1. HEMOSTASIS-TOPICAL ABSORBABLE HEMOSTATS
DANSON MWANIKI-PRODUCT SPECIALIST- ETHICON BIOSURGERY.

2. Surgery and blood loss management
For internal use - not for distribution
Surgery and blood loss management
Optimal surgical technique = effective blood loss management
Effectively control blood loss and avoid …
Prolonged operative time
Conversion of laparoscopic procedures
Unnecessary post-operative haematomas
Infection and increased morbidity
Increased length of hospitalisation
Increased re-operation rates
Haemodynamic deterioration, hypovolaemia, anaemia
Increased exposure to blood component transfusion
Impaired intra-operative visualisation
Key Messages
Surgical technique cannot be optimal unless it incorporates effective blood loss management.
This applies to any and all forms of surgery.
Presentation Notes
As the initial (‘Optimal surgical technique’) text appears – the presenter has the opportunity to introduce this slide by saying something to the effect of, ‘One of the key learnings of modern surgery is that effective blood loss management is an essential facet of great surgical technique’. The precise words of the presenter are not important as long as, in their introduction to this slide, the presenter strongly conveys Key Message one. The ‘Optimal surgical technique’ text provides visual reinforcement and, at the same time acts as a Key Message prompt for the presenter.
It is not necessary to read out all the bullet points for the factors that can be avoided through effective control of blood loss. It is suggested that the presenter mentions that, ‘there are a number of crucial complications that can be avoided by effective blood loss management, such as’ ... and then picks out a few key points, such as ‘Impaired intra-operative visualisation’ or ‘hypovolaemia’. This list can also be positioned as positive benefits – ie ‘effective blood loss management will provide the surgeon with a better view of the operative area; help reduce operative time, infection and morbidity’ ... etc.
Clinical Notes
Haemodynamic deterioration during surgery may occur as result of poorly managed or uncontrolled bleeding. The majority of the effects (on-slide) of poorly controlled bleeding are severe and clinically significant for patient recovery outcomes. Effective blood loss management concerns not only the ability to identify and arrest bleeding by effective haemostasis, but also the time taken to achieve haemostasis. 2

3. Surgery and blood loss management
For internal use - not for distribution
Surgery and blood loss management
Negative outcomes of blood transfusion can include:
Increased post-operative infection
Allergic and haemolytic transfusion reactions
Viral transmission
Increased mortality in CABG
Key Message
Blood transfusions carry a risk of increased morbidity and their use can be decreased by effective blood loss management.
Presentation Notes
Blood transfusions carry their own risks of increased morbidity. These have been shown in a new slide to avoid further cluttering the original slide. As with the list of blood loss outcomes on the previous part of this 2-slide set, the presenter does not need to read out all the potential negative outcomes of blood transfusion – it is sufficient to point out that blood transfusions carry extra health risks for patients (the audience can read the detail on the slide).
Clinical Notes
Blood transfusion complications can be broadly classified as ‘immune complications’ and ‘non-immune complications’. Immune complications are primarily due to the sensitisation of the recipient to donor blood cells (either red or white), platelets or plasma proteins, and typically include acute and delayed haemolytic reactions, and non-haemolytic reactions. Acute haemolytic reactions are usually due to blood type incompatibility, are often very severe (accounting for over 50% of transfusion-related deaths) and are frequently caused by human error (approximately 20% of the time). Delayed haemolytic reactions are generally mild in comparison and are mostly caused by the development of antibodies to foreign antibodies. There is a 1-1.6% chance of this occurring following a normal, compatible transfusion. Non-haemolytic reactions are due to sensitisation of the recipient to donor white cells, platelets or plasma proteins. These reactions include: febrile, urticarial (characterised by erythema, hives and itching), anaphylactic, pulmonary oedema, graft vs. host, purpura (spontaneous bleeding into the skin appearing as a rash) and immune suppression. Non-Immune Complications include complications associated with massive blood transfusion and infectious complications. Massive transfusion is usually defined as the need to transfuse from one to two times the patient's normal blood volume (10-20 units in a normal adult). Potential complications include blood clotting defects, hypothermia, and changes in serum potassium concentration. Infectious agents that can be passed along with blood transfusion include: hepatitis, AIDS, other viral agents (CMV, EBV, HTLV), parasites and bacteria.
Blood transfusions are associated with increased resource utilisation, postoperative morbidity and mortality in patients undergoing coronary artery bypass graft – Scott BH, Seifert FC, Grimson R. Blood transfusion is associated with increased resource utilisation, morbidity and mortality in cardiac surgery. Ann Card Anaesth Jan-Jun;11(1):15-9. 3

