Use Of Hemostatic Agents Research Articles

The Potential of Snake Venoms as Coagulation Agent for Hemorrhagic Trauma: A Review

Snake venom contains a variety of proteins and enzymes that can affect blood coagulation and have been investigated for their potential use as hemostatic agents to stop hemorrhage. Hemorrhage can be caused by a variety of factors, including injury, surgery, and certain medical conditions, and can be life-threatening if not controlled. Several components of snake venom have been identified as potential hemostatic agents. One such component is Batroxobin, a metalloproteinase found in the venom of the Bothrops atrox snake. Batroxobin has been shown to activate prothrombin to thrombin, which promotes clot formation and can be used to stop bleeding. Ancrod is a serine protease that can cleave fibrinogen, reducing the concentration of fibrinogen in the blood and preventing clot formation. Ancrod has been used as a hemostatic agent in the past, but its use has been limited due to concerns about its safety and efficacy. Other components of snake venom, such as those found in the venom of Russell's viper and the saw-scaled viper, have been found to have potential as hemostatic agents. These components have been shown to activate factor X and have been investigated as potential treatments for hemorrhage. The use of snake venom as a hemostatic agent is not without its challenges. One of the main concerns is the potential for adverse reactions, including allergic reactions, and the risk of complications such as thrombosis. Additionally, the availability of snake venom is limited, and the production of synthetic versions of these compounds can be challenging. Despite these challenges, the potential of snake venom as a hemostatic agent is promising, particularly in the development of new, more targeted treatments for hemorrhage. Further research is needed to fully understand the mechanisms of action of snake venom-derived hemostatic agents and to develop safe and effective therapeutic agents. In conclusion, snake venom contains a variety of components that have the potential as hemostatic agents to stop hemorrhage. While the use of snake venom-derived hemostatic agents is not without its challenges, these agents have promising potential in the treatment of a range of medical conditions. Keywords: Snake venom, coagulation agent, hemorrhagic trauma

Use of four-factor prothrombin complex concentrate (4F-PCC) for management of bleeding not associated with therapeutic anticoagulant use

IntroductionFour-factor prothrombin complex concentrate (4F-PCC) may be an option for patients with bleeding unrelated to therapeutic anticoagulation to help with bleeding cessation and reduce blood component requirements. Materials and methodsRetrospective, observational study of adult patients who received 4F-PCC for bleeding not associated with therapeutic anticoagulation between June 2019 and July 2021. Primary outcome was to describe off-label 4F-PCC use in patients not on therapeutic anticoagulation for bleeding management in surgical and non-surgical patients. Additional outcomes evaluated were blood product use, chest tube and drainage output, and coagulation studies before and after 4F-PCC administration as well as other hemostatic agent use and thromboembolic events. ResultsSeventy-six patients were included; median age 64 years (IQR 50–69), 66% of bleeding events were associated with surgery, and the majority of 4F-PCC doses ordered by cardiac surgery (68.4%). A total of 110 4F-PCC doses were administered; median 1 dose/patient (IQR 1–2), median total dose 1000 units (IQR 500–1484). Other hemostatic agents commonly administered were protamine (59%), desmopressin (43%), and tranexamic acid (42%). Packed red blood cells, fresh frozen plasma, platelet, and cell saver blood administration and prothrombin time (PT), international normalized ratio (INR), and partial thromboplastin time (aPTT) were significantly reduced following 4F-PCC administration. Eight patients (11%) experienced thromboembolic complications. ConclusionRelatively low doses of 4F-PCC (median total dose 1000 units) were associated with decreased blood component requirements and improved PT, INR, and aPTT values in patients with bleeding unrelated to therapeutic anticoagulation. Other hemostatic agent use was common and thromboembolic complications occurred.

The justification of the optimal composition and research of a local hemostatic agent based on naturally occurring polysaccharides

