Hemostatic Agents
Topical hemostatic agents applied to the surgical field to control bleeding that cannot be addressed by sutures, cautery, or simple pressure — typically diffuse oozing from raw surfaces, capillary bleeding, or venous bleeding on tissue that won't tolerate cautery. They are divided by mechanism into passive matrices (mechanically enhance clot formation) and active agents (direct biochemical effect on the coagulation cascade).
Mechanistic Classification
Passive hemostatic matrices
Porous or fibrous matrices that physically contact blood and platelets, promoting fibrin deposition and mechanical clot formation. Depend on the patient's platelets and clotting substrate to differing degrees; they do not correct systemic coagulopathy.
- Oxidized regenerated cellulose (Surgicel) — plant-cellulose-derived; contact activation of platelets
- Microporous polysaccharide hemospheres (Arista AH) — plant-starch-derived; absorbs water rapidly to concentrate clotting factors
- Gelatin matrices (Gelfoam, Surgiflo) — porcine gelatin; mechanical tamponade + platelet activation
Active hemostatic agents
Contain thrombin or other active coagulation factors that directly catalyze fibrin formation. May assist local clot formation in some coagulation defects, but thrombin alone still requires fibrinogen and is not a substitute for systemic reversal.
- Topical thrombin (Evithrom, Recothrom) — bovine-, pooled-human-, or recombinant-sourced thrombin
- FloSeal — flowable gelatin matrix combined with thrombin; current US FloSeal uses recombinant Recothrom (passive + active hybrid)
Combination / advanced sealing products
Discussed under Tissue Sealants & Adhesives:
- Fibrin sealants (Tisseel, Evicel) — fibrinogen + thrombin
- Collagen-fibrinogen patches (TachoSil, Evarrest) — solid-phase fibrin sealant
Selection by Clinical Situation
| Situation | Possible adjunct after source control |
|---|---|
| Broad raw surface, diffuse oozing (renal bed or pelvic sidewall; avoid intraluminal placement) | FloSeal |
| Venous bleeding on a pelvic sidewall | Surgicel or FloSeal |
| Partial nephrectomy renal bed | Suture control/renorrhaphy with selective adjunct; routine FloSeal benefit is not established[1] |
| Bone bleeding (pubic bone, sacrum) | Bone wax (outside this section) or Gelfoam |
| Bleeding around a nerve where cautery is contraindicated | A carefully selected adjunct with a removal plan; swelling can injure nerves |
| Diffuse capillary ooze from flap donor bed | Arista AH or Surgicel |
| Bleeding in a patient on anticoagulation | FloSeal or thrombin-augmented matrix (active agents outperform passive in impaired coagulation) |
| Peritoneum or serosa with persistent ooze | Thin Surgicel layer + gentle pressure |
| Urinary tract / mucosa | Avoid persistent foreign-body matrices; use active agents sparingly; many surgeons avoid cellulose in direct urinary contact due to stone-nidus concern |
Key Pitfalls
Urinary tract contact
- Oxidized cellulose (Surgicel) and gelatin matrices can serve as stone nidi if left in direct contact with the urinary collecting system
- In partial nephrectomy, place hemostatic agents on the parenchymal renal bed rather than within the calyceal reconstruction
Nerve compression
- FloSeal and Surgicel swell as they absorb fluid — can compress adjacent nerves or cause focal compression injury if packed against a nerve (e.g., lumbosacral trunk during pelvic dissection)
- Follow product-specific removal requirements near confined or vulnerable structures; do not simply pack around a nerve
Mass-effect / foreign body reaction
- Large volumes of Surgicel or gelatin matrices left in the body can produce organized granuloma mimicking tumor on surveillance imaging
- Document the location and volume in the operative note
Thromboembolic risk from intravascular migration
- Thrombin-containing products should never be injected into a vessel — rare case reports of pulmonary embolism from intravascular thrombin
Cost Hierarchy (Approximate)
| Agent | Per-unit cost |
|---|---|
| Gelfoam | Low ($10–30) |
| Surgicel | Low–moderate ($30–80) |
| Arista AH | Moderate ($80–150) |
| Topical thrombin (recombinant) | Moderate–high ($100–300) |
| FloSeal | High ($200–500) |
| Fibrin sealants | High ($300–600) |
| Collagen-fibrinogen patches | Very high ($700–1500) |
See Also
References
1. Baxter. FloSeal current US risk information. Urologic safety/effectiveness have not been established through randomized clinical studies; source-control, vascular-entry, swelling and collecting-system precautions.