4. The economic burden of blood loss
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The economic burden of blood loss
There can be severe financial costs associated with ineffective blood loss management
Longer operative time
Longer hospital stays
The cost of increased morbidity
Increased re-operation rates
The cost of blood transfusion
Fixed and variable
Key Message
The financial costs associated with the clinical complications of intra-operative blood loss are severe. Presentation Notes
The clinical factors leading to many of the financial costs have already been covered in the last couple of slides so there is no need to repeat them in detail, but the appearance of the ‘severe financial costs’ text gives the presenter the opportunity to reinforce, in their introduction to this slide, that many of the clinical issues covered in the previous slides can have severe financial consequences as well as patient health and recovery issues. Then, once the bullets have appeared, the presenter can expand a little on each one. For instance (on ‘Longer operative time’) the presenter might say – ‘It is well documented that theatre time is extremely expensive, so any delays in operative procedure due to inappropriately managed haemostasis will result in extra expense, as well as a backlog in operations schedules’. For ‘The cost of increased morbidity’ and ‘Longer hospital stays’ the presenter may say – ‘Increased morbidity can be caused by many of the clinical issues already raised – and this will inevitably lead to longer, more expensive hospital stays’. When the ‘Increased re-operation rate’ text box appears, it may be worth mentioning that, if a haematoma leads to a wound infection, a patient may have to be brought back into hospital after they have been sent home and operated on again – at huge expense. If the presenter is aware of the Johnson & Johnson MATCH project they can mention that the MATCH project provides economic data demonstrating cost savings associated with the use of haemostats in orthopaedic surgery. The MATCH project has shown that QUIXIL®, together with standard haemostatic technique, can help to reduce the transfusion needs in total knee replacement (TKR) and total hip replacement (THR) surgery, and is associated with a reduction of costs in hospital versus standard technique alone. The model has been built on the basis of clinical trials performed in TKR and THR and it demonstrates, under specific assumptions, the potential to achieve cost savings via offsetting the cost of QUIXIL® against the savings made by reducing blood loss. Clinical Notes
The fixed costs of blood transfusions include: donor recruitment, procurement, storage, transportation and blood matching. Variable costs include the management of complications and longer length of hospital stay. Impaired operative visualization can lead to intra-operative complications and longer operative times. Hypovolaemia and anaemia can lead to post-operative complications and longer hospital stays. Post-operative haematomas can result in increased morbidity rates, increased re-operation rates and longer rehabilitation times and hospital stays. 4

5. TRIM
Transfusion Related Immuno-Modulation

6. TRIM
Transfusion Related Immuno-Modulation

7. TA-GVHD
Transfusion Associated - Graft Versus Host Disease
Rare
90% fatal
Happens in immuno-compromised patients..Mortality rate is 80-90%..occurs in 0.1-1% of immuno-compromised patients.The donor T-lymphocytes attack the Lymphoid tissue in the receipient. Mortality rateis higher than in the GvHd involving bone marrow transplantation,where the bone marrow is the Donor’s already.Develops on 4-30 days..characterized by an erythematous maculopapular rash which progresses to generalised erythroderma,Toxic epidermal necrosis in extreme cases…Fever,Coughing,abdominal pains,vomiting and excessive diarrhoea(upto 8ltrs/day) Lab manifestation includes abnormal liver enzymes,pancytopenia(drastic reduction in levels of WBs,RBCs and Platelets) & electrolyte imbalance if diarrhoea is present.Death results due to infections,Haemorrhages and Liver dysfunction.Treatment is only supportive as there’s no documented cure.Prevention is by Gamma irradiation of Lymphocyte containing blood products when receipient is immuno-compromised and the donor is from a 1st degree relative or HLA matched platelets are to be transferred.

