How should I apply topical thrombin glue to achieve hemostasis during active bleeding?

Application of Topical Thrombin During Active Bleeding

Topical thrombin should be applied directly to the bleeding site surface when oozing blood and minor bleeding from capillaries and small venules is accessible, but it is contraindicated for massive or brisk arterial bleeding where the clot will be washed away by blood flow. 1, 2

Indications and Contraindications

When to Use Topical Thrombin

• Use for minor oozing and capillary bleeding when standard surgical techniques (suture, ligature, cautery) are ineffective or impractical 1
• Effective for venous or moderate arterial bleeding associated with parenchymal injuries 3
• Consider in patients with coagulopathy or thrombocytopenia where traditional hemostatic measures may fail 4

When NOT to Use Topical Thrombin

• Never inject directly into the circulatory system - this can cause life-threatening thrombosis 1
• Do not use for massive or brisk arterial bleeding - the fibrin clot will be washed away by blood flow, making it ineffective 1, 2
• Avoid in patients with hypersensitivity to thrombin, hamster proteins, or any components 1

Preparation and Application Technique

Reconstitution

• Reconstitute thrombin powder with sterile 0.9% sodium chloride to yield a solution containing 1000 units/mL 1
• For fibrin glue formulations, combine human fibrinogen concentrate with thrombin solutions containing calcium in equal volumes, applied simultaneously from separate syringes 5, 6

Direct Application Methods

• Apply solution directly to the bleeding site surface using topical application 1
• The amount required depends on the area of tissue to be treated - titrate to the size of the bleeding surface 1
• Application results in almost instantaneous coagulum formation when fibrinogen and thrombin components mix 4

Combined Application with Absorbable Gelatin Sponge

• Apply thrombin in conjunction with absorbable gelatin sponge (USP) for enhanced hemostatic effect 1
• This combination is particularly effective as the sponge provides a scaffold for clot formation 7

Clinical Effectiveness and Limitations

Expected Outcomes

• Hemostasis is typically achieved after one application in most patients, with a second application needed in approximately 20% of cases 4
• Meta-analysis demonstrates fibrin glue reduces perioperative blood loss and the number of patients requiring transfusion 7
• Thrombin gel is effective in reducing time to hemostasis compared to no treatment 7

Critical Limitations

• Fibrin glues are most appropriate for prevention of re-bleeding rather than arrest of active massive hemorrhage because the fibrin clot may be washed away by blood flow 7, 2
• Direct application at the bleeding site is required - the product cannot work systemically 7
• Particularly ineffective when the bleeding site is inaccessible or when blood flow is too brisk 2

Important Safety Considerations

Thrombosis Risk

• Thrombin may cause thrombosis if it enters the circulatory system - ensure topical application only 1
• Never inject into blood vessels - this is an absolute contraindication 1

Hypersensitivity Reactions

• Monitor for hypersensitivity reactions including anaphylaxis during and after application 1
• Antibody formation occurs in <1% of patients and does not neutralize native human thrombin 1

Thromboembolic Events

• The most common adverse reaction is thromboembolic events (incidence 6%) 1
• Use with caution in patients at high risk for thrombosis 1

Integration with Other Hemostatic Strategies

Adjunctive Use

• Consider topical hemostatics in combination with other surgical measures or with packing for optimal results 3
• Use as an adjunct to traditional surgical techniques to obtain hemorrhage control 3
• Consider antifibrinolytics (tranexamic acid, ε-aminocaproic acid) if not already being used for excessive bleeding 7

When Traditional Options Fail

• If fibrin glue/thrombin fails to control bleeding, consider recombinant activated factor VII when traditional well-tested options have been exhausted 7
• For massive coagulopathic bleeding, replacement therapy with FFP, cryoprecipitate, or prothrombin complex concentrates may be necessary 7

Common Pitfalls to Avoid

• Do not attempt to use thrombin for arterial bleeding that is brisk or pulsatile - it will fail and delay definitive surgical control 1
• Do not inject thrombin systemically - this can cause fatal thrombosis 1
• Do not rely on topical hemostatics alone when surgical control is achievable - they are adjuncts, not replacements for proper surgical technique 3
• Do not use in inaccessible bleeding sites where direct application is impossible 2