Alone Against Bleeding. Active or Mechanical Hemostatic in Severe Hemorrhage?

Abstract

Background and objective: There are many surgical maneuvers (Packing, Pringle maneuver, etc.), hemostatics with many forms of application (Flowable, Powder, Patch, etc.), coagulation activity (active, mechanical, etc.), or chemical structure (fibrin, thrombin, Modified Absorbable Polymers (MAP)) to manage hepatic bleeding in trauma surgery. In addition, both can always work together at the same time; however, could a single medicine be effective as a unique hemostatic surgical technique? Which could be better? Methods: Twenty swine were prospectively randomized to receive either active or passive hemostatics (Floseal TM or Perclot TM). We used a novel severe liver injury model that caused exsanguinating hemorrhage. The main outcome measure was total blood loss volume. Results: The total volume of blood loss, from injury to minute 120, was significantly lower in the Flowable group (407.5 cc; IqR:195.0 cc to 805.0 cc) than in the novel modified absorbable polymer group (1,107.5 cc; IqR:822.5 cc to 1,544.5 cc) (Hodges-Lehmann median difference: -645.0 cc; 95% CI: -1,144.0 cc to -280.0 cc; p=0.0087). With the exception of 6 min measurements (p=0.1136), the volume of blood lost was significantly lower in the flowable group than in the MAP group from injury to minutes 3, 9, 12, and 120. The mean arterial pressure gradually recovered in the flowable group up to 24 h, whereas in the MAP group, the mean arterial pressure was always below the baseline values. Kaplan–Meier survival analysis indicated similar rates of death between study groups (Logrank test p=0.3395) Conclusions: Both the flowable and the MAP hemostatic agents were able to effectively control surgical bleeding in this severe liver injury model, although the flowable gelatin-thrombin agent provided quick and better bleeding control