The use of autologous platelet and plasma products in salvage neck dissections: a prospective clinical study evaluating early and late wound healing.

OBJECTIVES: To evaluate the effect of autologous platelet and plasma adhesives (APA) on postoperative drainage and soft-tissue fibrosis following neck dissections. DESIGN: This was a blinded comparative prospective cohort study done as two parts: part one evaluated early post-surgical outcomes and part two evaluated late tissue fibrosis. METHOD: Salvage neck dissections were stratified into two groups based on severity of prior treatment. High risk patients were defined as those who had previously undergone chemoradiation therapy and autologous platelet adhesives were administered to the surgical wound intraoperatively. The low risk group consisted of patients undergoing salvage neck dissections following radiation only and acted as controls. Part one evaluated postsurgical wound drainage as the primary outcome as well as length of hospital stay and complications. Part two evaluated late postoperative tissue fibrosis by comparing neck skin using the Cutometer. R2 and F0 were the specific Cutometer parameters for quantifying the viscoelastic properties of the skin. RESULTS: Postoperative wound drainage was significantly less (253.7 vs. 345.8) in the autologous platelet adhesive group as compared to the control group (p less than 0.03). Length of stay in the APA group versus the control group was 3.13 and 3.86 days respectively (p less than 0.004). Both R2 and F0 measurements showed improved viscoelastic properties of the skin in the APA group (R2 p less than 0.05, F0 p less than 0.05). CONCLUSIONS: APA application following salvage neck dissections may reduce early postperative wound drainage and improve long-term skin quality.

Allogeneic single-donor cryoseal produced from fresh-frozen quarantine apheresis plasma as alternative for multidonor or autologous fibrin sealants.

BACKGROUND: Fibrin sealant is a human blood product consisting of two components: cryoprecipitate and thrombin. Commercial fibrin sealants are produced from multidonors, increasing the viral risk, and contain fibrinolytic inhibitors such as tranexamic acid or bovine aprotinin. Autologous fibrin sealants reduce the viral risk and are mostly produced during a surgical procedure or well in advance. Alternatively, the allogeneic single-donor fibrin sealant cryoseal can be used. In this study cryoseal was characterized and the manufacturing consistency of the production process was investigated. STUDY DESIGN AND METHODS: Cryoseal was produced from plasma collected on apheresis machines using a commercial device. In a research setting the protein composition and recovery were determined. Also, the manufacturing consistency of the production process was tested in a research setting as well as in a routine setting. RESULTS: In the research setting all produced cryoseal met the quality control requirements of a clotting time of less than 10 seconds and the presence of Factor (F)XIII (qualitative). In the routine setting, one procedure per year did not meet these requirements. The protein composition showed the following mean ± standard deviation (%recovery) results: thrombin 25.7 ± 11.1 IU/mL, fibrinogen 19.9 ± 4.6 (15%) mg/mL, FVIII 15.6 ± 5.4 (44%) IU/mL, FXIII 2.7 ± 0.7 (6%) IU/mL, and plasminogen 1.8 ± 0.2 (4%) U/mL. In both research and routine settings the production process resulted in a consistent product. CONCLUSION: The cryoseal manufacturing process resulted in a consistent product, which meets the predetermined specifications. The single-donor origin and the absence of fibrinolytic inhibitors make cryoseal a good alternative for multidonor and autologous fibrin sealants.

A new fibrin sealant from Crotalus durissus terrificus venom: applications in medicine.

Fibrin sealant, a widely available tissue adhesive, has been used since 1940 in a variety of clinical applications. Commercially available fibrin sealant products are synthesized from bovine thrombin and human fibrinogen, which may transmit infectious diseases, and recipients may also develop antibodies against bovine thrombin. Bearing these disadvantages in mind, a new fibrin sealant was developed in 1989 by a group of researchers from the Center for the Study of Venoms and Venomous Animals, in Sao Paulo State, Brazil. The main purpose was to produce an adhesive fibrin without using human blood, to avoid transmitting infectious diseases. The components of this novel sealant were extracted from large animals and a serine proteinase extracted from Crotalus durissus terrificus snake venom. The applicability of this sealant was tested in animals and humans with beneficial results. The new fibrin sealant can be a useful tool clinically due to its flexibility and diversity of applications. This sealant is a biological and biodegradable product that (1) does not produce adverse reactions, (1) contains no human blood, (3) has a good adhesive capacity, (4) gives no transmission of infectious diseases, and (5) may be used as an adjuvant in conventional suture procedures. The effectiveness of this new fibrin sealant is reviewed and its development and employment are described.

