Journal of Artificial Organs

, Volume 8, Issue 3, pp 137–142 | Cite as

Clinical benefits and risk analysis of topical hemostats: a review

  • Yasuko TomizawaEmail author


A variety of local hemostats including absorbable gelatin sponge, collagen hemostat, and oxidized cellulose are commercially available. Local hemostats are applied when cautery, ligature, or other conventional hemostatic method is impractical. Proper handling is essential to control bleeding and only the required amount should be used, even though the hemostat is expected to dissolve promptly. A dry local hemostat absorbs body fluid of several times its own weight and expands postoperatively. Therefore, when an absorbable hemostatic agent is retained on or near bony or neural spaces, the minimum amount should be left after hemostasis is achieved. Documentation is important with regard to the hemostat used, including the name of the agent, site, and amount. This information is used as a reference in the interpretation of postoperative diagnostic images, since retained hemostat may sometimes mimic an abscess or recurrent tumor. The antigenicity of collagen is known to be low because of homology. When the safety of collagen was evaluated, the incidence of positive reactions was reported as 3.0%, and collagen may cause allergic reactions. Minimum inflammation without strong foreign body reactions or blockade of healing is desirable after the use of local hemostats. Strong foreign body reactions, chronic inflammation, and infections can cause granuloma formation after local hemostat use. By using local hemostats, it is possible to improve the condition of the patient, reduce complications, and lower direct and indirect costs.