8. Transfusion Related Acute Lung Injury
T.R.A.L.I.
Transfusion Related Acute Lung Injury
Third most common cause of a transfusion related fatality.Associated with difficulties in weaning from mechanical ventilation.Characterized by fever,chills,cyanosis,hypotension…Bilateral pulmonary infiltrates develop after transfusion.These infiltrates clear in 96hrs in 80% of affected patients..may persist for 7 days in the remaining 20%.Leads to increased vascular permiability.Arterial blood shows hypoxemia and respiratory alkalosis which parallels the changes in the x-ray.Its caused by the presence of leukocyte antibodies in t donor plasma which work against the WBCs in the receipient..It develops in 1-2hrs after transfusion and is fully present by 4-6hrs.

9. Traditional methods of haemostasis
For internal use - not for distribution
Traditional methods of haemostasis
Mechanical
Haemostatic clamps
Ligating clips
Clips
Staples
Sutures
Bone wax
Digital pressure
External bandages
Tourniquets
Pharmacological
Systemic
Fibrinolysis inhibitors
Aprotinin
Tranexamic acid
Epsilon aminocaproic acid
Recombinant FVII
Local
Epinephrine/adrenaline
Prophylactic
Erythropoietin
Blood transfusion/blood salvage
Transfusion (autologous or allogenic)
Cell saver
Haemodilution
Hypotensive epidural anaesthesia
Surgical cauterisation
Electrocautery
Electrosurgery
Ultrasound
Laser
Cryogenic cautery
Key Message
There are many different ‘traditional’ techniques used to achieve haemostasis in different situations.
Presentation Notes
This table shows the different ‘traditional’ methods of haemostasis divided into four categories. There are too many aspects to talk through on one slide, so the next few slides present these by category. It is suggested that, for this slide, the presenter says something like, “Here’s a table showing the different ‘traditional’ methods of haemostasis – but, as there’s a lot of information here – let’s look at it section by section”.
Then go onto the next slide. 9

10. Situations where traditional haemostasis may not be effective
For internal use - not for distribution
Situations where traditional haemostasis may not be effective
Diffuse bleeding from a broad surface area
Bleeding from an isolated source
Isolated or diffuse bleeding from a poorly visualised source
Isolated or diffuse bleeding from an anatomical location that is difficult to access
Key Message
Traditional methods of haemostasis are not always practical or effective. They are useful in many situations but may become impractical, or even clinically inadvisable in others.
Presentation Notes
This slide allows the presenter to talk about situations where traditional haemostasis is not effective. The slide only gives the minimal heading/explanation for each of the four instances to avoid overcrowding the slide – so the presenter needs to be able to contextualise each point comfortably by expanding as per the clinical notes below.
Clinical Notes
Traditional haemostasis is not always effective when there is:
Diffuse bleeding from a broad surface area – which would preclude the use of isolated ligature/occlusion methods or the use of energy-based systems (ie electrocautery).
Bleeding from an isolated source – where placement of a suture or the use of energy would not be practical because of the risk of damage to fragile tissue or to adjacent critical structures.
Isolated or diffuse bleeding from a poorly visualised source – where “blind” placement of a suture or the application of coagulating energy would also risk injury to important adjacent structures
Isolated or diffuse bleeding from an anatomical location that is not easily approached – with standard instruments for placement of sutures, clips; or with standard methods of haemostasis. 10

