Demystifying Topical Hemostatic Agents: A Mental Model for Surgeons

Patrick Georgoff: Welcome back to Behind the Knife. This is Patrick, and I wanna let you guys know that this podcast is also available as a video on our website, on our app, and on the YouTube channel. So imagine this, you've, you've packed the liver. This is a bad trauma. You've pringled and anesthesia is asking about MTP, and the scrub tech

asks you, "Hey, do you want to use FlowSeal or maybe you want an Everest patch?"

And so today we're gonna talk about when that's the right call, when it's the wrong call, and when it's just plain, uh, expensive. So topical hemostatic agents are effective adjuncts. Uh, they work, but they are not substitutes for

meticulous surgical hemostasis. And the strongest and most consistent evidence shows that there's faster time to hemostasis, but in general, no significant reduction in transfusion, reoperation for bleeding or mortality, and this, uh, is across general vascular and cardiac surgery literature.

Kevin Kniery: Yeah, I'm

excited about today's episode.

John Mclellan: begs the question,

Kevin Kniery: hemostatics are the most used, least taught tools in the operating room. They work, but they are also one of the biggest discretionary items in the OR

Nick Teman: goal today is not to talk to you out of using topical hemostatic agents. It's

Patrick Georgoff: trauma at Duke. And today, uh, uh, if you guys have heard, I'm joined by BTK founder John McClellan, who's a

trauma and acute care surgeon at UNC, BTK founder Kevin Kniery a vascular of, trauma uh, at Madigan Army today,, I'm a founder at BTK and Dr.

Nick Teman who's a cardiothoracic surgeon, and director of ECMO at the University of Colorado. And I do have one disclosure. I, I have for surgeons where we discussed how to categorize bleeding as it relates to these topical hemostatic

agents, And I was paid for that trip.

Um, so, uh, let's get started by, uh, I think probably, guys, we should make one thing absolutely crystal clear, is that topical hemostatic agents, are effective adjuncts. As we've mentioned, they are not substitutes started we most important message of, uh, clear, topical podcast and video.

They are best adjuncts. They

low-pressure bleeding from raw surfaces that you can't, you know, sew, staple, et cetera.

Um, so, uh, that, that, that's, that's really the, the biggest and most bottom line.

Kevin Kniery: so before you have them open any of the packages, you really need to ask ourselves three questions. The first line, a dissection bed, yes, this is a good candidate. But anything that's pulsatile, anything

you can see bleeding directly, no, that's a stitch or a clip. question you need to ask is: Can this patient clot at all? This is the question almost nobody asks, and it determines which product will work best. More on this in a minute. And then always, you know, you gotta start with pressure. So you have to ask yourself: Have we tried holding pressure? Really, you should wait about

two minutes, two

minutes by the clock

without peeking.

This resolves a large share of the

bleeding that otherwise would be treated

with a four hundred dollar product. It's the least

glamorous and highest yield line

Patrick Georgoff: Yeah.

Kevin Kniery: the

Patrick Georgoff: Agree. And all these products, uh, they share, uh, ridiculously similar sounding, uh, names. So we've developed a mental model, uh, that allows you to understand what these products do, what they are, what's

the difference, and there are two major identifying features. products, they is active or whether it's inactive, meaning are there clotting factors like thrombin model, that baked in, or are they simply a scaffold that allows clot to form on it?

You know, this matters significantly because you as the surgeon will need to make the determination as to whether or

not your patient's coagulopathic. Uh, the second feature is the form of the product. Specifically, is it flowable? So really, is it a, a liquid or a patch? And we're gonna cover more on this in a little bit.

John Mclellan: Yeah, I like this mental model because it, uh, requires the surgeon really

to only ask themselves two questions:

the patient make their own clot, and do I need a flowable agent to reach the area of interest?