The analysis of existing methods and products for controlling bleeding reveals that medical means exhibit significantly higher efficacy compared to mechanical methods of achieving hemostasis. However, it is important to note that medical means cannot entirely replace surgical hemostasis in cases of severe bleeding from large veins and arteries. In emergency situations, such as during military conflicts or workplace injuries, the use of local contact hemostatic agents is preferred. These agents do not require specialized skills for application, making them accessible to individuals in need of immediate assistance. If included in a first-aid kit, these agents enable victims to address minor injuries promptly and control bleeding. In critical bleeding situations, any nearby individual can use the tool to provide aid. Given the ongoing military activities within our country’s territory, the development of effective domestic hemostatic agents has become an urgent priority. This initiative aims to ensure the availability of such products to our military personnel. Aim. The aim of this work is to justify the optimal composition of a local hemostatic agent based on readily available raw materials and feasible technologies. Materials and methods. After conducting an extensive review of domestic and foreign literature, the basis for the development of the future contact hemostatic agent was chosen to be adsorbing materials derived from biologically active components of mineral, synthetic, phyto-, and organic origins. The focus of this study is on natural polysaccharides with potential hemostatic activity, specifically alginate, kappa carrageenan, guar gum, and xanthan gum. One key property of polysaccharides is their ability to swell, which positively influences hemostasis. The hemostatic effect of model hemostatic compositions was evaluated using a femoral artery bleeding model induced by mechanical damage. Additionally, a model involving capillary-parenchymal bleeding from a laceration wound on the liver in adult rats was employed for further investigation. Results. Experimental studies have provided evidence of the hemostatic effect of natural polysaccharides due to their water absorption and swelling properties. In comparison with well-known medical products Celox and Revul®, substances with hemostatic activity, including alginate, kappa carrageenan GU 805, and the comparative drug Celox, have demonstrated significant reductions in bleeding time. Specifically, alginate, kappa carrageenan GU 805, and Celox have shown reductions of 38 %, 53 %, and 57 % respectively, compared to the positive control (PC) group. To enhance the hemostatic activity, a combination of the leading compounds with the addition of 7 % calcium gluconate was developed. The inclusion of calcium gluconate in the combination is associated with the involvement of calcium ions in all stages of blood coagulation, thereby increasing the overall hemostatic effect of the combination. Based on the obtained results, it can be concluded that substances with hemostatic activity, such as alginate, kappa carrageenan GU 805 in combination with calcium gluconate, miramistin, and a mixture of phytocomponents, as well as the comparative drugs Celox and Revul®, reliably reduce bleeding time by 46 %, 47 %, 37 %, and 36 %, respectively, in comparison to the PC group. Conclusions. The optimal composition of a contact hemostatic agent, formulated as a multicomponent powder known as Plantor, has been developed. This composition is based on natural saccharides and incorporates a complex of antiseptic and wound-healing substances derived from natural and synthetic sources. The formulation of Plantor demonstrates optimal consistency, biopharmaceutical properties, and pharmacotechnological characteristics. The addition of 7 % calcium gluconate to the composition was found to effectively enhance the level of hemostatic activity. This enhancement is attributed to the involvement of calcium ions in all stages of blood coagulation. Experimental studies conducted using a hemostatic model have confirmed that the proposed composition of the pharmacotherapeutic agent significantly reduces bleeding time by 47 % and accelerates the overall process of hemostasis. The observed efficacy of the Plantor formulation surpasses that of reference local hemostatic agents, indicating its superior effectiveness in promoting hemostasis.

Clinical and Economic Burden Associated with Disruptive Surgical Bleeding: A Retrospective Database Analysis.

Hemostatic agents are used to control surgical bleeding; however, some patients experience disruptive bleeding despite the use of hemostats. In patients receiving hemostats, we compared clinical and economic outcomes between patients with vs without disruptive bleeding during a variety of surgical procedures. This was a retrospective analysis of the Premier Healthcare Database. Study patients were age ≥18 with a hospital encounter for one of 9 procedures with evidence of hemostatic agent use between 1-Jan-2019 and 31-Dec-2019: cholecystectomy, coronary artery bypass grafting (CABG), cystectomy, hepatectomy, hysterectomy, pancreatectomy, peripheral vascular, thoracic, and valve procedures (first procedure = index). Patients were grouped by presence vs absence of disruptive bleeding. Outcomes evaluated during index included intensive care unit (ICU) admission/duration, ventilator use, operating room time, length of stay (LOS), in-hospital mortality, and total hospital costs; 90-day all-cause inpatient readmission was also evaluated. Multivariable analyses were used to examine the association of disruptive bleeding with outcomes, adjusting for patient, procedure, and hospital/provider characteristics. The study included 51,448 patients; 16% had disruptive bleeding (range 1.5% for cholecystectomy to 44.4% for valve). In procedures for which ICU and ventilator use is not routine, disruptive bleeding was associated with significant increases in the risks of admission to ICU and requirement for ventilator (all p≤0.05). Across all procedures, disruptive bleeding was also associated with significant incremental increases in days spent in ICU (all p≤0.05, except CABG), LOS (all p≤0.05, except thoracic), and total hospital costs (all p≤0.05); 90-day all-cause inpatient readmission, in-hospital mortality, and operating room time were higher in the presence of disruptive bleeding and varied in statistical significance across procedures. Disruptive bleeding was associated with substantial clinical and economic burden across a wide variety of surgical procedures. Findings emphasize the need for more effective and timely intervention for surgical bleeding events.