11. Many factors affect which method is chosen
For internal use - not for distribution
To control bleeding effectively the best choice needs to be made in each situation
Many factors affect which method is chosen
The severity of bleeding
Anatomic location of the source of bleeding
Visibility and identification of the source
Access to the source
Proximity of adjacent critical structures
The source of bleeding
Tissue type and fragility/friability
Coagulation system status
Surgical technique
Key Message
The selection of an appropriate method or product with which to control bleeding is dependent upon many factors.
Presentation Notes
Here, the presenter has a chance to talk through some of the factors that affect which method or product is chosen to control bleeding. Even though this gives the presenter the opportunity to cover some detail about the factors affecting this choice, the most important element here is the overall key message that there are many factors that affect the choice of method or product used to control bleeding – ie this is a complex area with a number of factors to consider that will affect outcome. This will begin to lay down a foundation for the premise that there are also a range of different approaches to control bleeding, each of which will be appropriate in different situations. The following comments are suggested for some of the bullets on this slide: The severity of bleeding (single bullet) – some haemostatic products and procedures are more suited to manage heavy bleeding.
Location, visibility and access bullet points – certain methods of haemostasis will not be appropriate/may be more appropriate, if the source of blood loss is difficult to find, visualise, isolate or reach.
Proximity and source – If there are ‘at risk’ anatomical structures near to the blood loss source, or if the source is in an ‘at risk’ area, this should affect haemostatic choice. This scenario may occur at any time during surgery, but is particularly likely to occur during certain types of surgery, such as neurological or spinal surgery.
Tissue type and coagulation – Certain tissue types may be more fragile/prone to bleeding (friable), and some patients may be haemostatically compromised due to their underlying health status or medication (such as warfarin) that they may have been taking.
Surgical technique – different surgical techniques will require different haemostatic solutions. It may be, however, that a surgeon is used to using one particular technique (eg diathermy) when a more efficacious solution is available. If a surgeon is used to using one particular technique it may take time for the surgeon to become familiar and comfortable with using a different technique. 11

12. For internal use - not for distribution
Good use of appropriate haemostats can improve surgical technique and outcomes
Minimise blood loss
Improve visualization
Save operative time
Reduce or avoid transfusion
Manage anticoagulated patients
Avoid conversion of laparoscopic procedures
Prevent leakage
Air, faeces, urine, CSF, bile, lymph
Decrease post-op drainage and infection
Reduce haematoma related complications
Decrease length of hospital stay
Key Message
The appropriate use of haemostats is valuable and necessary for high standards and outcomes in all types of surgical procedures.
Presentation Notes
The point of this slide is to begin to build the picture that haemostats are not simply a ‘nice to have’ – they can positively affect surgical outcomes – in fact surgery is highly likely to be poorer if they are not used. The purpose of this slide is to focus the audience on the benefits of haemostats. What’s in it for them and what’s in it for their patients? Well – the answer is – ‘a great deal!’ It is suggested that the presenter can spend a little time expanding on each point along the lines of the clinical notes below.
Clinical Notes
Minimise blood loss: This will help to lessen the need for blood transfusion and will generally reduce morbidity and improve patient recovery time.
Improve visualisation: If the surgeon can see the operation site more clearly then his/her ability to operate effectively will be improved.
Save operative time: If the surgeon can operate more effectively (as above) then operation time will be reduced.
Reduce or avoid transfusion: A reduction in blood loss via the effective use of haemostats, will reduce the need for blood transfusion with the associated benefits this carries.
Manage anticoagulated patients: Effective blood loss management via the appropriate use of haemostats is particularly important when patients are at risk of uncontrolled bleeding because they are anticoagulated.
Avoid conversion of laparoscopic procedures: Even a small amount of bleeding during a laparoscopic procedure can hinder visualisation of the magnified field. This may lead to a situation where a surgeon has to convert the procedure into open surgery – which is much more invasive for the patient. Haemostats can help prevent this.
Prevent leakage: Of air, faeces, urine, CSF, bile, lymph – with the appropriate use of sealants.
Decrease post-op drainage and infection: A more effective and appropriate use of haemostats and sealants during surgery will help minimize fluid leakage into the operation site, which will reduce post op drainage and lessen the possibility of infection.
Reduce haematoma related complications: More effective haemostasis during surgery will lead to a reduction in haematoma formation and associated complications.
Decrease length of hospital stay: All of the above will result in reduced morbidity, improved patient recovery time and shorter hospital stays. 12