Nick Teman: Exactly. And so let's break this down further. Now, we're gonna name brands and use brand names only so that you can recognize what's on your own shelf. Um, but remember, the products within these buckets are to a large degree interchangeable, and So if you're watching this episode, uh, as a video, check out the table

that we built in Open

Patrick Georgoff: uh, we're particularly proud of a new partnership with Open Evidence. It's an obviously incredible group of humans doing absolutely mind-boggling things. And, uh, we've integrated Open Evidence not just into this episode in terms of how we've built this and this mental model, but into, uh, for example, fact-checking our upcoming AppSite review

book, which will be a new, uh, edition this year.

Uh, we've used Open Evidence to help build our, our latest AppSite question bank as well. And we're gonna be releasing a really exciting feature called, uh, Learn More with Open Evidence into our surgical critical care curriculum and as part of a huge, uh, a project that we're working on, which is a modern, uh, a, a really,

uh, exciting comprehensive general surgery curriculum, uh, that will, uh, hopefully be ready soon.

We're, we're cranking on it.

John Mclellan: All right, so let's start with active versus

inactive. Active agents contain thrombin

and/or fibrinogen and are designed to be u- used in patients that are coagulopathic

Nick Teman: Right. And, and these are the products that work the best. So that begs the question, why don't we just use them every time?

And, And, it really, it comes down to price. Uh, these products are gonna be the most expensive. Uh, the actual dollar amounts will vary pretty widely based on hospital

contracting and things like that.

But typically, they're sold to hospitals, uh, in amounts that range from around 200 to 1,000 dollars per package, per use. Uh, and to be clear, that's not what the patients are charged, which oftentimes is

Kevin Kniery: Yeah, exactly. So let's move on to the split

within active agents, which is flowable or not. As of October twenty twenty-six, the primary non-flowable agents, specifically patches, are Everest and Tacosil, which both contain fibrinogen and thrombin

John Mclellan: And the flowable agents, and this can get confusing because they all have very similar names, are generally in two groups. The

first contain thrombin only and are delivered via an expanding gelatin matrix, and these are FlowSeal and SurgiFlow. Again, these contain thrombin only, so they may not work as well in coagulopathic patients, especially if they are low in fibrinogen. The other group is, of

flowable agents is Tisseel, Evicell, and VistaSeal, which are gels that all

Patrick Georgoff: Great.

All right. So

John Mclellan: and

Patrick Georgoff: talked about active agents being flowable and non-flowable. That's the biggest cutoff. And then, John, you, you specified for these flowable agents, uh, uh, some that contain thrombin only and those that contain thrombin and fibrinogen. So that's the k- the key differentiating factor amongst the active, uh, agents.

So we can move on now to the

passive or inactive agents.

Uh, these are scaffolds, and they require in- an intact, um, and active clotting cascade within your patients

Nick Teman: Yeah, and, and most of these agents are, are non-flowable. Um, these include things like GelFoam or SurgiFoam, uh, which are,

uh, porcine gelatin sponges. Uh, collagen products like Avitene or Helistat. Uh, w- uh, side note, Helistat cannot be used with, uh, Cell Saver. Uh, you have the Surgicel family of products, which are different varieties of oxidized cellulose, and, uh, Arista and

Patrick Georgoff: And, uh, this is a nice but, but albeit

arbitrary, uh, breakdown of these products as there's no formal way that these are, are categorized yet. And so again, we've created this as, as a, as we think to be the best mental model. And there's a reference card if you're watching on the video. We'll share it within, uh, the show notes as well, so you can take a look.

Now, one important note is that all of these products are designed to be left in the body. Although we should note that there

are some manufacturer recommendations for some of the products we just mentioned that recommend that, for example, uh, excess product be washed off once you've allowed it to set.

Um, but there are also hemostatic products that need to be removed, uh, as well that some peop- you know, naturally might clump together with some of the things we've talked about. And, and most

specifically and most commonly, these are activated gauze products like kaolin-impregnated, uh, QuickClot, um, combat gauze, for example.

Um, that's for external use. And then there's a, a product called QuickClot Control Pro- Plus that is, uh, are kaolin-impregnated lap pads that are designed for, uh,

internal use during surgery, need to be removed, but they can be left, uh, for packing. And, um, again, I think the, the most common times you see this is the QuickClot Control Plus can be used certainly in trauma situations, liver, uh, pelvic packing, et cetera.