Review of perioperative outcomes and management of hip fracture patients on direct oral anticoagulants.

Anticoagulation use is common in elderly patients presenting with hip fractures and has been shown to delay time to surgery (TTS). Delays in operative treatment have been associated with worse outcomes in hip fracture patients. Direct oral anticoagulants (DOACs) comprise a steadily increasing proportion of all oral anticoagulation. Currently, no clear guidelines exist for perioperative management of hip fracture patients taking DOACs. DOAC use is associated with increased TTS, with delays frequently greater than 48 h from hospital presentation. Increased mortality has not been widely demonstrated in DOAC patients, despite increased TTS. Timing of surgery was not found to be associated with increased risk of transfusion or bleeding. Early surgery appears to be safe in patients taking DOACs presenting with a hip fracture, but is not currently widely accepted due to factors such as site-specific anesthesiologic protocols that periodically delay surgery. Direct oral anticoagulant use should not routinely delay surgical treatment in hip fracture patients. Surgical strategies to limit blood loss should be considered and include efficient surgical fixation, topical application of hemostatic agents, and the use of intra-operative cell salvage. Anesthesiologic strategies have utility in minimizing risk and a collaborative effort to minimize blood loss should be undertaken by the surgeon and anesthesiologist. Anesthesia team interventions include considerations regarding positioning, regional anesthesia, permissive hypotension, avoidance of hypothermia, judicious administration of blood products, and the use of systemic hemostatic agents.

Emicizumab for acquired haemophilia A: A case series.

Emicizumab is approved to prevent bleeding in patients with congenital haemophilia A with or without inhibitors. However, no randomized trials addressed the efficacy of emicizumab in acquired haemophilia A (AHA). To report the clinical and biochemical response of emicizumab in AHA. This single-centre retrospective study included seven adults with AHA between November 2020 and May 2022. We collected patient characteristics, laboratory coagulation parameters, the use of haemostatic agents, bleeds and thrombotic events. Treatment was monitored using chromogenic FVIII assays. The assay with human reagents assesses both the emicizumab FVIII-like-activity and native patient FVIII-activity. The assay with bovine reagents only measures the patients' native FVIII-activity as emicizumab does not bind to bovine reagents. Patients presented with spontaneous hematoma (n=7), intramuscular bleeding (n=2), haematuria (n=2) and/or gastro-intestinal bleeding (n=2). Six patients had major bleedings. At diagnosis, APTT was prolonged (91 seconds, IQR 73-103), FVIII activity was 0% (IQR 0-1) and FVIII inhibitor 182 BU/mL (IQR 104-228). Emicizumab was administered weekly (3mg/kg) for 4 weeks, and thereafter every 2 weeks until regression of the inhibitor. Three patients received activated FVIIa (cumulative dose of 1.7mg/kg, IQR 1.2-2.2). All bleedings were controlled after treatment initiation, without further bleeds. After starting emicizumab, FVIII-like activity reached ≥5% at 12 days (IQR 7-14), whereas recovery of the intrinsic FVIII-activity ≥5% occurred at 128 days (IQR 88-173), coinciding with the disappearance of the FVIII inhibitor. There were no safety issues. In this AHA case series, no new clinically relevant bleeds were observed after initiation of emicizumab in conjunction with standard immunosuppressive therapy.

(502) Arista™ Hemostat Associated with Decreased Odds of Infection and Reoperation Following Inflatable Penile Prosthesis Surgery in a Diverse, Multiethnic Academic Center

