

We describe herein a new system for the preparation of autologous fibrin glue by means of ethanol. The system produces a good yield of fibrin glue with a high concentration of fibrinogen in a short period of time, making the glue an efficient hemostatic agent and surgical sealant, and autologous fibrin glue has the obvious advantages of safety from transmission of viral agents and from immunologic reactions.

The use of autologous fibrin adhesive in skin transplantation.

A method for preparing concentrated fibrinogen for use in autologous fibrin adhesive is described. The adhesive was used in seven patients with eight chronic leg ulcers. The ulcers were divided into two equal sections, and the adhesive was used to seal split-thickness skin grafts in one section, while no adhesive was used to seal the grafts in the other section of the ulcer. The strength of adhesion was measured 3 1/2 minutes after transplantation of a 1-cm2 test split-thickness skin graft. In the sealed grafts, the breaking strength varied from 12 to 26 gm. In the unsealed transplants, the strength was less than 5 gm. The take of the meshed split-thickness skin grafts was equal in the sealed and the unsealed areas, varying from 90 to 100 percent. Biopsies taken on day 7 showed a splitting between graft and recipient bed in half the unsealed grafts; none of the sealed grafts showed splitting, indicating a more stable graft in the sealed areas. Biopsies taken on day 21 showed no difference between sealed and unsealed grafts.

[Autologous fibrin glue--preparation and clinical use]. / Autolog fibrinklaeber--fremstilling og klinisk anvendelse.

Fibrin tissue adhesive is a tissue adhesive in which the two components are fibrinogen concentrate and a thrombin solution, respectively. In autologous fibrin tissue adhesive, the fibrinogen is prepared from the patient's own blood in contrast to the fibrin adhesive available commercially where the fibrinogen is prepared from pooled donor plasma. In 42 heart and lung operations, autologous fibrin tissue adhesive prepared by a new method was employed in which the fibrinogen is separated from the patient's own plasma by precipitation with ethanol. Either 44 or 88 ml blood was employed for concentration of the fibrinogen. This resulted in 2.5 ml and 4.9 ml fibrinogen concentrate which was mixed with 0.3 parts of thrombin solution containing calcium and aprotinin (fibrolysis inhibitor) so that the total volumes of tissue adhesive were 3.3 ml and 6.4 ml. Production of autologous fibrin tissue adhesive is uncomplicated and takes less than 90 minutes. A new method of production of autologous tissue adhesive based on ethanol is described. The fibrin tissue adhesive prepared in this manner has a high concentration of fibrinogen and is effective as a haemostatic and as an adhesive in surgical operations and it has the further advantage that it is not associated with the risk of transmission of viral or for immunological reactions.

Autologous fibrin glue--preparation and clinical use in thoracic surgery.

Autologous fibrin glue was used in 20 patients undergoing lung resection to reduce pulmonary air leaks and improve hemostasis. The fibrinogen in the glue was prepared by ethanol precipitation of plasma separated from 88 ml of the patient's blood. The mean volume of fibrinogen concentrate +/- SD was 4.9 +/- 0.5 ml with a fibrinogen concentration of 28 +/- 5 mg/ml. The yield obtained by the separation was 81% +/- 9%. One part of fibrinogen concentrate was converted to solid fibrin by means of 0.3 parts of thrombin solution. The outcome was 6.4 ml of two-component fibrin glue. The preparation was performed in a closed system to ensure sterility, and was completed within 90 min. Pulmonary air leak decreased following sealing of the resection lines with autologous fibrin glue and the hemostasis was effective. No adverse effects were observed, and all cultures from the glue were negative. Autologous fibrin glue has the obvious advantages of safety from transmission of viral diseases and from immunological reactions. In summary, we report a new technique for preparing autologous fibrin glue with a high concentration of fibrinogen making it a safe and effective sealant of pulmonary air leak and hemostatic agent in thoracic surgery.

Autologous fibrin sealant in reconstructive rabbit oviduct microsurgery.

A simple method for preparing concentrated fibrinogen for use in a tissue adhesive system is described. Approximately 75% to 80% of the plasma fibrinogen can be separated and concentrated within 45 to 60 minutes from a small blood sample collected from the patient before the operation. Autologous fibrinogen prepared by this method was evaluated in reconstructive microsurgery of the rabbit oviduct.

Fibrinogen prepared from small blood samples for autologous use in a tissue adhesive system.

The two-component tissue adhesive system where the one component is a concentrated human fibrinogen solution and the other component is a thrombin solution containing Ca2+ is becoming increasingly important in surgery. In the commercially available tissue adhesive, the fibrinogen is separated from pooled plasma. The risk of transmitting foreign immunogens and viruses, always present when foreign biological materials are used, will be eliminated if the fibrinogen is separated from the patient's own blood. A method using ethanol precipitation is described for preparing a concentrated fibrinogen solution from plasma separated from small amounts of blood. The method is fast, the final product can be obtained within 30-60 min after collection of the blood. The recovery is compared with the recovery obtained by separating the fibrinogen with ammonium sulfate precipitation and with cryoprecipitation. The method using ethanol is by far the most profitable, and the product is evaluated by experimental liver surgery in pigs.

The effect of citrate, calcium, and magnesium ions on the potassium movement across the human platelet membrane.

