Background : Hemostasis can be difficult to achieve after blunt abdominal trauma, particularly if the patient is coagulopathic. The U.S. Food and Drug Administration has recently approved the Rapid Deployment Hemostat (RDH) bandage (Marine Polymer Technologies, Cambridge, MA) as a treatment for external bleeding after extremity trauma. It has not been evaluated for internal bleeding. We tested whether the RDH bandage could achieve hemostasis when used as an adjunct to standard laparotomy pad packing after severe liver injury.
Methods : Anesthetized swine (n = 10, 35-45 kg) received an isovolemic 45% blood volume replacement with refrigerated Hextend (6% hetastarch). Core body temperature was maintained at 33° to 34°C with intra-abdominal ice packs. A hypocoagulopathic state was documented by thromboelastography (p < 0.001). At this point, a severe liver injury was induced by the avulsion of the left lateral hepatic lobe. Animals were randomized to standard abdominal packing (control) or packing plus RDH bandage. The abdomen was closed and the animal resuscitated with one unit of blood plus lactated Ringer's as needed to maintain a mean arterial pressure > 70 mm Hg. After 1 hour, the packing was removed, the abdomen was closed, and data were collected for an additional 2 hours.
Results : The RDH bandage reduced mortality, total blood loss, and total intravenous fluid requirements and increased survival time when used as an adjunct to standard abdominal packing after severe liver injury.
Conclusion : Further work in the clinical arena is warranted.
Liver injury is common after blunt trauma. Most of these injuries are managed conservatively and do not require operative intervention. However, mortality in the higher grade injuries requiring surgery (grades V and VI) ranges from 50% to 100%. 1,2 Exsanguination is the primary cause of death in these patients. Hemostasis in these patients is hindered by coagulopathy, which results from hypothermia, dilution of clotting factors, thrombocytopenia, and acidosis. Topical hemostatic agents are frequently used as adjuncts in the control of intraoperative bleeding. Although a number of different materials in a variety of forms have been used with fair success, each has potential drawbacks, making a more effective topical hemostatic agent desirable. Currently available products include oxidized cellulose (Surgicel), absorbable gelatin sponge (Gelfoam), microfibrillar collagen powder (Avitene), fibrin sealant (Tisseel), fibrin sealant dressing (TachoComb), fibrin glue (Bolheal), and topical thrombin. No single product has emerged as dominant.
A new polysaccharide product, fully acetylated poly-N-acetyl glucosamine (p-GlcNAc) (Marine Polymer Technologies, Danvers, MA) has been recently developed. P-GlcNAc is a polysaccharide polymer produced by a fermentation process and isolated from controlled, aseptic, microalgal cultures grown on a defined culture medium. 3 Gel formulations of this substance have been evaluated as hemostatic agents and found to be effective. 4,5 The membrane formulation of p-GlcNAc, applied to one surface of a standard gauze bandage, has been termed the Rapid Deployment Hemostat (RDH) bandage.
The mechanism of action of p-GlcNAc is thought to work outside of the coagulation cascade. In this respect, it should maintain efficacy in the setting of coagulopathy. Patients with severe liver injuries often present with or quickly develop hypothermia and coagulopathy, complicating hemostasis. We hypothesized that the addition of the RDH bandage to gauze packing for hemorrhage control, despite a coagulopathy, would result in reduced blood loss compared with standard treatment with gauze packing alone. This study was performed to evaluate the effectiveness of the RDH bandage for hemorrhage control after severe liver injury in the presence of a hypothermic and dilutional coagulopathy.