Abstract Introduction Using hemostatic agents to manage intraoperative bleeding or assist in surgical closures is well established practice. Currently, several hemostatic agents such as Arista™, Surgiflo®, and Surgicel® are available for surgeon use when placing inflatable penile prosthesis (IPP). However, the effect of these agents on postoperative infection remains to be seen. Thus, we conducted a study to compare postoperative infection and reoperation rates of Arista™ to other hemostatic agents. Objective Primary objective was to determine if use of Arista™, when compared to other hemostatic agents, was associated with decreased rates of infection and reoperation in patients from a diverse, multiethnic population undergoing a primary IPP implantation. Methods A single institution retrospective study of patients who underwent IPP implantation between December 2015 and February 2022 from a single surgeon was conducted. Patients were sorted into groups based on use of intraoperative hemostatic agents. Demographic data, intra- and peri-operative patient characteristics, reoperation, and post-operative infection information was extracted from electronic medical records. Results A total of 434 patients undergoing primary IPP (95.4% Coloplast and 4.6% AMS devices) met inclusion criteria; of which, 158 (36.4%) received Arista™ and 276 (63.6%) received other hemostats such as Surgiflo®, and Surgicel®. There was no significant difference between age, race, preferred language, BMI, or smoking status between the Arista™ and other hemostat groups. Cardiovascular disease (CVD) and diabetes were prevalent in 76.7% and 56.3% of our sample, respectively. A vast majority (84%) of CVD patients had concomitant diabetes. Median Operative time was significantly shorter in the other hemostat group compared to the Arista™ group (62 minutes vs. 75, P <0.001). There was no significant difference in post-operative instances of urinary retention, emergency department visits, or readmission between the two hemostat groups. Multivariable model controlling for age and CVD (Table 1) revealed that Arista™ was associated with significantly decreased odds of postoperative infection and reoperation when compared to other hemostats (OR = 0.36; 95% CI (0.14 – 0.97), P=0.04). Conversely, active smoking were associated with significantly higher odds (OR = 3.92; 95% CI (1.39 – 11.04), P=0.01). Conclusions Our retrospective study indicates that use of Arista™, regardless of patient CVD status, may lead to decreased infections and subsequent reoperations. Prospective randomized control trials should be pursued to adequately assess the benefits of Arista™ compared to other hemostatic agents. Disclosure No

A polymer-based systemic hemostat for managing uncontrolled bleeding.

Uncontrolled bleeding is a life-threatening emergency that requires immediate intervention. Currently available on-site bleeding interventions largely rely on the use of tourniquets, pressure dressing, and other topical hemostatic agents, which can only treat bleeding injuries that are known, accessible, and potentially compressible. Synthetic hemostats that are stable at room temperature, easy to carry, field-usable, and able to stop internal bleeding at multiple or unknown sources, are still lacking. We recently developed a hemostatic agent via polymer peptide interfusion (HAPPI), which can selectively bind to activated platelets and injury sites after intravascular administration. Here we report that HAPPI is highly effective in treating multiple lethal traumatic bleeding conditions in normal as well as hemophilia models via either systemic administration or topical application. In a rat liver traumatic model, intravenous injection of HAPPI resulted in a significant decrease in blood loss and a four-fold reduction in mortality rate within 2 h after injury. When applied topically on liver punch biopsy wounds in heparinized rats, HAPPI achieved a 73% of reduction in blood loss and a five-fold increase in survival rate. HAPPI also exhibited hemostatic efficacy in hemophilia A mice by reducing blood loss. Further, HAPPI worked synergistically with rFVIIa to induce immediate hemostasis and 95% reduction in total blood loss compared to the saline-treated group in hemophelia mice models. These results demonstrate that HAPPI is a promising field-usable hemostatic agent for a broad range of different hemorrhagic conditions.

