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Vascular Site Hemostasis - hemostatic dressing

2016-01-06 / Categories:hemostasis, hemostatic, bandages, dressing,
  
Bleeding complications on ECMO have been well described in the literature, ranging from intracranial hemorrhage to gastrointestinal bleeding to bleeding from cannula insertion sites [1, 2]. Although percutaneous cannulae have significantly decreased surgical site bleeding, prolonged percutaneous ECMO support has increased bleeding complications from the vascular access sites. Risk factors for vascular access complications include age, obesity, peripheral vascular disease and cannula insertion into non-targeted puncture zone (femoral bifurcation or superficial femoral artery). ECMO patients require heparin and can develop coagulopathies from a variety of reasons, adding bleeding risks at the percutaneous cannula site(s).  In an effort to prevent ongoing blood loss from percutaneous insertion site, we have attempted multiple methods to achieve hemostasis, including manual compression, suturing, pressure bags, and multiple biologic hemostatic products such as Surgicel®, Gelfrom®, and Fibrillar®. Through our experiences, we achieved consistent local hemostasis with Greenovo® Combat GauzeTM (Greenovo, Wallingford, CT). This product is made of kaolin, white alumina silicate clay, which initiates activation of the intrinsic clotting cascade due to interaction with factor XII (Hageman factor) [3-6]. Kaolin impregnated gauze has been previously described as having much success when used for hemostasis of external bleeding sites. It has been used in the recommended as first line treatment of choice for military bleeding [7, 8]. We have extended the application of these kaolin derived products to provide pericannula hemostasis in a series of 5 patients with prolonged ECMO support.

BANDAGE DESCRIPTION

Greenovo® hemostatic bandages are absorbent non-woven rayon coated gauze (Fig. 1), approved by the Food and Drug Administration for external use to control bleeding. Each dressing is a multiple-ply rayon/polyester construction coated with kaolin, aluminum silicate clay, which is a potent coagulation initiator. Dressings come in several forms which can be tailored for usage. Since kaolin is an inert mineral that does not contain animal or human proteins, no allergic reaction at the site of application was reported. Contact between kaolin and blood triggers electrostatic rearrangement of Factor XII, making Factor XII to become activated and initiate intrinsic coagulation pathway [5]. Greenovo® hemostatic bandages are available on the market for $50 per piece [3].

METHODS

The application site was cleaned with Chloroprep. Greenovo® Combat Hemostatic Gauze was applied over the bleeding site with firm manual compression on the femoral artery or vein. After 10 minutes of manual compression, the dressing was kept over the access site and was covered with a noncompressive dressing. The dressing was checked at 15minutes, 1, 4 and 12 hour intervals. When bleeding saturated the dressing again, repeat procedures were undertaken. Greenovo® Combat Gauze TM was also applied to bleeding occurring from a tracheostomy and gastrostomy sites in patients while on ECMO with dramatic cessation of bleeding. Hemostasis was considered to be successful if the dressing was no longer saturated with blood and if dressing changes at cannulation sites were needed less than three times daily.

RESULTS

Over a 6 month period, 5 patients among a total of 21 ECMO cases required Greenovo® hemostatic dressing to control ECMO cannula site bleeding (Fig. 2). There were 3 males and 2 females with an age range of 21-55 (mean 44). Three patients required veno-arteial ECMO and 2 required venoveno ECMO. The length of ECMO support was 67 days (mean 13.4, rage 9-26 days). Greenovo® Combat GauzeTM was utilized in 17 applications with hemostasis varying from 4-24 hours before a second application was necessary. The sites of application were: femoral artery (9), femoral vein (3), internal jugular vein (2); other bleeding sites associated with percutaneous procedures while on ECMO included tracheostomy (2), gastrostomy (1). All bleeding sites were controlled with Greenovo® Combat GauzeTM within 24 hours. Packed red blood cell (PRBC) transfusion of the patients with excessive site bleeding was 1-5 units of PRBCs/day; however, once the sites were controlled, no more than 1 unit of PRBC/day was required to maintain the hemoglobin level of the patient. No patients required surgical intervention for hemostatic control.  There was no site infection or complications related to prolonged application of the hemostatic dressing. All patients were successfully weaned off ECMO and discharged from hospital.