Hemostasis and Biosurgicals in Trauma and Orthopedic Surgery from freeamfva's blog
Trauma and orthopedics is a specialty in which significant blood loss can be incurred both in terms of traumatic injuries and operative management. This chapter starts with a brief review of the biology of hemostasis followed by the importance of hemostasis in surgery. This is followed by a discussion on the ideal hemostatic agent. Various strategies of achieving hemostasis will be discussed including mechanical, thermal, pharmacological and topical agents in both elective orthopedic and spine surgery as well as in trauma. Specifically, we will look at synthetic agents such as cyanoacrylate, polyethylene glycol hydrogel and glutaraldehyde cross-linked albumin and absorbable agents such as gelatin foams and oxidized cellulose. We will also look at biological agents such as topical thrombin, sealants and platelet gels. Hemostatic dressings will be discussed in detail.To get more news about Hemostatic Gauze, you can visit rusunmedical.com official website.
There are a number of factors that influence patient outcome in trauma and orthopedic surgery in relation to hemorrhage. These can include patient factors, for example anticoagulant and antiplatelet medications, coagulopathies and other conditions, as well as surgical factors such as bony bleeding, large surgical incisions, diffuse venous bleeding and unseen sources of bleeding [1, 2].
Trauma still remains a leading worldwide cause of morbidity and mortality [3] and despite various developments over the years, hemorrhagic shock from trauma continues to form one part of the terrible triad contributing to mortality in both the military and civilian settings [4].
Effective hemostasis during surgery is advantageous to the surgeon as it prevents diffuse bleeding from capillaries and venules obscuring the surgical field and adding to operation time and infection risk [5, 6].
Significant blood loss has been associated with increased need for allogeneic and autologous blood transfusion [2, 7, 8]. These are associated with attendant risks including nosocomial infections [9], transfusion-related injury and fluid overload [10, 11]. In fact blood transfusion is an independent risk factor for infection, respiratory complications and the need for critical care support in traumatic injuries and resulted in a twofold increase in complications and critical care admissions, with more than two units of blood transfusion [7]. The risk of major perioperative complications is also increased with high intraoperative blood loss [2, 12, 13]. Therefore, patient outcome is optimal when the balance between bleeding and clotting is maintained during surgery such that tissue perfusion is adequate without excessive blood loss [5, 6].
Hemostasis in regard to trauma and surgery is a highly regulated process, maintaining flow through vessels at the same time as the thrombotic response to tissue damage is occurring [14], thereby ensuring tissue perfusion and limiting blood loss. The process is a complex interaction between vascular endothelium, platelets, the coagulation and fibrinolytic systems [15, 16].
Following injury, a temporary vascular smooth muscle contraction occurs in an attempt to stem blood flow. Endothelial disruption exposes the subendothelial layer and circulating Von Willebrand factor attaches to the site of injury. Surface glycoproteins also adhere to platelet surfaces. The subendothelial collagen activates adhering platelets and their surface receptors then bind circulating fibrinogen, forming a soft platelet plug comprising aggregated platelets and fibrinogen [14]. The adhering platelets secrete humoral factors including serotonin, prostaglandins and thromboxane that maintain a reduced blood flow, creating an environment that is conducive to clot formation at the site of bleeding. At the same time, circulating coagulating factors produced by the liver are activated in a series of precisely controlled sequential and dependant reactions [14, 17].
Mechanical methods include direct pressure, ligating clips and staples, sutures, fabric pads and gauze while hemostatic scalpels and lasers also reduce bleeding during surgery [6, 7, 17]. However, these methods have their drawbacks with respect to certain situations. The location of bleeding is particularly important with respect to orthopedics and in particular trauma. Bony surface bleeding and bleeding from the intramedullary canals are almost impossible to control with mechanical methods. Inflamed or friable tissues may contain a dense network of friable capillaries may prove a challenge [1, 2, 7]. Junctional bleeding in trauma may be potentially catastrophic and its control may not be amenable to the above methods.
The use of pharmacological methods can be a useful adjunct to other methods in these circumstances [7]. These may include epinephrine, desmopressin, tranexamic acid, vitamin K, aminocaproic acid and others.
There are a number of factors that influence patient outcome in trauma and orthopedic surgery in relation to hemorrhage. These can include patient factors, for example anticoagulant and antiplatelet medications, coagulopathies and other conditions, as well as surgical factors such as bony bleeding, large surgical incisions, diffuse venous bleeding and unseen sources of bleeding [1, 2].
Trauma still remains a leading worldwide cause of morbidity and mortality [3] and despite various developments over the years, hemorrhagic shock from trauma continues to form one part of the terrible triad contributing to mortality in both the military and civilian settings [4].
Effective hemostasis during surgery is advantageous to the surgeon as it prevents diffuse bleeding from capillaries and venules obscuring the surgical field and adding to operation time and infection risk [5, 6].
Significant blood loss has been associated with increased need for allogeneic and autologous blood transfusion [2, 7, 8]. These are associated with attendant risks including nosocomial infections [9], transfusion-related injury and fluid overload [10, 11]. In fact blood transfusion is an independent risk factor for infection, respiratory complications and the need for critical care support in traumatic injuries and resulted in a twofold increase in complications and critical care admissions, with more than two units of blood transfusion [7]. The risk of major perioperative complications is also increased with high intraoperative blood loss [2, 12, 13]. Therefore, patient outcome is optimal when the balance between bleeding and clotting is maintained during surgery such that tissue perfusion is adequate without excessive blood loss [5, 6].
Hemostasis in regard to trauma and surgery is a highly regulated process, maintaining flow through vessels at the same time as the thrombotic response to tissue damage is occurring [14], thereby ensuring tissue perfusion and limiting blood loss. The process is a complex interaction between vascular endothelium, platelets, the coagulation and fibrinolytic systems [15, 16].
Following injury, a temporary vascular smooth muscle contraction occurs in an attempt to stem blood flow. Endothelial disruption exposes the subendothelial layer and circulating Von Willebrand factor attaches to the site of injury. Surface glycoproteins also adhere to platelet surfaces. The subendothelial collagen activates adhering platelets and their surface receptors then bind circulating fibrinogen, forming a soft platelet plug comprising aggregated platelets and fibrinogen [14]. The adhering platelets secrete humoral factors including serotonin, prostaglandins and thromboxane that maintain a reduced blood flow, creating an environment that is conducive to clot formation at the site of bleeding. At the same time, circulating coagulating factors produced by the liver are activated in a series of precisely controlled sequential and dependant reactions [14, 17].
Mechanical methods include direct pressure, ligating clips and staples, sutures, fabric pads and gauze while hemostatic scalpels and lasers also reduce bleeding during surgery [6, 7, 17]. However, these methods have their drawbacks with respect to certain situations. The location of bleeding is particularly important with respect to orthopedics and in particular trauma. Bony surface bleeding and bleeding from the intramedullary canals are almost impossible to control with mechanical methods. Inflamed or friable tissues may contain a dense network of friable capillaries may prove a challenge [1, 2, 7]. Junctional bleeding in trauma may be potentially catastrophic and its control may not be amenable to the above methods.
The use of pharmacological methods can be a useful adjunct to other methods in these circumstances [7]. These may include epinephrine, desmopressin, tranexamic acid, vitamin K, aminocaproic acid and others.
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| By | freeamfva |
| Added | Jun 13 '22 |
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