MP77-01 TRENDS, OUTCOMES, AND COSTS OF HEMOSTATIC UTILIZATION FOR MAJOR UROLOGIC SURGERY

You have accessJournal of UrologyCME1 Apr 2023MP77-01 TRENDS, OUTCOMES, AND COSTS OF HEMOSTATIC UTILIZATION FOR MAJOR UROLOGIC SURGERY Camilo Arenas-Gallo, Patrick Lewicki, Megan Prunty, Aaron Brant, Stephen Rhodes, Spyridon P. Basourakos, Alec Zhu, Ilon Weinstein, Bashir Al Hussein Al Awamlh, and Jonathan E. Shoag Camilo Arenas-GalloCamilo Arenas-Gallo More articles by this author , Patrick LewickiPatrick Lewicki More articles by this author , Megan PruntyMegan Prunty More articles by this author , Aaron BrantAaron Brant More articles by this author , Stephen RhodesStephen Rhodes More articles by this author , Spyridon P. BasourakosSpyridon P. Basourakos More articles by this author , Alec ZhuAlec Zhu More articles by this author , Ilon WeinsteinIlon Weinstein More articles by this author , Bashir Al Hussein Al AwamlhBashir Al Hussein Al Awamlh More articles by this author , and Jonathan E. ShoagJonathan E. Shoag More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003351.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Hemostatic agents are used to prevent hemorragic complications in surgeries. The national trends in the use and the cost associated with these agents in major urologic procedures are largely unknown. METHODS: This retrospective US analysis used the Premier Healthcare database. Patterns of hemostatic agent use in major urologic surgeries were investigated and correlated with patient and hospital characteristics over the past two decades. Multivariable mixed-effects logistic regression was used to identify predictors of hemostatic agent use. RESULTS: The final patient cohort included 385,261 patient encounters for urologic surgery from 2000 to 2020. In 2020, hemostatic agents were used in 36.91% of prostatectomies, 41.69% of radical nephrectomies, 60.22% of partial nephrectomies and 40.77% of cystectomies. In the multivariable models, For patients undergoing prostatectomy odds for receiving hemostatic agent was 14% higher in Hispanic men (OR 1.07, CI 1.22- 1.24; p<0.001) and 7% lower in Black patients men (OR 0.93, CI 0.90- 0.97; p<0.001), 33% lower for open surgery compared to laparoscopic/robotic approach (OR 0.67, 95% CI 0.63- 0.71; p<0.001). For radical nephrectomy patients, odds of receiving hemostatic agent were 16% higher for open approach (OR 1.16, 95% CI 1.12- 1.21; p<0.001), 7% lower for Black race (OR 0.93, 95% CI 0.88- 0.99; p 0.014). For partial nephrectomy patients odds for receiving hemostatic were 18% higher for open approach (OR 1.18, 95% CI 1.10- 1.27; p<0.001). The specific cost for hemostatic use did not differ between lap/robotic and open approaches for any procedure. CONCLUSIONS: The use of hemostatic agents has increased markedly in the last decade. Patient characteristics, surgeon, and hospital factors are highly associated with the use of hemostatic agents. Specific costs of the hemostatic and the proportion of the total cost of hospitalization have increased. There is a great need to develop controlled clinical trials capable of demonstrating the true efficacy of hemostatic agents to determine their specific indications. Source of Funding: J.E.S is supported by the Frederick J. and Theresa Dow Fund of the New York Community Trust, the Vinney Scholars Award, and a Damon Runyon Cancer Research Foundation Physician-Scientist Training Award © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1101 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Camilo Arenas-Gallo More articles by this author Patrick Lewicki More articles by this author Megan Prunty More articles by this author Aaron Brant More articles by this author Stephen Rhodes More articles by this author Spyridon P. Basourakos More articles by this author Alec Zhu More articles by this author Ilon Weinstein More articles by this author Bashir Al Hussein Al Awamlh More articles by this author Jonathan E. Shoag More articles by this author Expand All Advertisement PDF downloadLoading ...

MP42-20 TO SEAL OR NOT TO SEAL: EXAMINING THE ROLE OF TISSUE ADHESIVES FOR BLADDER AND URETERAL RECONSTRUCTION

You have accessJournal of UrologyCME1 Apr 2023MP42-20 TO SEAL OR NOT TO SEAL: EXAMINING THE ROLE OF TISSUE ADHESIVES FOR BLADDER AND URETERAL RECONSTRUCTION Juan Ramirez, George E. Aninwene, and Renea M. Sturm Juan RamirezJuan Ramirez More articles by this author , George E. AninweneGeorge E. Aninwene More articles by this author , and Renea M. SturmRenea M. Sturm More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003280.20AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: While surgical adhesives may be FDA approved as adjunct hemostatic agents or sealants, application is typically off-label for urinary tract tissue. Current literature lacks consensus regarding the role of tissue adhesives for bladder and ureteral reconstruction. This systematic review synthesizes clinical and animal data across key adhesives that have been applied to bladder and ureteral tissue, assessing trade-offs between competing parameters affecting agent selection and effectiveness. METHODS: A literature search was conducted in Pubmed, Web of Science, Embase, and Cochrane databases to identify articles published from 2000-2021 that reported urologic reconstruction and the use of adhesive, hemostatic agents, and/or sealants. Figure 1A illustrates identification and inclusion/exclusion criteria. RESULTS: 29 publications were included (18 human, 11 animal; Figure 1B). Fibrin sealant was the most commonly evaluated adhesive, followed by cyanoacrylate and bovine serum/albumin/glutaraldehyde (bioglue). Clinically, all three adhesive types effectively managed fistulas, with significant decrease in operative time, decrease blood loss, and resolution of urinary leakage. When comparing acute inflammatory and wound healing responses, cyanoacrylate demonstrated higher cytotoxicity in comparison to fibrin sealant. No significant inflammation at 1 week (in comparison to sutured closures) occurred following bioglue application. In prior characterization studies, cyanoacrylate had the strongest tensile strength and adhesive parameters; however, no study assessed mechanical or adhesive parameters of fibrin sealants or bioglues in bladder or ureteral tissue. CONCLUSIONS: This systemic review provides overall low-level evidence for the application of the three major adhesive types to bladder and ureteral reconstruction as a suture reinforcement. However, these three adhesive types are not equivalent, demonstrating trade-offs between adhesive strength and cytotoxicity. Future research is needed to assess comparative parameters of all three major adhesives, including mechanical and adhesive benchtop testing, effects on wound healing, and long-term outcomes of clinical application to bladder and ureteral tissue. Source of Funding: National Science Foundation and UCLA Tech Development Group © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e575 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Juan Ramirez More articles by this author George E. Aninwene More articles by this author Renea M. Sturm More articles by this author Expand All Advertisement PDF downloadLoading ...