13. J&J ETHICON BIOSURGERY PORTFOLIO of PRODUCTS
For internal use - not for distribution
J&J ETHICON
BIOSURGERY
PORTFOLIO of
PRODUCTS
Key Message
J&J ETHICON Biosurgery is the only company able to provide a complete haemostats portfolio.
Presentation Notes
This is the introductory title slide for the section on J&J ETHICON Biosurgery’s products. 13

14. Biosurgicals-The range
TAH
Biologics
Synthetic Sealants
SURGICEL
SPONGOSTAN
SURGIFLO plus flextip
(Internal expertise & Ferrosan partnership)
EVICEL / QUIXIL
SURGIFLO + EVITHROM
Fibrin Patch
EVITHROM
(Omrix BioPharmaceuticals
partnership)
OMNEX CV
Pulmonary Sealant
(Closure/Internal Medical-acquisition)
I often get the question….”What’s a Biosurgical?”
TAH = Topical Absorbable Hemostats (aka Traditional Hemostats)
BIOLOGICS = Plasma-based products (aka Advanced Hemostats)
SYNTHETIC SEALANTS = Chemistry-based products (aka Internal Sealants)
OUT OF SCOPE:
Adhesion Prevention (Interceed/ORC);
Tissue Adhesives (Dermabond and Prineo)

15. TAHs Classification
The hemostats in the market have two different origins: plant based or animal origin; all the plant based hemostats go through hydrolytic absorption.

16. TAHs Absorption HYDROLYTIC ABSORPTION 1-2 WEEKS
ENZYMATIC ABSORPTION
4-6 WEEKS
6-10 WEEKS
Readily degradable through
fluid absorption and gelling
Plant based haemostats are absorbed faster and with minimal tissue reaction, than animal based haemostats. They’re readily absorbed from the site of implantation because it is melted in interstitial fluids, in the fluids of the body. The other products are reabsorbed after complex chemical reactions.

17. The SURGICEL* family For internal use - not for distribution 17
Key Message
The three products in the SURGICEL* family provide optimal haemostatic solutions for the effective management of many different mild to moderate blood loss situations.
Presentation Notes
This slide gives the presenter the opportunity to overview the SURGICEL* family of products in more detail. The slides in this section deliver important factual information about the SURGICEL* family of products. The overall aim for the presenter is that, by the end of this section, the audience should understand that the SURGICEL* family of products provide the best haemostatic solution for mild to moderate blood loss situations where a traditional haemostat is required.
This slide introduces the brand names of the three SURGICEL* products. The three different products in the SURGICEL* family are called SURGICEL* Original; SURGICEL* NU-KNIT; and SURGICEL* FIBRILLAR. 17

18. Strength and Coverage Heavy flexible weave
Blanket protection against heavier bleeding
Excellent for wrapping (sternum, liver,spleen)
Can be passed down trocar (laparoscopic procedures)
Holds suture
3X density of SURGICEL Original
Higher density: 3 times more dense than Surgicel

19. Optimal versatility, adherence, and conformability
Extensive surface area for platelet adhesion and more rapid haemostasis
Faster haemostat
Conforms to irregular surfaces – Sticks/Adheres to tissue
Soft layered (7) format
Can be applied in layers, tufts, peanuts, rolls, etc.
Specially for Neuro, CV, Vascular, General