Preparation and characterization of human thrombin for use in a fibrin glue.

Cryoprecipitate is frequently combined with thrombin to produce a fibrin sealant to enhance haemostasis during surgical procedures. We evaluated the thrombin produced from plasma using the Thrombin Processing Device (TPD)trade mark (Thermogenesis, Rancho Cordova, CA, USA). Plasma (250 mL) was processed in the CryoSeal FS System using the CP-3 disposable to produce cryoprecipitate by automated freezing and thawing. Simultaneously, thrombin was generated using the attached TPD. The cryoprecipitate and thrombin were harvested after approximately 50 min and then frozen and stored at -80 degrees C until analysis of total protein, fibrinogen, factor VIII (FVIII) activity, von Willebrand factor (vWF) and thrombin activity. Sodium dodecyl sulphate (SDS) gel electrophoresis was used to compare thrombin. After combining the thrombin with cryoprecipitate, the rate of clot initiation and strength was measured using a Thromboelastograph (TEG) (Haemoscope Corp, Skokie, IL, USA). Cryoprecipitate was produced, with a fibrinogen concentration of 22 +/- 7.7 g L(-1) (20 +/- 2% recovery), FVIII activity of 14.2 +/- 4.0 IU mL(-1) and vWF of 19.9 +/- 5.2 IU mL(-1). The separate thrombin product had a concentration of 64.3 +/- 16.7 IU mL(-1) of thrombin and a total protein of 0.39 +/- 0.1 g, with SDS gel electrophoresis showing a major band at 37 kD, as did the commercial human thrombin. The TEG curves of cryoprecipitate and TPD-produced or commercial thrombin were compared. The R values (time to clot initiation) were somewhat slower with the TPD-produced thrombin, but the maximum strength (MA) of the clots was similar. In conclusion, human thrombin can be produced during automated cryoprecipitate production. This thrombin is in sufficient concentration to initiate clotting and cross-linking of fibrin from cryoprecipitate to produce an entirely autologous fibrin glue.

Fibrin glues of human origin.

Wound healing is the response to injury and the process of tissue repair. Recent advances in cellular and molecular biology have greatly expanded our understanding of this process, which includes chemotaxis, production of matrix protein, cell replication, neovascularization and tissue remodelling. Tissue injury causes the disruption of blood vessels that is responsible for extravasation or haemorrhage of blood constituents and the first step of process in the platelet activation after exposure of collagen. Platelets initiate clotting through the coagulation system. When thrombin is formed, fibrinogen is transformed into fibrin; this is the real first step of wound healing. Fibrin glues reproduce this process and have been widely used in surgery to obtain haemostasis and expedite the process of wound healing. Immunogenicity of xenogenic products and risks of viral or prion disease transmission through commercial products have generated new interest in home-made autologous glues whose complexity was increased when platelets were added to coagulation proteins as a source of cytokines and growth factors. For the preparation of these products, the blood bankers took advantage of their usual technologies and several automated apparatuses are currently employed for the preparation of fibrinogen and thrombin concentrates. The machines for sequestration and multicomponent collection have been adapted for the concurrent procurement of plasma and platelets. A further level of complexity was introduced by the addition to glues of peripheral, bone marrow and cord-blood-derived stem cells to help or determine tissue regeneration. Instead of more new technologies, larger studies are now needed to quantify the benefits and clarify the optimal application for these products.

Fibrin sealant produced by the CryoSeal FS System: product chemistry, material properties and possible preparation in the autologous preoperative setting.

BACKGROUND AND OBJECTIVES: The CryoSeal FS has been introduced as an automated device for the production of fibrin sealant from small volumes of plasma. We tested this device and compared the product with commercially available fibrin sealants and with the requirements of the European Pharmacopoeia. MATERIALS AND METHODS: The CP3 program and disposables required were used to manufacture fibrin sealant. The chemistry and mechanical properties of the product were investigated. RESULTS: The cryoprecipitate generated with CryoSeal contains concentrated fibrinogen and critical clotting factors. The efficiency of the production process is poor, but the production procedure itself is simple and not time-consuming. The volume of plasma required allows application in the preoperative autologous setting. CONCLUSIONS: The CryoSeal FS is an automated device for cryoprecipitation and production of thrombin. It can be implemented easily in the clinical routine, although, owing to product specifications, the efficacy of the CryoSeal fibrin sealant requires further clinical trials.

Relative purity of thrombin-based hemostatic agents used in surgery.