The intracellular K+ concentration in platelets is reduced during storage in citrated plasma. As shown previously, pH has a marked influence on this reduction. The effect of citrate and Ca2+ and Mg2+ on the K+ permeability of the membrane and on the active K+ transport across the membrane was investigated. Platelets were incubated in dialyzed plasma at 37 degrees C, pH 5.5 to 7.9, with and without added Ca2+ and Mg2+ and citrate. After 60- to 120-minute incubation, a steady state was reached, and ouabain was added to inhibit the active K+ transport. In the pH interval 5.5 to 6.2 citrate, Ca2+ and Mg2+ had no influence on either the active K+ transport or the K+ permeability. Between pH 7.1 and 7.9, Ca2+ and Mg2+ decreased the permeability, whereas citrate increased it. At pH 7.9, citrate had a depressing effect on the active transport. These results indicate that a low citrate concentration and a pH below 7 are important for maintaining a high intracellular K+ of platelets during storage in plasma.

The effect of pH on the K+ movements across the human platelet membrane during in vitro incubation in plasma at 37 degrees C.

(1) The K+ concentration in human blood platelets, separated at room temperature from citrated platelet-rich plasma at pH 7.1, was 88 mumol/10(11) platelets. (2) Changing pH in the plasma altered immediately the intracellular K+ concentration in platelets. An equilibrium was reached within 60--90 min and no further change was observed during the next 90 min. The maximum value was found at pH 6.0--6.4. (3) The velocity of passive K+ efflux varied with pH, having a minimum value at pH 6.0--6.4. Increasing the pH to 7.9 accelerated the velocity by a factor of 15. This was found in platelets incubated with ouabain to inhibit the active (Na+, K+)-pump.

Effect of Pentagastrin, secretin, and cholecystokinin on gastric secretion of pepsin in man.

In eight volunteers the effect of pentagastrin (0.15, 1.0 and 6.0 microgram/kg body weight/h), secretin (0.5 and 1.0 clinical units/kg b.w./h), and cholecystokinin (CCK) (0.5 and 1.0 Ivy dog units/kg b.w./h) on the gastric secretion of pepsin was investigated to ascertain whether interaction occurred. A high intraindividual variation was found, and also a significant washout of pepsin in the initial period after stimulation. Pepsin secretion was stimulated after pentagastrin (50% above basal level) and even more after secretin (75%-200% above basal level), whereas no stimulation but a tendency for depression was seen after CCK. With the doses of gastrointestinal hormones used in this investigation, no interaction between secretin and CCK on gastric secretion of pepsin in man was demonstrated.

Measurement of duodeno-gastric reflux in dogs.

For the elaboration of a formula estimating the reflux volume of duodenal secretion into the stomach, gastric and duodenal secretion have been studied during pentagastrin and secretin stimulation. In the stimulated gastric secretion the concentration of sodium varied with the secretion rate, whereas the concentration of chloride was nearly constant. The concentration of sodium in duodenal juice was constant, but the chloride concentration dropped significantly during secretin stimulation. Secretin induces duodenal reflux. When duodenal reflux occurs, a substantial amount of the sodium in gastric juice is attributable to intruding duodenal juice. The formula gives the duodenal reflux volume in 15-min samples on the basis of the sodium in gastric secretion and in the duodenal juice. A concentration of sodium in samples of gastric juice twice exceeding the concentration of sodium in maximally stimulated gastric secretion (8 +/- 2 mmol/l, mean +/- S.D.) may suggest 'contamination' of the samples with duodenal juice. The present formula allows for quantitative determination of this 'contamination.'

The influence of acetylsalicylic acid (aspirin) on gastric mucosal content of energy-rich phosphate bond.

The mucosal content of adenosine triphosphate, adenosine diphosphate and adenosine monophosphate in mini-pig corpus gland area and in pyloric gland area was examined after aspirin ingestion in acute experiments and after ingestion for several weeks. Ingestion of aspirin led to a statistically significant decrease of adenine nucleotide content in corpus gland and in pyloric gland area. An inverse correlation between the pH of the aspirin suspensions and the size of the decrease was established in the short-time experiments. In non-affected pyloric gland area mucosa and adenine nucleotide content was significantly lower than in the corpus gland area. Pyloric mucosa was more susceptible to aspirin-induced lowering of adenine nucleotide content than was the corpus mucosa. Prolonged aspirin ingestion led to statistically significant reductions of adenine nucleotide pool. The findings explain the decrease in mucous secretion and in acid secretion demonstrated in several studies. The finding of lower and more susceptible adenine nucleotide pool in the pyloric area might be the explanation for the preponderant occurrence of aspirin ulcerations in this region.

Salicylate- and aspirin-induced uncoupling of oxidative phosphorylation in mitochondria isolated from the mucosal membrane of the stomach.

The hypothesis that the damaging effect on the stomach mucosa of salicylic acid and its derivatives is ascribable to an uncoupling of oxidative phosphorylation has been investigated by testing of mitochondria isolated from the corpus gland area of mini-pig gastric mucosa. Mitochondria, influenced by salicylate or acetylsalicylate (0.7-5.6 mmol/l), demonstrated increased respiration rate, decreased respiratory control ratio, and decreased P/O ratio when tested in vitro. Uncoupling of oxidative phosphorylation occurred at a salicylate concentration between 3.5 and 5.6 mmol/l.