Fibrin Foam with Thrombin

A fibrous protein matrix of a wide range of mechanical and biological properties has been prepared from the human plasma proteins involved in the natural coagulation mechanism. This matrix is designed to combine the function of an absorbable tampon with thrombin activity, for use in those instances of haemorrhage where conventional methods fail. Initially, Bering24 in 1944, worked on the development of fibrin foam. Bailey et al.25,26 in 1944 continued the use of the agents in 1970 neurosurgical patients at the Peter Bent Brigham Hospital and the Children's Hospital, Boston under varying conditions. Its rapid haemostatic action was highly appreciated. The material was left in place in all the patients in amounts varying from small fragments to the size of a golf ball. There was no evidence of cortical irritation in any case. Furthermore, there was no evidence of inflammatory reaction or other unfavorable result in later autopsies. Experiments on monkeys were also carried out, and the earliest tissue reaction in the meninges was the appearance of small numbers of mononuclear and polymorphonuclear leukocytes. This was followed by rapid disappearance of foam with condensation into a more compact mass. The cellular infiltration, never extensive, became minimal and there was a slight proliferation of fibrous tissues. Only very small bits of foam were present after one week, and no fragments at all could be identified at three weeks. One of the most significant contributions to haemostasis has resulted from the large-scale plasma fractionation programme conducted by the department of physical chemistry, Harvard Medical School. One of the products of this was fibrin foam, which Bering24 described in 1944. Ingraham and Bailey tested this material on the cerebral cortex of monkeys.

Woodhall,6 in 1944, reported on the use of fibrin foam soaked in thrombin in 226 neurosurgical operations and found that a good haemostatic effect was obtained.

Fibrin sealant has come a long way, and it is being used as a haemostatic agent for operations of heart, liver, and spleen. It is also used for prevention of sarcoma formation after soft tissue dissection, closure of fistulas, and reduced suture vascular and intestinal anastomosis.27 It was used in nephron sparing surgery by Stojkovic et al.28 in 2005 and was found to be an efficient haemostatic agent for polar resection of kidney. Histology showed less intense and smaller scarring, compared with sutures. Vaiman et al.29 compared fibrin sealant Quixil in a prospective random trial on 179 patients for rates of haem-orrhagic complications between bipolar and needle point electro-cautery with fibrin glue after tonsillectomy and adenoidectomy. The results of haemostasis were better, with good systemic and local compatibility. Pruthi et al..30 used it for hand assisted laparoscopic partial nephrectomy and found that in addition to haemostatic properties, the fibrin sealant had sealing properties which could prevent urinary leakage. In 2002, Schenk-Worthington et al.31 conducted a prospective, random study to test the efficacy of fibrin sealant in PTFE graft replacement for dialysis in upper limb and found it to be a superior haemostatic agent in this vascular procedure, compared with gelfoam, thrombin, and surgical. In an experimental study on rabbits, Kheirabadi et al..32 compared the efficacy of common haemostatic agents in the fibrin sealants and assessed the functional strength to secure haemostasis in lieu of placing extra sutures. They found fibrin sealant to be most efficacious, with the potential to ease the anastomosis and shorten the duration of the vascular procedure. Nervi et al..33 used fibrin sealant in burn patients in 2001, to test its efficacy as topical haemostatic agent in a multi-centre clinical trial. Fibrin sealant was efficacious, significantly decreased time to haemostasis at the donor skin harvest sites, and had no adverse reactions. In 2000, Paulson et al34 found it to be effective in reducing post-procedural bleeding after open liver biopsy in anticoagulated and non-anticoagulated swine. Fibrin glue was also used successfully for skin graft fixation by Buckley et al35 in 1999. All patients had more than 90% take with no adverse reactions or infections. In another multi-centre, prospective, random trial Atkinson et al.36 tested the efficacy of fibrin sealant as haemostatic agent at the cannulation site in neonates undergoing ECMO (extracorporeal membrane oxygenation). The fibrin sealant was solvent/detergent treated and plasminogen depleted. The results were good.

Concerns of viral transmission with blood and blood products exist. Hino et al.37,38 reported iatrogenic human parvovirus B19 infection resulting from the use of the same batch of fibrin sealant under operation.

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