What are the principles of hemostasis (stoppage of bleeding) in surgery?

From the Guidelines

Hemostasis in surgery is most effectively achieved by combining mechanical, thermal, and chemical methods, with a focus on using the most recent and highest quality evidence to guide the choice of topical hemostatic agents, such as those based on collagen, gelatin, or fibrin, as recommended by the most recent European guideline on management of major bleeding and coagulopathy following trauma 1. The principles of hemostasis in surgery involve several key methods aimed at controlling bleeding during and after procedures.

Mechanical Methods

Mechanical techniques include:

• Direct pressure, which compresses bleeding vessels
• Suture ligation, where vessels are tied off with materials like silk or vicryl
• Vessel clamping using instruments such as hemostats
• Tamponade with gauze or specialized hemostatic agents

Thermal Methods

Thermal methods encompass:

• Electrocautery, which uses electrical current to seal vessels
• Laser coagulation
• Argon beam coagulation for broader surface bleeding

Chemical Methods

Chemical hemostasis utilizes topical agents like:

• Gelatin-based products (Gelfoam)
• Oxidized cellulose (Surgicel)
• Fibrin sealants (Tisseel)
• Tranexamic acid (typically 1g IV at induction, with possible repeat dosing) The choice of topical hemostatic agent should consider several factors, such as the type of bleeding, severity, coagulation status, and each agent's specific characteristics, as outlined in the European guideline on management of major bleeding and coagulopathy following trauma 1. Some of the local haemostatic agents available include:
• Collagen-based agents, which trigger platelet aggregation resulting in clot formation when in contact with a bleeding surface
• Gelatin-based products, which can be used alone or in combination with a procoagulant substance
• Fibrin and synthetic glues or adhesives, which have both haemostatic and sealant properties
• Polysaccharide-based haemostatics, which can be divided into two broad categories: N-acetyl-glucosamine-containing glycosaminoglycans purified from microalgae and diatoms and microporous polysaccharide haemo-spheres produced from potato starch Systemic approaches to hemostasis include:
• Maintaining normothermia (temperature >36°C)
• Correcting acidosis (pH >7.2)
• Ensuring adequate calcium levels (>1.0 mmol/L)
• Managing coagulopathy with blood products like fresh frozen plasma (10-15 mL/kg), platelets (for counts <50,000/μL), and cryoprecipitate (for fibrinogen <150 mg/dL) These methods work by enhancing the body's natural hemostatic mechanisms: platelet aggregation, the coagulation cascade, and fibrin clot formation, as supported by the European guideline on management of major bleeding and coagulopathy following trauma 1. Proper hemostasis reduces blood loss, improves surgical field visibility, decreases transfusion requirements, and prevents postoperative complications like hematoma formation and infection. The most recent European guideline on management of major bleeding and coagulopathy following trauma 1 provides the most up-to-date recommendations for achieving effective hemostasis in surgery.

From the FDA Drug Label

Desmopressin acetate injection will often maintain hemostasis in patients with hemophilia A during surgical procedures and postoperatively when administered 30 minutes prior to scheduled procedure Desmopressin acetate injection will often maintain hemostasis in patients with mild to moderate von Willebrand’s disease during surgical procedures and postoperatively when administered 30 minutes prior to the scheduled procedure

The principles of hemostasis in surgery involve maintaining adequate levels of clotting factors, such as factor VIII, to prevent excessive bleeding.

• Desmopressin acetate injection can help maintain hemostasis in patients with hemophilia A and mild to moderate von Willebrand’s disease during surgical procedures and postoperatively.
• It is essential to administer desmopressin acetate injection 30 minutes prior to the scheduled procedure to ensure adequate levels of clotting factors are achieved.
• Bleeding time and factor VIII coagulant activity should be checked during administration of desmopressin acetate injection to ensure that adequate levels are being achieved 2.

From the Research

Principles of Hemostasis in Surgery

The principles of hemostasis in surgery are crucial for achieving a positive outcome in any surgical intervention 3, 4. Hemostasis can be achieved through various methods, including:

• Mechanical techniques, such as manual pressure application or vessel ligation
• Thermal techniques, such as electrocautery
• Energy-based techniques, such as electrical tissue cauterization
• Topical hemostatic agents, such as fibrin sealants, microfibrillar collagen, gelatin hemostatic agents, oxidized regenerated cellulose, and cyanoacrylates adhesives 3, 4, 5
• Systemic administration of blood products or procoagulation agents 4, 6

Topical Hemostatic Agents

Topical hemostatic agents are used in a wide variety of surgical settings to aid in hemostasis when bleeding is not controllable with pressure application, vessel ligation, or electrocautery 4. These agents include:

• Fibrin sealants, which improve perioperative hemostasis and reduce the need for red blood cell transfusions 5
• Microfibrillar collagen, which promotes hemostasis by enhancing platelet aggregation and fibrin formation
• Gelatin hemostatic agents, which provide a matrix for clot formation
• Oxidized regenerated cellulose, which promotes hemostasis by enhancing platelet aggregation and fibrin formation
• Cyanoacrylates adhesives, which provide a physical barrier to bleeding

Effective Use of Topical Agents

The effective use of topical hemostatic agents is highly dependent on the surgeon's experience or preference and their availability in the surgical setting 4. It is essential for surgeons to be familiar with the different types of topical hemostatic agents, their mechanism of action, and their effective applications to ensure optimal use in the operating room 3. Additionally, the use of topical agents should be guided by evidence-based guidelines to minimize risks and maximize benefits 6.

Intraoperative Hemostasis

Intraoperative bleeding can be difficult to manage and is associated with worse patient outcomes 7. Good intraoperative hemostasis by the surgeon is a key factor in ensuring a bloodless field and reducing intraoperative blood loss 7. The decision of which hemostatic technique to use will depend on patient and procedural factors as well as the surgeon's preference 7.