BACKGROUND: Hemostatic agents used in surgery contain thrombin isolated from either a bovine or human source. The use of thrombin derived from a bovine source has been associated with the development of an abnormal immune response, but a study of the immunoreactivity of the various commercially available thrombin preparations has not been conducted. This study determined the relative purity of commercially available thrombin preparations, if humans have natural antibodies that recognize these preparations, and if elicited antibodies against bovine thrombin cross-react with other bovine or human hemostatic agents. STUDY DESIGN: The purity of hemostatic agents was determined by protein and substrate assays, electrophoresis, and immunoblotting. The natural antigenicity and cross-reactivity of elicited antibodies were measured by ELISA using serum samples from 82 donors from the Red Cross and serum collected from patients exposed to bovine thrombin, respectively. RESULTS: All of the bovine thrombin preparations were found to contain the xenogeneic carbohydrate galactosealpha1-3galactose. The natural antigenicity of the bovine thrombin preparations was greater than that of a human thrombin preparation and similar to that of porcine aortic endothelial cells. Antibodies elicited against bovine thrombin were found to cross-react with other bovine preparations and other xenoantigens but not with human hemostatic preparations. CONCLUSIONS: All patients have antibovine thrombin antibodies, even before exposure to bovine thrombin-containing hemostatic agents. The cross-reactivity of elicited antibovine thrombin antibodies indicates that if a patient has been sensitized to a bovine product, it is likely safer to use a human-derived product in lieu of a bovine product.

Large volume apheresis of autologous plasma and preparation of autologous fibrin glue from the plasma.

Autologous blood transfusion (ABT) is useful for prevention of undesirable effects of allogeneic blood transfusion. In our hospital, not only autologous whole blood but also autologous red blood cells, autologous fresh frozen plasma (Auto-FFP), and autologous fibrin glue (Auto-FG) are routinely produced for surgical patients. The Auto-FG is prepared from plasma which is separated from manually collected whole blood. However, when a large volume of Auto-FG is required, the plasma obtained by an apheresis method may be useful. Therefore, a pilot study was conducted to determine whether a collection of 2 U (160 ml) of red blood cells (RBCs) and 400 ml of plasma at 1 apheresis is acceptable. We first performed the apheresis on healthy donors, and then applied for autologous blood donation. The apheresis is safe. The collected plasma is used for the production of Auto-FFP and Auto-FG. The remaining RBCs also are used for ABT. The preparation of Auto-FG is simple, and it is effective for the reduction of allogeneic fibrin glue.

Rapid preparation of small-volume autologous fibrinogen concentrate and its same day use in bleb leaks after glaucoma filtration surgery.

The authors evaluated small-volume preparation of autologous fibrin glue (AFG) and same day use in postglaucoma filtration surgery patients with Seidel positive bleb leaks and determined fibrinogen concentrations in autologous fibrinogen concentrates (AFCs) from 10 volunteers. Thirty milliliters of blood was centrifuged (5 min, 2400 x g); plasma was frozen (5 min-ethanol and ice), thawed (1-6 C, 30-60 min), and centrifuged (10 min, 5 C, 2800 x g); and the precipitate was transferred to a 1.0-ml tuberculosis syringe. Thrombin (1000 U) was dissolved (0.8 sterile water, 0.2 ml aminocaproic acid) and warmed (37 C). Average preparation time was 90 minutes. Alternating drops of AFC and thrombin were applied to bleb leaks until AFC clotted. Seidel testing with fluorescein determined success. AFC was prepared from 10 volunteers and fibrinogen was measured. AFG was initially successful with two (Seidel negative) eyes; one eye remained negative. AFG was unsuccessful in one briskly Seidel-positive leak. Mean +/- SD fibrinogen concentration in AFCs from the 10 volunteers was 2314 +/- 643 mg/dl (range 1608-3431 mg/dl). AFG may successfully close bleb leaks in outpatient settings. Brisk aqueous flow may impair effectiveness of AFG. Fibrinogen concentrations were comparable with previous reports.

Haemophilia and advanced fibrin sealant technologies.