20. SURGICEL* bactericidal properties
For internal use - not for distribution
SURGICEL* bactericidal properties
Key Message
SURGICEL* (Original; NU-KNIT; and FIBRILLAR), are all bactericidal, and are the only haemostatic products that have proven this with different clinical papers (in-vitro as well as in-vivo) demonstrating a bactericidal effect against 25 different bacteria, including antibiotic-resistant bacteria such as MRSA. Presentation Notes
This slide gives the presenter the opportunity to review the proven bactericidal effects of the SURGICEL* family of haemostats. The graph (taken from the Spangler et al study) clearly shows the bactericidal effect of all three SURGICEL* haemostats from the first hour of exposure against MRSA, compared to a control (regular gauze).
Under normal conditions the pH value of blood is around 7.4. This is suitable for bacterial contamination since a pH of 4.4 – 9.0 is the range within which bacteria can survive. Bacteria become less active under acidic conditions (pH < 7.0) and many are unable to survive at pH levels lower than 4.4. The cellulose in SURGICEL* transforms into cellulosic acid (pH 2.4) when it comes into contact with blood (pH 7.4). This decreases the overall blood pH to levels below 4.0, which means bacteria cannot proliferate and will eventually die. This mode of action gives the SURGICEL* family of haemostats a broad range of antimicrobial activity.
Awareness of SSIs is constantly increasing throughout the EMEA. SSI rates range between 1.5% and 20%, depending mainly on the type of surgical procedure and wound. SSI could be costing European healthcare systems between €1.47 billion and €19.1 billion per annum. Increased length of stay ranges from 7 to 14 days (9.8 days average). Patients who develop SSIs tend to stay in hospital twice as long, resulting in a cost of care increase of between €1,000 and €8,225 per patient.
Common pathogens associated with SSIs are: Staphylococcus aureus, Staphylococcus epidermis, Escherichia coli, and Streptococcus. Infections in organs are very serious and can become life-threatening. In many cases a re-operation may be required. The bactericidal effect of SURGICEL* may help to reduce the risk of an SSI.
SURGICEL* ORC has a broad range antimicrobial activity. It has been shown that 25 different bacteria, including recently developing antibiotic resistant strains, are killed by the SURGICEL* pH effect, including: methicillin-resistant Staphylococcus aureus (MRSA); methicillin-resistant Staphylococcus epidermidis (MRSE); vancomycin-resistant Enterococcus (VRE); and penicillin-resistant Streptococcus pneumoniae (PRSP). In the Spangler et al (2003) paper, all forms of SURGICEL* were exposed to 10 different types of bacteria in vitro, including antibiotic resistant bacteria such as MRSA. After one hour SURGICEL* (Original; NU-KNIT; and FIBRILLAR) had all started to kill bacteria (see graph on slide). Bacteria populations decreased to zero in 24hrs. In the control group the bacteria population increased as expected. In testing with nine of ten bacteria, including three antibiotic resistant clinical isolates (VRE, MRSA, and PRSP), three-Log or greater reductions were seen at 24-h exposure, with all forms of SURGICEL*. Supporting references Alfieri S, et al. (2007) The role of oxidized regenerated cellulose in the prevention of Surgical Site Infections: a prospective randomized study of 49 patients with “dirty” surgical wounds. Ospedali d’Italia Chirurgia, 13:
Spangler D, et al. (2003) In Vitro Antimicrobial Activity of Oxidized Regenerated Cellulose against antibiotic-resistant microorganisms. Surgical Infection, 4(3):
Kuchta, Dineen (1983) : Effects of Absorbable Hemostats on Intraabdominal Sepsis. Infections in surgery 441: 444.
Dineen P. (1977) The effect of Oxidized Regenerated Cellulose on experimental Infected Splenotomies. Journ. Surg. Research, 23:
Leaper DJ, van Goor H, Reilly J, Petrosillo N, Geiss HK, Torres AJ, et al. Surgical site infection - a European perspective of incidence and economical burden. Int Wound Journal 2004; 1(4)
Awareness of the importance of SSIs is constantly increasing throughout EMEA 20

21. LATEST TECHNOLOGIES Available technologies
For internal use - not for distribution
LATEST TECHNOLOGIES
Available technologies
Section sub-title slide 21