Um, now it, it, it also probably goes without saying that these, uh, for example, the Control Plus is a--

it's more expensive than a given lap pad. So you wanna think about how you're layering these into the patient's abdomen or, or pelvis. You want the active, uh, uh, product exposed, uh, to the actual vascular surface, uh, and then the rest can be filled in with standard lap pads.

Now a, a side note on kaolin, which I'd mentioned is the activating product in these QuickClot,

uh, varieties. This is, this is interesting. It's actually a highly negatively charged, uh, particle. It comes from a clay mineral, aluminum silicate, and the negative charge, uh, helps activate, uh, the clotting system, uh, specifically factor, uh, twelve in th- in this case.

Kevin Kniery: Wow, I'm learning so much from this episode already. Uh, never had even heard of it. Uh, but a quick note, uh, because these are at least to some degree left in the

Patrick Georgoff: Actually, let's pause on that.

Kevin Kniery: the

Patrick Georgoff: Kevin, let's specify, let's transition, say, back to the ones we were talking about. I think it's a little confusing. It sounded like

it was a continuation of me blabbering on about these QuikClot ones. I would say,

you know, back to these, back to the, the, um, the topical hemostatics that we talked about before that are meant to be left in the body.

They can, you know

Kevin Kniery: Okay, banana, banana. Okay, so back to the topical hemostatics we were talking about before. Um, it's important to

note that, you know, at least to some degree, they're left in the body, and you can often see the remnants of these products on CT scan, which can lead to confusion. The best example is oxidized cellulose products in the SURGICEL family. They can leave a mass that reads on postoperative CT as a rim-enhancing collection with gas, indistinguishable from an abscess

or a recurrent tumor in an oncologic bed. So be sure to,

first of all, dictate that you put these products in, and then also read the op notes to understand what was used and where

Nick Teman: Yeah, I mean, that's, that's a great point. You will get called by a radiologist telling you that there's an abscess, uh, where you've packed some Surgicel. That, that will happen every time. But, uh, regardless of what you use, uh, I think one word of

advice is to apply the product, pack the surface, hold some pressure, and then start watching the clock and, and don't peek.

I, uh, am just as guilty of this as anybody else. I'm terrible at this. But, but really being impatient is the most common reason that these products will fail

Patrick Georgoff: You gotta set, you gotta set that clock. You gotta say out loud, you know, two

minutes and then,

know, start a separate conversation 'cause just like you, this is the longest two minutes of your life. It's so, it's so painful. No peeking allowed

John Mclellan: Yeah, exactly. Well, the good news that most of these products, you know, generally do, at least the ones I've used have, do what they claim to do. They

stop surface bleeding really faster than doing nothing or just holding pressure.

The biggest question, Nick, is that

does it really improve outcomes, metrics like mortality, OR time, blood transfusions?

Nick Teman: Yeah, you know, I mean, uh, it's a great question obviously. The, there, there is some data. The evidence is really, uh, best in the liver resection, uh, literature. Uh, there was

a, uh, Bayesian network meta-analysis of 20 randomized control trials with over 3,000 patients. Uh, they found that active flowable agents like Tisseel, Evicel, and VISTASEAL, uh, as well as non-flowable patches like Everest or TachoSil are the most effective for achieving hemostasis at four and 10 minutes.

Uh, but there was no difference in blood loss, no difference in transfusions, in bile leaks, in kinda other complications, any reoperation, or mortality. So based on that, the authors concluded that these agents should not be used as a routine practice, but as a targeted adjunct when you really

Patrick Georgoff: Yeah, and that, that liver literature

is, is probably the most developed. And when it comes to trauma patients, uh, there's surprisingly, uh, little direct evidence in, in, you know, operative management of trauma patients. It's largely observational and, and more so extrapolated from other surgical, especially it's like the liver stuff that Nikki just talked about.