Microporous Hemostatic Sponge Based on Silk Fibroin and Starch with Increased Structural Retentivity for Contact Activation of the Coagulation Cascade.

Hemostatic agents with diverse forms and materials are necessitated to control excessive bleeding to improve surgical site visibility during operation. The adequate use of hemostatic agents dramatically reduces the chance of dehydration, absence of oxygen, and, in severe cases, death. Polysaccharide-based hemostatic agents are widely used as they are safe for the human body. Among diverse polysaccharides, starch has exhibited a high swelling ability, but its powder formulation is limited during incompressible bleeding. Herein, starch was blended with silk protein and crosslinked using glycerol to improve structural integrity. The silk/starch solution was lyophilized to be a sponge with interconnected pores, which is beneficial to blood coagulation by increased swelling ratio and underwater retentivity to absorb blood plasma. The surface contact between the blood component and the sponge initiates clotting by intrinsic pathway activation and platelet activation without the hemolytic effect or cytotoxicity. The clinical effectiveness of the sponges as topical hemostatic agents was confirmed by animal bleeding model tests.

Risk Factors for Delayed-Onset Infection after Mandibular Wisdom Tooth Extractions

Wisdom tooth extraction is one of the most commonly performed procedures by oral maxillofacial surgeons. Delayed-onset infection (DOI) is a rare complication of wisdom tooth extraction, and it occurs ~1-4 weeks after the extraction. In the present study, risk factors for DOI were investigated by retrospectively analyzing the cases of 1400 mandibular wisdom tooth extractions performed at Kagawa University Hospital from April 2015 to June 2022. Inclusion criteria were patients aged >15 years with a wisdom tooth extraction per our procedure. The exclusion criteria were patients with insufficient medical records, a >30-mm lesion around the wisdom tooth shown via X-ray, colonectomy, radiotherapy treatment of the mandible, the lack of panoramic images, and lesions other than a follicular cyst. The DOI incidence was 1.1% (16 cases), and univariate analyses revealed that the development of DOI was significantly associated with the Winter classification (p = 0.003), position (p = 0.003), hypertension (p = 0.011), and hemostatic agent use (p = 0.004). A multivariate logistic regression analysis demonstrated that position (OR = B for A, 7.75; p = 0.0163), hypertension (OR = 7.60, p = 0.013), and hemostatic agent use (OR = 6.87, p = 0.0022) were significantly associated with DOI development. Hypertension, hemostatic use, and position were found to be key factors for DOI; long-term observation may thus be necessary for patients with these risk factors.

Enhancing the Reliability of Intraoperative Ultrasound in Pediatric Space-Occupying Brain Lesions

Intraoperative ultrasound (IOUS) may aid the resection of space-occupying brain lesions, though technical limits may hinder its reliability. IOUS (MyLabTwice®, Esaote, Italy) with a microconvex probe was utilized in 45 consecutive cases of children with supratentorial space-occupying lesions aiming to localize the lesion (pre-IOUS) and evaluate the extent of resection (EOR, post-IOUS). Technical limits were carefully assessed, and strategies to enhance the reliability of real-time imaging were accordingly proposed. Pre-IOUS allowed us to localize the lesion accurately in all of the cases (16 low-grade gliomas, 12 high-grade gliomas, eight gangliogliomas, seven dysembryoplastic neuroepithelial tumors, five cavernomas, and five other lesions, namely two focal cortical dysplasias, one meningioma, one subependymal giant cell astrocytoma, and one histiocytosis). In 10 deeply located lesions, IOUS with hyperechoic marker, eventually coupled with neuronavigation, was useful to plan the surgical route. In seven cases, the administration of contrast ensured a better definition of the vascular pattern of the tumor. Post-IOUS allowed the evaluation of EOR reliably in small lesions (<2 cm). In large lesions (>2 cm) assessing EOR is hindered by the collapsed surgical cavity, especially when the ventricular system is opened, and by artifacts that may simulate or hide residual tumors. The main strategies to overcome the former limit are inflation of the surgical cavity through pressure irrigation while insonating, and closure of the ventricular opening with Gelfoam before insonating. The strategies to overcome the latter are avoiding the use of hemostatic agents before IOUS and insonating through normal adjacent brain instead of corticotomy. These technical nuances enhanced the reliability of post-IOUS, with a total concordance to postoperative MRI. Indeed, the surgical plan was changed in about 30% of cases, as IOUS showed a residual tumor that was left behind. IOUS ensures reliable real-time imaging in the surgery of space-occupying brain lesions. Limits may be overcome with technical nuances and proper training.