Key words

Local hemostat Collagen Biomaterial Granuloma 


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  1. 1.
    Gray, E 1915Fibrin as a hemostatic in cerebral surgerySurg Gynecol Obstet21452454Google Scholar
  2. 2.
    Harvey, S 1916The use of fibrin paper and foams in surgeryBoston Med Surg174658659Google Scholar
  3. 3.
    Frantz, V 1943Absorbable cotton, paper and gauze (oxidized cellulose)Ann Surg118116126Google Scholar
  4. 4.
    Correll, J, Wise, E 1945Certain properties of a new physiologically absorbable spongeProc Soc Exp Bio Med58233235Google Scholar
  5. 5.
    Natsume, T, Okumura, N, Shimizu, Y 1993A cotton-like fibrous collagen hemostatic agentJpn J Artif Organs22348352(in Japanese)Google Scholar
  6. 6.
    Miyata, T, Taira, T, Noishiki, Y 1992Collagen engineering for biomaterial useClin Mater9139148Google Scholar
  7. 7.
    Tomizawa, Y, Komori, M, Takada, K, Nishida, H, Endo, M, Kurosawa, H 2002Conditions to accelerate vessel formation in wound healingJ Jpn Coron Assoc83840 (in Japanese)Google Scholar
  8. 8.
    Tomizawa, Y, Komori, M, Takada, K, Nishida, H, Endo, M, Kurosawa, H 2003In vivo evaluation of collagen hemostats: biocompatibility and resorptionJpn J Cardiovasc Surg321722 (in Japanese)Google Scholar
  9. 9.
    Timpl, R 1984Immunology of the collagensPiez, KReddi, A eds. Extracellular matrix biochemistryElsevierNew York159190Google Scholar
  10. 10.
    Stenzel, K, Miyata, T, Rubin, A 1974Collagen as a biomaterialAnnu Rev Biophys Bioeng3231253Google Scholar
  11. 11.
    DeLustro, F, Condell, RA, Nguyen, MA, McPherson, JM 1986A comparative study of the biologic and immunologic response to medical devices derived from dermal collagenJ Biomed Mater Res20109120Google Scholar
  12. 12.
    Cooperman, LS, Mackinnon, V, Bechler, G, Pharriss, BB 1985Injectable collagen: a six-year clinical investigationAesthetic Plast Surg9145151Google Scholar
  13. 13.
    The Canadian Multicenter Hemashield Study Group1990Immunologic response to collagen-impregnated vascular grafts: a randomized prospective studyJ Vasc Surg12741746Google Scholar
  14. 14.
    Kitamura, K, Yasuoka, R, Ohara, M, Shimotsuma, M, Hagiwara, A, Yamane, T, Yamaguchi, T, Takahashi, T 1995How safe are the xenogeneic hemostats? Report of a case of severe systemic allergic reactionSurg Today25433435Google Scholar
  15. 15.
    Chvapil, M, Owen, JA, DeYoung, DW 1983A standardized animal model for evaluation of hemostatic effectiveness of various materialsJ Trauma2310421047Google Scholar
  16. 16.
    Silverstein, ME, Keown, K, Owen, JA, Chvapil, M 1980Collagen fibers as a fleece hemostatic agentJ Trauma20688694Google Scholar
  17. 17.
    Solheim, E, Anfinsen, OG, Holmsen, H, Sudmann, E 1991Effect of local hemostatics on platelet aggregationEur Surg Res234550Google Scholar
  18. 18.
    Wagner, WR, Pachence, JM, Ristich, J, Johnson, PC 1996Comparative in vitro analysis of topical hemostatic agentsJ Surg Res66100108Google Scholar
  19. 19.
    Chapman, WC, Wren, SM, Lebovic, GS, Malawer, M, Sherman, R, Block, JE 2002Effective management of bleeding during tumor resection with a collagen-based hemostatic agentAm Surg68802807Google Scholar
  20. 20.
    Alpaslan, C, Alpaslan, GH, Oygur, T 1997Tissue reaction to three subcutaneously implanted local hemostatic agentsBr J Oral Maxillofac Surg35129132Google Scholar
  21. 21.
    Tamargo, RJ, Epstein, JI, Reinhard, CS, Chasin, M, Brem, H 1989Brain biocompatibility of a biodegradable, controlled-release polymer in ratsJ Biomed Mater Res23253266Google Scholar
  22. 22.
    Tomizawa, Y 2004In vitro and in vivo evaluation of the biocompatibility and cytotoxicity of local hemostatic agentsJpn J Cardiovasc Surg33382386 (in Japanese)Google Scholar
  23. 23.
    Tomizawa, Y, Endo, M, Kitamura, M, Shiikawa, A, Yagi, Y, Koyanagi, H 1991Coronary artery bypass graft stenosis suspected to be due to hemostatic agents: a case reportKyobu Geka44764766 (in Japanese)Google Scholar
  24. 24.
    Igari, T, Iwaya, F, Abe, T, Hagiwara, K, Tanji, M, Satokawa, H, Watanabe, M, Midorikawa, H, Sato, Y, Kashida, M, Ono, T, Hoshino, S 1990A case of foreign body granuloma after aortic valve replacementKyobu Geka43550552 (in Japanese)Google Scholar
  25. 25.
    Ibrahim, MF, Aps, C, Young, CP 2002A foreign body reaction to Surgicel mimicking an abscess following cardiac surgeryEur J Cardiothorac Surg22489490(author reply 490)Google Scholar