And the major US trauma organizations really don't say

much about these as of, you know, October twenty twenty-six in last check. There's, there's not any, you know, significant, uh, or strong recommendations, um, uh, when it comes to the, the agents we just discussed, the ones that are meant to be left in.

There are some notes about, uh, external, uh, bleeding and, uh, packing with activated gauze agents

like QuickClot. Uh, but, uh, Kevin, I'm curious, in the vascular world, is there anything more robust?

Kevin Kniery: Yeah. So, uh, there was a systematic review done of 12 randomized controlled trials, and it found that all topical agents achieved hemostasis

significantly faster than

manual compression, with the dual agents, um, being faster but

Patrick Georgoff: And real quick, Nick, so, so again, Kevin, those dual agents you're talking about, again, just to, to really hammer home, if you're in the OR standing there and someone says, "Well, what do you wanna use?"

The dual agents you're talking about are activated agents, right? With thrombin and fibrinogen specifically, which is again, that, that there's a

huge cut, and Nick, you'd mentioned earlier the biggest reason we care is 'cause of cost, right?

So it's significantly more expensive when you start throwing active, active clotting factors into these, uh, into these, uh, uh, products that we use, whether it's flowable or a patch, uh, uh, and that's the, the huge difference. And so you had mentioned, um, Kevin, for the

studies on the vascular side, again, these are activated agents, meaning they are more costly.

And again, you gotta step back and say, oh, you're putting it on some, uh, you know, uh, a, uh, stitch, uh, leak, uh, for your anastomosis that has a little bit of ongoing oozing. You know, just two minutes of holding a, a gauze pad or whatever, you know,

uh, treat that or are you just opening up something expensive?

So again, I just coming back to this main idea of, of how you think about these things since we've never been taught about it,

that hu-huge divide, active or non-active. Sorry, Nick, you were gonna... And we'd mentioned, you know, what's going on in the CT world.

Nick Teman: Yeah, and, and certainly we use these

products all of the time, and we have to weigh the cost against, you know, if, if even if there is a, a reduction in time to hemostasis, that's OR time, right? That-- there's a cost associated with that too. So it all, it all kind of, uh, you know, I guess maybe evens out at the end.

But i-in the cardiac surgery literature, there was a meta-analysis looking at both cardiac and vascular patients,

uh, twenty-one studies, seventy-six hundred patients, uh, and they found similar findings. They found that, um, if you use an active agent, uh, like we've talked about, you will get a statistically significant, uh, reduction in blood loss, now about a hundred and twenty milliliters, so not a, not a, a huge clinical impact, uh, and, and shorter time to

hemostasis, so by about two and a half minutes.

So that's the trade-off, right? Uh, there was no difference in, again, postoperative transfusion, no difference in reoperation for bleeding, no difference in mortality. So I think, uh, I think this further supports selective use when you need it to achieve hemostasis rather than routinely breaking these products out.

John Mclellan: So I think we, we can all agree that the data overall is pretty limited, and most of the trials that are out there

are manufacturer-funded and built really just for product clearance or getting another product on

Patrick Georgoff: Yeah, I think that's super important, John. You know, as in preparation for this, there are-- you can find the studies in terms of like volume listed studies one, two, three, four,

five studies on your search, you know, return whatnot. But you start digging a little bit, uh, uh, they are again, um, not as robust as you might like, and the outcomes may not be as clinically relevant as, as may be important.

And again, uh, you gotta always check, uh, a lot of these are, uh, industries funded for clearance purposes. So with that, we can talk money.

So these, these products are expensive. We want to

use them appropriately.

Uh, uh, Nick, any,

um, any thoughts on cost? Any literature numbers we can, we can share?

Nick Teman: Yeah. Well, maybe that's the better place to focus on, right? Maybe it's better to focus on how you can get these products for cheaper. So there was a, a database study, uh, um, involving industry, uh, comparing two different active

flowable products. Uh, they found no difference in outcomes and complications between the two groups, but there was a supply expenditure gap of roughly three hundred dollars between the two products.