Intraoperative hemostatic agent use and surgical site infection rates after hysterectomy; are they really to blame?

Intraoperative hemostatic agent use and surgical site infection rates after hysterectomy; are they really to blame?

Hemostatic agents use during cesarean delivery and the risk for uterine rupture during subsequent TOLAC

Hemostatic agents were found to be associated with post-cesarean infections in general and endometritis specifically. We aim to evaluate the association between a hemostatic agent used at the time of cesarean delivery to uterine scar rupture or dehiscence at the subsequent trial of labor. A multicenter retrospective cohort study of women who underwent their first trial of labor after cesarean delivery between 2005 and 2021. Women with a singleton pregnancy in whom a hemostatic agent was placed at the time of the index cesarean were compared to women in whom no such agent was placed. The primary outcome of this study was the rate of uterine rupture or dehiscence. Secondary outcomes were adverse maternal and neonatal outcomes. Univariate analyses were followed by multivariate analysis (adjusted Odds Ratio (aORs); [95% Confidence Interval]). During the study period, 7204 women underwent a trial of labor and met inclusion and exclusion criteria, of whom 431 (6.0%) had prior use of a hemostatic agent and 6773 (94.0%) didn't. History of the use of hemostatic agent wasn't found to be significantly associated with uterine scar rupture (0.9% vs. 0.4%, p=0.15) or dehiscence (0.9% vs. 0.5%, p=0.21). Moreover, we found no differences between the study groups in any maternal or neonatal parameter examined (Table 1). This was confirmed on multivariate analysis as well [aOR 1.95 (0.67–5.69), p = 0.22] for uterine rupture (Table 2). Amongst women undergoing a trial of labor, a history of hemostatic agent use confers no additional risk than no use. Further prospective studies in other settings to strengthen these findings are needed.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

"Familial Multiple Coagulation Factor Deficiencies of FXI and FXII in an Asymptomatic Saudi Woman".

Factor XI deficiency (FXI) is the third most common coagulation factor deficiency after hemophilia A and B, ie, in the hierarchy after factors VIII and IX, taking into account von Willebrand's factor deficiency, as bleeding disorders are higher than in hemophilia C. Factor XII deficiency (FXII) is a congenital condition, inherited in the vast majority of cases in an autosomal recessive manner, more often associated with thromboembolic complications. A combination of both factor deficiencies has been found very rarely, and it can be familial multiple coagulation factor deficiency (FMCFD). This study reports the case of a 39-year-old woman from Saudi Arabia who had the combination of FXI and FXII deficiencies, known to be on treatment for hypothyroidism and was referred to a hematology clinic with an incidental finding of prolonged activated partial thromboplastin time (aPTT). Although there was no history of bleeding tendency, her siblings had a family history of an unknown type of bleeding disorder. On physical examination, the patient did not show any bruising, petechiae, or ecchymosis. The aPTT was 69 seconds (27-38) with normal use of other hemostatic agents and was corrected after a 50:50 mixing study. Intrinsic coagulation factors were evaluated, and they revealed severe FXI and moderate FXII deficiencies. Due to a strong family history, the patient was diagnosed with FMCFD. In conclusion, familial combined multiple clotting factor deficiency (FCMFD) is a rare condition that requires attention and reporting. The management strategy in such cases has not been well studied, especially in the long-term symptomatic patient with severe but asymptomatic combined FXI and FXII deficiencies, which is an area for review and further study.