  26. 26.
    Ibarrola, JL, Bjorenson, JE, Austin, BP, Gerstein, H 1985Osseous reactions to three hemostatic agentsJ Endod117583Google Scholar
  27. 27.
    Bjorenson, JE, Grove, HF, List, MG,Sr, Haasch, GC, Austin, BP 1986Effects of hemostatic agents on the pH of body fluidsJ Endod12289292Google Scholar
  28. 28.
    Magro-Ernica, N, Magro-Filho, O, Rangel-Garcia, I 2003Histologic study of use of microfibrillar collagen hemostat in rat dental socketsBraz Dent J141215Google Scholar
  29. 29.
    Barbolt, TA, Odin, M, Leger, M, Kangas, L 2001Pre-clinical subdural tissue reaction and absorption study of absorbable hemostatic devicesNeurol Res23537542Google Scholar
  30. 30.
    Smith, KJ, Skelton, HG, Barrett, TL, Welch, M, Beard, J 1996Histologic and immunohistochemical features in biopsy sites in which bovine collagen matrix was used for hemostasisJ Am Acad Dermatol34434438Google Scholar
  31. 31.
    Green, JG, Durham, TM 1991Application of INSTAT hemostat in the control of gingival hemorrhage in a patient with thrombocytopenia. A case reportOral Surg Oral Med Oral Pathol712730Google Scholar
  32. 32.
    Beirne, OR, Koehler, JR 1996Surgical management of patients on warfarin sodiumJ Oral Maxillofac Surg5411151118Google Scholar
  33. 33.
    Dineen, P 1976Antibacterial activity of oxidized regenerated celluloseSurg Gynecol Obstet142481486Google Scholar
  34. 34.
    Dineen, P 1977The effect of oxidized regenerated cellulose on experimental intravascular infectionSurgery82576579Google Scholar
  35. 35.
    Hill, GB 1978Enhancement of experimental anaerobic infections by blood, hemoglobin, and hemostatic agentsInfect Immun19443449Google Scholar
  36. 36.
    Scher, KS, Coil, JA,Jr 1982Effects of oxidized cellulose and microfibrillar collagen on infectionSurgery91301304Google Scholar
  37. 37.
    Robicsek, F, Duncan, GD, Born, GV, Wilkinson, HA, Masters, TN, McClure, M 1986Inherent dangers of simultaneous application of microfibrillar collagen hemostat and blood-saving devicesJ Thorac Cardiovasc Surg92766770Google Scholar
  38. 38.
    McClure, M, Duncan, GD, Born, GV, Robicsek, F 1987In vitro effect of a microfibrillar collagen hemostat on plateletsHaemostasis17349352Google Scholar
  39. 39.
    Tomizawa, Y, Noishiki, Y, Endo, M, Hashimoto, A, Koyanagi, H 1996Evaluation of blood absorption, hemostatic ability and purity of a polyepoxy compound cross-linked cotton-type collagen hemostatKyobu Geka49126129 (in Japanese)Google Scholar
  40. 40.
    Orr, MD, Ferdman, AG, Maresh, JG 1994Removal of Avitene microfibrillar collagen hemostat by use of suitable transfusion filtersAnn Thorac Surg5710071011Google Scholar
  41. 41.
    Gondo, G, Yamashita, T, Ishiwata, Y, Hirata, K, Satoh, M 1989Peculiar computed tomographic images after intracranial use of microfibrillar collagen hemostat: report of three casesNo Shinkei Geka1710671071 (in Japanese)Google Scholar
  42. 42.
    Sandhu, GS, Elexpuru-Camiruaga, JA, Buckley, S 1996Oxidized cellulose (Surgicel) granulomata mimicking tumour recurrenceBr J Neurosurg10617619Google Scholar
  43. 43.
    Kothbauer, KF, Jallo, GI, Siffert, J, Jimenez, E, Allen, JC, Epstein, FJ 2001Foreign body reaction to hemostatic materials mimicking recurrent brain tumor. Report of three casesJ Neurosurg95503506Google Scholar
  44. 44.
    Ribalta, T, McCutcheon, IE, Neto, AG, Gupta, D, Kumar, AJ, Biddle, DA, Langford, LA, Bruner, JM, Leeds, NE, Fuller, GN 2004Textiloma (gossypiboma) mimicking recurrent intracranial tumorArch Pathol Lab Med128749758Google Scholar
  45. 45.
    Oto, A, Remer, EM, O'Malley, CM, Tkach, JA, Gill, IS 1999MR characteristics of oxidized cellulose (Surgicel)AJR Am J Roentgenol17214811484Google Scholar
  46. 46.
    Spiller, M, Tenner, MS, Couldwell, WT 2001Effect of absorbable topical hemostatic agents on the relaxation time of blood: an in vitro study with implications for postoperative magnetic resonance imagingJ Neurosurg95687693Google Scholar
  47. 47.
    Patane, F, Zingarelli, E, Verzini, A, di Summa, M 2001Complication due to excessive use of SurgicelEur J Cardiothorac Surg201034Google Scholar
  48. 48.
    van Gelderen, F, Swinnen, J 1996Appearance of oxidized cellulose (Surgicel) on abdominal radiographsAJR Am J Roentgenol1671593Google Scholar
  49. 49.
