Severe Coagulopathy following Intraoperative Use of Topical Thrombin

doi:10.1007/s10016-004-0028-3

Annals of Vascular Surgery

Volume 18, Issue 3, May 2004, Pages 349-351

https://doi.org/10.1007/s10016-004-0028-3 Get rights and content

This report describes a case of severe coagulopathy and bleeding related to the intraoperative use of topically applied thrombin. Commercial thrombin preparations contaminated with bovine factor V have been shown to stimulate the production of antibodies directed against factor V. These antibodies can cause coagulopathy. Our patient developed antibodies against factor V after intraoperative exposure to topical thrombin. The resulting antibody-mediated depletion of factor V caused a severe and refractory coagulopathy. Vascular surgeons should be aware that the use of topical bovine thrombin can cause severe coagulopathy.

Section snippets

CASE REPORT

An 84-year-old man presented with abdominal pain and hematochezia 3 years after an aortobiiliac bypass for aortoiliac aneurysm. An abdominal computed tomography (CT) scan showed perigraft fluid and gas. We diagnosed an aortic graft infection and probable graft enteric erosion. The patient was taken to surgery where an axillobifemoral bypass was performed. This procedure was immediately followed with an exploratory laparotomy, which confirmed the presence of an aortic graft infection and

DISCUSSION

Factor V is an essential cofactor for the conversion of prothrombin to thrombin. Because this step is the final common pathway linking the intrinsic and extrinsic coagulation cascades, factor V plays an essential role in hemostasis (Fig. 1). Acquired antibodies that inhibit factor V are rare but can be found in association with surgical procedures, malignancy, infection, autoimminue disorders, and aminoglycoside exposure.³ These inhibitors can cause depletion or inactivation of factor V. The

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Obtaining rapid and effective hemostasis: Part I. Update and review of topical hemostatic agents
2013, Journal of the American Academy of Dermatology
Effective and rapid hemostasis is critical to optimize surgical outcomes. An advantageous adjunct in accelerating the clotting process during dermatologic surgery is the use of topical hemostatic agents, which allow dermatologic surgeons to quickly clear the surgical field while avoiding the adverse effects of systemic medications. The growing rate of patients with pacemakers and defibrillators limits the possibility of electrosurgery. It is not unusual for patients to be taking ≥1 anticoagulant medication(s). For these reasons, the use of topical hemostatic agents is likely to gain more recognition in the literature. The term topical hemostatic agents encompasses an array of pharmacotherapies, sealants, adhesives, absorbable agents, biologics, and combination products. The optimal use of topical hemostatic agents demands that dermatologic surgeons be familiar with each of these options, because the type of product used must be selected based on surgical location, wound size, and the extent of bleeding. With few randomized controlled trials in existence reviewing the efficacy of these medications, the subject of topical styptic agents has largely gone unstudied. Part I of this continuing medical education article reviews the available topical hemostatic agents and the ideal clinical settings for their use.
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Salmon fibrin glue in rats: Antibody studies
2012, Biologicals
Fibrin sealants and topical thrombin preparations are often used for haemostatic and sealing applications in clinical practice. Some of these preparations contain coagulation factors from bovine sources. To minimize the risk of infection and immunogenicity connected with mammalian blood products, proteins derived from the plasma of farmed Atlantic salmon have been considered as an alternative to these mammalian sources. The purpose of this study is to characterize the immunogenicity of salmon fibrin glue in an animal model focusing on crossreactivity of IgG antibodies to host endogenous counterparts. After two immunizations with salmon fibrin glue, rats developed antibodies of IgG and IgM type to both fibrin glue components. Weak crossreactivity to endogenous fibrinogen and thrombin was seen in a subset of rats after the second application of salmon proteins. Coagulation tests showed that salmon fibrin application has no effect on coagulation profiles in mammalian hosts, consistent with previous reports that found no evidence of significant crossreactivity with host proteins. These studies support the potential suitability of salmon fibrin glue for the development of preparations with clinical impact. Before human use can be considered, however, additional data about safety of this preparation in other animal models, including large animal studies, should be obtained.
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Citation Excerpt :
The thrombins short-circuit the coagulation cascade by adding the crucial enzymatic end product directly to the bleeding site and enabling topical thrombin cleavage of fibrinogen to produce the fibrin clot.6,15 Thrombins are practical when the patient's own coagulation system is impaired because of heparinization, mild coagulopathy, or other conditions.6,15 These agents are unlikely to be effective as a stand-alone intervention in cases of profound coagulopathy, especially in patients with hypofibrinogenemia.15
Achieving perioperative hemostasis is vital to surgical success. Inadequate control of bleeding is associated with serious adverse outcomes, including extended duration of surgery, unanticipated blood transfusions, shock, infection, impaired wound healing, longer hospital stays, and mortality. Appropriate clinical management of bleeding in the surgical and trauma settings requires careful collaborative planning and coordination by the entire perioperative team. Perioperative nurses, because of their strategic role in patient care, must be familiar with risk factors for excessive bleeding and the fundamental roles of hemostatic agents, environmental temperature, and blood transfusion in controlling bleeding in the surgical patient. Knowledge of the characteristics, safety, efficacy, and costs of available topical hemostatic agents promotes their appropriate selection in the OR. By incorporating evidence-based approaches into practice, perioperative nurses can support effective intraoperative hemostasis, thereby improving patient outcomes.

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Case ReportsSevere Coagulopathy following Intraoperative Use of Topical Thrombin

Section snippets

CASE REPORT

DISCUSSION

Blood

J. Vasc. Surg.

Blood

Case Reports
Severe Coagulopathy following Intraoperative Use of Topical Thrombin