Um, there was another report, uh, y- where one academic center consolidated all of their topical hemostatic agents to a single vendor, uh,

and they-- and their supply expenditure dropped by twenty-five percent, uh, with no change in postoperative hemorrhagic events. So, you know, that starts to make it look a little bit more appealing if you can g- if you can get the price reduced, uh, by, by selectively choosing specific

Kevin Kniery: Yeah, and that brings us back to the point at the top of the podcast where we

said topical hemostatic agents are effective adjuncts but not substitutes for meticulous surgical hemostasis.

They are best at treating diffuse low-pressure bleeding from a raw surface you cannot sew, which means you should

Patrick Georgoff: Yeah. but I think-- And Nick, you'd, you'd mentioned before though, right? You'd, you'd mentioned OR costs, et cetera.

There's another side to the argument, right?

Nick Teman: Yeah. I mean, we really should steel man the other side too, right? If a product prevents one return to the OR for a hematoma or reoperation for bleeding, or if it reduces the operative time by ten, 15 minutes, or reduces the need for a blood transfusion, it pays for itself many times over. So that is a legitimate argument.

Um, uh,

however, based on the limited available data that we have, uh, those differences in return to the OR blood

Patrick Georgoff: Yeah. So Nick, in the CT world, uh, we're gonna go through some cases in a minute, but, uh, kind of overarching, how do you see it used across the United States, especially when it comes to,

um, centers doing big time CT surgery? Are,

are people putting these patches and glues on routinely now?

Nick Teman: Uh, I mean, I think we use these products all the time in the cardiac ORs. I will say there's probably a direct correlation between, uh, how, how far you are along in your cardiac surgery career and how many products you pull. You know, I know that senior surgeons,

they, they have a little bit more patience to just hold pressure and they know it's gonna get better.

Whereas when you're early faculty or when you're in training, you know, you, you kind of pull those products quickly. Uh, and, and so I think it just depends on, on kind of your experience level and everything else. But I mean, the fact of the matter is these are bloody operations

Patrick Georgoff: be said for vascular, right, Kevin? What do you see, uh, or what's your

interpretation of how these are being used in the world of, uh, let's say you're doing an open, uh, um, triple A or a lower extremity, uh, revasc. How are they used?

Kevin Kniery: Yeah. So I think, uh, I mean, it's just we open them, you know, standard for the case, but typically we're talking about the

cheap ones. We're talking about the inactivated, um, you know, non-flowable products like Surgicel, um, some, uh, the, uh, thrombin gel fo- or GelFoam. Things like that are kind of what we open on the back table before

the operation, and then typically we save the, you know, uh, activated, uh, compounds

Patrick Georgoff: And I would say what you

mentioned, the OGs of, of the Surgicell family that comes in, uh, there's, uh, snow, there's the, the woven, there's a whole bunch of different types,

right? Those are cheaper, they're not active. And then you also mentioned, uh, uh, something that you'll oftentimes see the techs, uh, cook up, which is GelFoam and thrombin, right?

Uh, a mix. That's really the OG in this

space, um, and is still also very effective. So you may see, uh, thrombin being reconstituted or drawn up and put onto like a GelFoam piece and then applied, and that is an activated agent that we mentioned, but it's not a, uh, uh, necessarily, besides the GelFoam product, it's not necessarily branded per se as a

pad.

Um, and, and that is, is gonna be cheaper too. And so I, I would say that if you go back in time before, uh, these named and branded, uh, products have taken off or, you know, uh, uh, to some degree may have advanced, that was the original, uh, the original. John, what about, uh, your... You know, you and I are trauma surgeons and, and ACS, you know, sick

patients.

Do you have any thoughts in, in, or maybe even from the military side about how they're being used?

John Mclellan: Yeah. So, uh, I think it's kind of what, you know, Nick was saying is that you'll see probably early career surgeons starting to

like throw everything you have at them, um, in the beginning versus just the patients. And the other thing, it doesn't... And we'll get into this with some of our cases too. It doesn't really substitute the, like the core principles of trauma and probably cardiac and vascular surgery with like good balanced resuscitation, warming, and packing, right?