    Melamed, JW, Paulson, EK, Kliewer, MA 1995Sonographic appearance of oxidized cellulose (Surgicel): pitfall in the diagnosis of postoperative abscessJ Ultrasound Med142730Google Scholar
  50. 50.
    Young, ST, Paulson, EK, McCann, RL, Baker, ME 1993Appearance of oxidized cellulose (Surgicel) on postoperative CT scans: similarity to postoperative abscessAm J Roentgenol160275277Google Scholar
  51. 51.
    Turley, BR, Taupmann, RE, Johnson, PL 1994Postoperative abscess mimicked by SurgicelAbdom Imaging19345346Google Scholar
  52. 52.
    O'Connor, AR, Coakley, FV, Meng, MV, Eberhardt, S 2003Imaging of retained surgical sponges in the abdomen and pelvisAm J Roentgenol180481489Google Scholar
  53. 53.
    Schiller, VL, Joyce, P, Sarti, D 1994Hemostatic agent and concomitant abdominal abscessAm J Roentgenol162236Google Scholar
  54. 54.
    Iwabuchi, S, Koike, K, Okabe, T, Tago, S, Murakami, T 1997Iatrogenic paraplegia caused by Surgicel used for hemostasis during a thoracotomy: report of a caseSurg Today27969970Google Scholar
  55. 55.
    Brodbelt, AR, Miles, JB, Foy, PM, Broome, JC 2002Intraspinal oxidized cellulose (Surgicel) causing delayed paraplegia after thoracotomy – a report of three casesAnn R Coll Surg Engl849799Google Scholar
  56. 56.
    Lovstad, RZ, Steen, PA, Forsman, M 1999Paraplegia after thoracotomy – not caused by the epidural catheterActa Anaesthesiol Scand43230232Google Scholar
  57. 57.
    Awwad, EE, Smith, KR,Jr 1999MRI of marked dural sac compression by Surgicel in the immediately postoperative period after uncomplicated lumbar laminectomyJ Comput Assist Tomogr23969975Google Scholar
  58. 58.
    Alander, DH, Stauffer, ES 1995Gelfoam-induced acute quadriparesis after cervical decompression and fusionSpine20970971Google Scholar
  59. 59.
    Friedman, J, Whitecloud, TS,III 2001Lumbar cauda equina syndrome associated with the use of Gelfoam: case reportSpine26E485E487Google Scholar
  60. 60.
    FDA Public Health Notification: Paralysis from absorbable hemostatic agent. Feb 4, 2004. Scholar
  61. 61.
    Dutton, JJ, Tse, DT, Anderson, RL 1983Compressive optic neuropathy following use of intracranial oxidized cellulose hemostatOphthalmic Surg14487490Google Scholar
  62. 62.
    Nakayama, T, Shimazaki, K, Ono, J, Ohsato, K, Yamaura, A 1994Intracranial foreign body granuloma caused by fine cotton fibers: a case reportNo Shinkei Geka2210811084 (in Japanese)Google Scholar
  63. 63.
    Ito, H, Onishi, H, Shoin, K, Nagatani, H 1989Granuloma caused by oxidized cellulose following craniotomyActa Neurochir (Wien)1007073Google Scholar
  64. 64.
    Nakajima, M, Kamei, T, Tomimatu, K, Manabe, T 1995An intraperitoneal tumorous mass caused by granulomas of microfibrillar collagen hemostat (Avitene)Arch Pathol Lab Med11911611163Google Scholar
  65. 65.
    McGregor, DH, MacArthur, RI, Carter, T 1986Avitene granulomas of colonic serosaAnn Clin Lab Sci16296302Google Scholar
  66. 66.
    Chung, AF, Menon, J, Dillon, TF 1978Acute postoperative retroperitoneal fibrosis and ureteral obstruction secondary to the use of AviteneAm J Obstet Gynecol132908909Google Scholar
  67. 67.
    Erstad, BL 2001Antifibrinolytic agents and desmopressin as hemostatic agents in cardiac surgeryAnn Pharmacother3510751084Google Scholar
  68. 68.
    Harmon, DE 1996Cost/benefit analysis of pharmacologic hemostasisAnn Thorac Surg61S21S25discussion S33–S34Google Scholar
  69. 69.
    Oz, MC, Cosgrove, DM,III, Badduke, BR, Hill, JD, Flannery, MR, Palumbo, R, Topic, N 2000The Fusion Matrix Study Group. Controlled clinical trial of a novel hemostatic agent in cardiac surgeryAnn Thorac Surg6913761382Google Scholar
  70. 70.
    Fischel, RJ, McKenna, RJ,Jr 1998Bovine pericardium versus bovine collagen to buttress staples for lung reduction operationsAnn Thorac Surg65217219Google Scholar
  71. 71.
    Sirlak, M, Eryilmaz, S, Yazicioglu, L, Kiziltepe, U, Eyileten, Z, Durdu, MS, Tasoz, R, Eren, NT, Aral, A, Kaya, B, Akalin, H 2003Comparative study of microfibrillar collagen hemostat (Colgel) and oxidized cellulose (Surgicel) in high transfusion-risk cardiac surgeryJ Thorac Cardiovasc Surg126666670Google Scholar

Copyright information

© The Japanese Society for Artificial Organs 2005

Authors and Affiliations

  1. 1.Department of Cardiovascular SurgeryTokyo Women's Medical UniversityTokyoJapan

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