8010 Postoperative Abscess Risk with Hemostatic Agent Use in Hysterectomy

<h3>Study Objective</h3> We noticed a trend of increased re-admissions for post-op pelvic abscesses. In an attempt to further investigate causality, we identified use of hemostatic agents as a possible culprit. The study objectives were to determine if intra-operative use of hemostatic agents was associated with postoperative abscess formation in patients undergoing hysterectomy. <h3>Design</h3> Retrospective chart review identified women who underwent hysterectomy by a Gynecologic Oncologist for any indication at a single institution from January 1, 2019, through December 31, 2019. Patient and surgical characteristics were abstracted, and comparisons were made among those who received any hemostatic agent and those that did not. <h3>Setting</h3> Study was performed at an academic institution in rural Virginia. <h3>Patients or Participants</h3> 428 hysterectomies were identified among five providers over a one-year period, with a postoperative pelvic abscess rate of 3.7%. <h3>Interventions</h3> The relationship between intra-operative hemostatic agentuse and post-op pelvic abscess formation was determined using multivariate logistic regression. Secondary outcomes evaluated included the presence of other major post-operative adverse events, such as post-operative blood transfusion, presentation to the emergency room, readmission or re-operation. <h3>Measurements and Main Results</h3> Abscesses were identified in 4 (2.2%)of cases without <i>vs</i> 12 (4.9%) of cases with hemostatic use with a logistic regression model demonstrating no significant difference in the groups (OR=2.10, <i>p</i>=0.22). Data showed an increase in presentation to the ED (OR=3.43, <i>p</i>=0.002 adjusted) and higher odds of readmission to the hospital within 30 days of surgery (OR=3.19, <i>p</i>=0.03) with hemostatic agent use. <h3>Conclusion</h3> There was no association found between the use of hemostatic agent use and abscess formation; however, data showed hemostatic agent use in surgery was associated with increased odds of presentation to the ED and readmission to the hospital within 30 days of surgery.

TriService Nursing Research Program: A critical component to support military nursing science

TriService Nursing Research Program: A critical component to support military nursing science

Evaluating the risk of post-operative abscess formation following use of hemostatic agents at time of hysterectomy

ObjectiveAt an academic institution in rural Virginia, we noticed a trend of increased re-admissions for postoperative pelvic abscesses. The primary study objective was to determine if intraoperative use of hemostatic agents (HA) was associated with postoperative abscess formation in patients undergoing hysterectomy. MethodsRetrospective chart review identified women who underwent hysterectomy by a Gynecologic Oncologist for any indication at a single institution from January 1, 2019 through December 31, 2019. Patient and surgical characteristics were abstracted and comparisons were made among those who received any HA and those that did not. The relationship between intraoperative HA use and postoperative pelvic abscess formation was determined using multivariate logistic regression. Secondary outcomes evaluated included the presence of other major post-operative adverse events. Results428 hysterectomies were identified with a postoperative pelvic abscess rate of 3.7 %. Abscesses were identified in 4 (2.2 %) of cases withoutvs12 (4.9 %) of cases with HA use with a logistic regression model demonstrating no significant difference in the groups (OR = 2.10,p = 0.22).Data showed an increase in presentation to the Emergency Department (ED) (OR = 3.43,p = 0.002 adjusted) and higher odds of readmission within 30 days of surgery (OR = 3.19,p = 0.03) with HA use. ConclusionsNo association was found between HA use and abscess formation; however, data showed HA use was associated with increased odds of presentation to the ED and readmission to the hospital within 30 days of surgery.Given the potential negative impact on patient outcomes, use of these products at time of hysterectomy should be made with careful consideration.

Stopping intra-abdominal bleeding with promising local biocompatible hemostatic agents

BACKGROUND: In this study, for the first time, an experimental evaluation of the effectiveness of samples of a new local biocompatible hemostatic agent in the form of a gel based on chitosan was carried out with ongoing intra-abdominal bleeding.&#x0D; AIM: to evaluate the effectiveness of promising local biocompatible hemostatic agents for ongoing intra-abdominal bleeding in an experiment using biological objects.&#x0D; MATERIALS AND METHODS: When performing this work, an experimental model was developed on biological objects (rabbits) to evaluate the effectiveness of hemostatic agents in the form of a gel with continued bleeding from a liver wound.&#x0D; RESULTS: During the experiment, the high efficiency of new LBHA samples was established, which allowed to avoid mortality in comparison with the control group, where the mortality rate was 100%.&#x0D; CONCLUSION: The developed experimental model, which includes injury to the liver with the subsequent development of intense intra-abdominal bleeding, has fully justified itself. The use of local biocompatible hemostatic agents in the form of a gel is a promising way to achieve hemostasis in the early stages of medical evacuation for abdominal injuries, which in turn has the potential to significantly reduce the number of deaths caused by ongoing intra-abdominal bleeding. The data obtained, indicating the high efficiency of individual samples, make it possible to consider the continuation of research in this direction appropriate. Further evaluation of the efficacy and safety of local biocompatible hemostatic agents requires additional studies on medium and large biological objects with all the samples presented to determine their effect on the body, biocompatibility, as well as local irritant action.