Like you need to do

all those things or you're never actually gonna form a clot. but that

being said, I do, I do think there's so many different options out there, and it takes a

Patrick Georgoff: So I think there's-- I agree, John, and there's a tension here, right? Because the agents work

Um, when you push, push a, you know, an Everest pad down on a, on a oozy surface that

doesn't stop bleeding, it tends to make the bleeding stop. Maybe that might have stopped with two minutes of good pressure too, but they, they work.

Um, but what we see also is people just routinely pulling these. And again, I think, uh, to your point, Nick mentioned earlier, uh, you know, how far along in your career, what, what have you seen? How do you understand where that, where that patient's at and what you're doing?

Um, and it's interesting because we're, and the reason we're doing this, this episode is even us, the four on this, uh, the four folks on this podcast and video, um, have not been educated in this.

Certainly the, you know, us coming into this with maybe really these things exploding the last five years, truly, uh, five to

10 years, uh, as being something that's actually available to us and marketed, uh, to us that most people don't know how they work. And again, that's why this episode is important and, uh, and to be good stewards of, of the resources available that if you're going to choose to use them again, having that, that cutoff of active and non-active and that on that price line.

So let's do some cases because I do think that

takes, uh, this to something that's a little more realistic. So we have some trauma cases, an ACS case, we have vascular and CT cases to demonstrate how, you know, we, we might use them and hopefully demonstrate some of that value added, like when it might be, uh, uh, the most important.

So John, you and I have, we have, we have three cases. Let's start with

ours. We had an MVC. It's a grade four liver. There's a large stellate laceration, a significant hemorrhage. The patient's frankly coagulopathic. They're, they're cold and, and you're starting to see the oozing and you're trying to get out of the OR.

So we've done the escalation of care with the, the liver pathway. It's been packed with some, some response with the

anesthesia alone to catch up. We've tried a Pringle maneuver and, uh, it slowed the bleeding to some degree, but when you come off the Pringle, it does come back. Uh, we've even tried some parenchymal sutures, uh, some big uglies, uh, through the liver, trying to get that, that approximation, but nothing's worked well enough that you're going to pack and leave the OR at this

time.

Um, and so, uh, when we were talking, you know, an agent that comes to mind is a non-flowable agent, an active agent, like an Everest patch. Note that the Everest patch and TacaSil have an active side and an inactive side. So if you're going down into a crevice, you got to think about

which, you know, putting two pads in or how you're putting that pad in so that it's active.

Uh, if it's on top of the liver more so, that's easier because you're going to smack it onto that flat surface. Uh, the other option, uh, John, are the flowable agents, right? Uh, so FlowSeal and SurgiFlow are the two that come to mind. Again, these are the thrombin, um, enhanced agents with

the, uh, gelatin granules.

So it's that kind of, uh, yellowy, um, thicker thing that you guys have, you guys have probably, everyone's probably seen. Uh, you can put that down into a crack and pack the liver from there to see if, if that works. Um, but John, what's the, the, i-if you, if you were teaching me

the fundamentals of this case, you would be telling me something else, right?

Not, not topical hemostatic agents. What would you be preaching on again and again?

John Mclellan: Yeah. And this is, I mean, this is a tough case, right? So you're, you're already into a grade four liver. You're in the OR with a grade four liver, which is already a bad

situation, right? You're dealing with hemorrhage, and you've tried a few things now, and you're not making any progress. Uh, I think, you know, I think a lot of surgeons would just do a very tight pack, and what I've seen from a lot of these topicals, there's a good ti- chance to use them is when you do the take back after a really strong pack.

But that being said, uh, I have definitely

thrown patches of Everest all down into the cracks of a bunch of liver and on top of the liver, and it's, it's worked quite well. The flowables, I think you mentioned FlowSeal and SurgiFlow, are good. The, the only downside of any, putting any of those hemostatics in there is that it starts to kind of cloud your view of the liver, right?