Fibrin sealant, which consists mainly of fibrinogen and thrombin, provides rapid haemostasis as well as tissue sealing and adhesion. Commercial, viral-inactivated products are available in Europe, Canada, and Japan. Liquid fibrin sealant (LFS) has been used clinically in haemophiliacs to perform dental procedures, orthopedic surgeries, non-orthopaedic surgeries, and circumcisions. LFS use is expected to increase as commercial products will soon be available in the US. Recombinant sources and transgenic animal bioreactor systems will replace plasma-derived products and become the predominant sources for this product in the next decade. Other areas of innovation include the development of fibrin sealant bandages or dressings, expandable foams, and spray powders which will provide the haemophiliac the ability to rapidly attain control of traumatic haemorrhages prior to hospital treatment with a significant reduction in the use of i.v. clotting factors. Fibrin sealant products have the potential to provide life-saving control of haemorrhage, reduction in factor dependency, lower viral exposure risk, and medical care cost reduction.

An autologous fibrin tissue adhesive with greater bonding power.

OBJECTIVE: To describe and evaluate an autologous fibrin tissue adhesive (AFTA) that uses a combination of ethanol and freezing to precipitate fibrinogen (AFTA-E). DESIGN: The bonding power of AFTA-E was compared with that of a conventional AFTA based on ammonium sulfate precipitation of fibrinogen (AFTA-A). In this study, Silastic, porcine dermis, and human dura mater blocks were bonded together for 10 and 30 minutes with AFTA-E or AFTA-A. The blocks were then separated and the bonding power was measured. The efficacy of AFTA-E was also evaluated after a 24-hour refrigeration. SETTING: The Department of Otolaryngology Research Laboratory at the University of Illinois Eye and Ear Infirmary, Chicago, Ill. PARTICIPANTS: Blood was drawn from 86 healthy volunteers and AFTA-E and/or AFTA-A was manufactured. RESULTS: The AFTA-E was shown statistically to bond stronger than the AFTA-A. In addition, it was found that the efficacy of AFTA-E was unchanged after a 24-hour refrigeration. CONCLUSIONS: The improved AFTA, AFTA-E, is a superior alternative to the conventional AFTA-A. Furthermore, AFTA-E can be manufactured before surgery and stored, thus minimizing preparation time during surgery.

Fibrin sealant in the United States: clinical use at the University of Virginia.

Fibrin sealant use in the United States has been limited because of the lack of a commercially available, government approved product. However, the significant need and usefulness of this material at the time of surgical operations has stimulated alternative sources of production. At the University of Virginia, the Blood Bank produces concentrated single donor or autologous fibrinogen for use with commercially available bovine thrombin in order to make fibrin sealant. The hemostatic and adhesive properties of fibrin sealant have been used since 1985 at this Center in a wide variety of operations with over 90% effectiveness. This chapter will review the development and role of this material in modern clinical surgery at this institution. The advantages, disadvantages, and never applications of this substance in various forms will be assessed. The role of fibrin sealant is increasing in this country and additional developmental work is continuing. The era of a commercially available product in the United States appears to be on the horizon.

[Autologous fibrin glue from concentrated platelet rich plasma: intraoperative plasma sequestration using autotransfusion device].

Making autologous fibrin glue from intraoperatively collected concentrated platelet rich plasma (C-PRP) was attempted in 5 patients who underwent elective coronary artery bypass. The autologous blood was withdrawn from the patient before cardiopulmonary bypass and sequestrated for C-PRP, concentrated red cells (CRC) and platelet poor plasma (PPP) using an Electromedics Elmd-500 autotransfusion device. CRC and PPP were returned intravenously to the patient as needed intraoperatively or postoperatively. Aprotinin was dissolved in C-PRP to yield a concentration of 1000U/ml to the aim of suppressing the plasmin activity. In another syringe, thrombin was dissolved in 2% calcium chloride solution to 1000U/ml. The C-PRP/aprotinin was mixed in ratios of 20:1, 10:1, 5:1, 3:1 to the thrombin/C a++ solution and observed the time for clotting. The 10:1 and 5:1 mixture usually clotted within 3-5 seconds, whereas it was necessary 5 or more seconds in other ratios. Therefore we used in the ratio of 5:1 for all patients. The fibrin glue from this technique is little different from the fibrin glue on the market in its viscosity, and has some major advantages 1. large amount of glue is available 2. simple and inexpensive 3. eliminate the risk of side effect such as virus transmission.

[Autologous fibrin glue from preoperative blood or plasma donors]. / Autologer Fibrinkleber aus präoperativer Blutoder Plasmaspende.

Cryoprecipitate was prepared from autologous plasma donation (fresh frozen plasma). The composition of this cryoprecipitate (fibrinogen, factor XIII, fibronectin) meets the requirements for the fibrinogen component of a fibrin glue. The prepared glue has tensile strength values in dura mater gluing as good as the commercial tissue glues.