22. Composition A two-component fibrin sealant:
For internal use - not for distribution
Composition
A two-component fibrin sealant:
1 – Human Fibrinogen – a concentrated solution of human clottable proteins (mainly fibrinogen and fibronectin) with no tranexamic acid
2 – Human Thrombin - A high potency solution of purified human thrombin and calcium chloride – for activation of clotting of the final combined product
Key Message
EVICEL™ Solutions for Sealant is fast acting, easy to use and reliable – and is formulated to support haemostasis when standard surgical techniques are insufficient. Presentation Notes
The next three slides give the presenter the opportunity to talk about EVICEL™ Solutions for Sealant. The three slides cover the headings: ‘Composition’; ‘MOA’; and ‘Features’ – with short descriptions relevant to each heading. The full brand name of EVICEL™ is EVICEL™ Solutions for Sealant. The formulation of EVICEL™ Solutions for Sealant is based on a concentrate of human clottable protein (with no tranexamic acid); and a high potency solution (1000 IU/ml) of purified active human thrombin with CaCl2. When combined, these two components quickly form fibrin, which cross-links directly with exposed tissue collagen, anchoring the clot firmly to the wound. Clinical Notes
The Biological active component (BAC) is a concentrated solution of clottable plasma proteins, consisting mainly of fibrinogen, fibronectin and other proteins with no tranexamic acid – so the product will no longer be contraindicated in neurosurgery. The second component of EVICEL™ is a high potency solution of purified human thrombin and calcium chloride for activation of clotting of the final combined product. Thrombin is a highly specific protease that transforms the fibrinogen contained in BAC into fibrin. When combined, the two components quickly form fibrin, which cross-links directly with exposed tissue collagen, providing excellent tissue adhesion and anchoring the clot firmly to the wound.
NB: Prescribing information is available at this meeting 22

23. Haemostats/sealants and the cascade
For internal use - not for distribution
Haemostats/sealants and the cascade
Low pH causes vasoconstriction
Provides a matrix for platelet adhesion and aggregation
ORC
Aids in fibrin clot formation
THROMBIN / GELATINE COMBINATIONS
Provides a matrix for platelet adhesion and aggregation
GELATINE or COLLAGEN
Key Message
Each haemostat technology has a specific role and MOA in the haemostatic cascade. Presentation Notes
This slide sets out the specific MOA of each haemostat technology relevant to the haemostatic cascade, and gives the presenter the opportunity to talk through these in more detail. Depending on available time the presenter can cover this in more or less detail. NOTE: When the slide initially appears, ‘SYNTHETIC SEALANTS’ also appears (in a blue text box) – away from the haemostatic cascade – to show that they do not interfere with the haemostatic cascade.
Clinical Notes
ORC products such as SURGICEL* NU-KNIT or SURGICEL* FIBRILLAR Absorbable Haemostats, absorb blood, which acts on the cellulose in the hemostat, turning it into cellulosic acid (the substance responsible for the bactericidal qualities of SURGICEL* haemostats). As well as being bactericidal, the lower pH at the wound site (caused by the development of cellulosic acid) leads to local vascular constriction, which helps limit blood loss from the wound site. Platelets adhere to the structure of the ORC haemostat, which provides a matrix for platelet adhesion and aggregation, allowing the coagulation cascade to rapidly perform its functions. Gelatine (eg SPONGOSTAN*) and collagen products will adhere to the wound site, absorbing blood on contact and providing a matrix for platelet adhesion to help the body achieve haemostasis. When used with thrombin, a flowable gelatine like SURGIFLO* Hemostatic Matrix will also aid in fibrin clot formation. Thrombin/gelatine combinations facilitate blood clotting by converting fibrinogen to fibrin as well as aiding mechanical haemostasis. A fibrin sealant (eg QUIXIL® or EVICEL™) mimics the final steps of the physiologic coagulation cascade to achieve haemostasis. A fibrin sealant will function independently of the body’s coagulation mechanism and will work even in patients with coagulopathies, or those receiving heparin or anti-coagulants. The velocity of the primary reaction between thrombin and fibrinogen has been shown to be dependent on the concentration of thrombin, so surgical sealants that are formulated with a high concentration of human thrombin (eg QUIXIL® or EVICEL™) will have a very rapid primary reaction.
Provides all the components necessary for fibrin clot formation
FIBRIN SEALANT
Provides a matrix for platelet adhesion and aggregation
Aids in fibrin clot formation when used with thrombin
FLOWABLE GELATINE
SYNTHETIC SEALANTS 23

24. THANK YOU