You just start putting more

things in there, and it's hard to see, and next thing you know, you're just throwing money into a liver because, you know, you can't... You're gonna eventually remove those in a couple minutes anyway when it either bleeds off, because you don't have surgical bleeding controlled, or it just, you're just

gonna wipe them away when you do another round of packing. So those are the big things I see from this

Patrick Georgoff: Yeah, and I think again, it goes-- If anyone's

listening to this or watching this,

again, you could pick apart that,

that case is there's a lot going on in a case like that, and good quality trauma care in terms of warming and resuscitation and limiting your OR time and packing, getting out of dodge, using adjuncts like IR, getting back to the I...

That is the foundation, okay?

We've, we've, we've-- Again, just imagine we've done all the most perfect trauma things you can do. We're trying to get down to that point where, you know, someone like John or myself might say, "Okay, I'm willing to open up an eight hundred dollar piece of Everest because I clinically think this is gonna help the patients."

And again, it's, it's, we don't know this for certain,

but this is a case where I have seen that we've done a lot of different things. And if, again, if you just think about-- forget about like a deep crack, you're just talking about a liver. You've turned the Bovie up, you've tried pressure, you've done the Surgicel, you've done sutures, uh, maybe even like done like an omental patch and pulled all these things, and it's still not working great.

Really, that patient needs resuscitation and time and warming.

But we've seen, John and I, you put a patch on and it can work. So they do work to some degree, so we're trying to... Again, this is a, a tightrope you're walking to say, "Is this the right thing?" And again, I think for all the listeners, especially for trainees,

the patch is not the answer.

Can it be an adjunct? Absolutely. And that's what we're trying to,

uh,

uh,

discuss with these cases. So let's do another one where I think this is a nice-

Yeah

Nick Teman: Well, real quick, I, I just wanna echo, uh, something that John said that I,

think is

super important, is

that if you're like underwater, right, like it's just hemorrhage, you, you can't see, I mean, like, like that is not the time to break out a hemostatic agent. That is just, you're just wasting money at that point, right?

That person needs packing with sponges.

They, whether you're in the chest or the belly or wherever you are, they need packing until it, uh, a- and then management from the anesthesia side with products and things like that to get some degree of coagulation, and then break out the products. Don't start squirting flowables when you can't even see anything.

It's just, it's gonna do absolutely nothing

Patrick Georgoff: 100%. So let's-- here's another frustrating one, John. So you,

uh, you're... It's late night, it's 2:00 AM. You got a big nasty colon, uh, septic shock. It's a perforated sigmoid diverticulitis, and, uh, you are working down the splenic flexure a little bit. Let's say you had to take it up, uh, some of the descending colon had to come out too.

And, uh, when you're doing some packing and when you were mobilizing the

inferior, uh, pole of the spleen, uh, it got, uh, it has a little avulsion injury on the capsule. And so you started by turning the Bovie up to shock mode. You're up to eighty, a hundred, and you're frying the thing. That doesn't do anything.

You do it, and then you see a little char, and then all of a sudden, the blood just starts pooling out of it again. You've

done your due diligence, you packed, okay? Uh, you, um, packed and you didn't peek. Let's say you did three full minutes. John's a very patient man. He, he waited three full minutes packing.

Uh, that didn't work. And you- you-- And, and, and the more you just kinda monkey around, and again, this patient's septic, they're on ster- they're on pressors, et cetera, you're like, "Man,"

the thought comes in your mind about a splenectomy. So what might work, uh, you know, for this patient to start at least? What would you recommend or what would you try?

John Mclellan: Yeah. You know, this is a, this is a classic case of a, you know, a trauma surgeon. You know, you're doing this at 2:00 AM, and,

uh, chief resident got their big paw up there and tore down on the, on the, on the s- like splenic flexure and tore the, tore the spleen or something like that, um, which is, you know, is

common in these type operation. But now you're also thinking you're maybe not doing this through

Patrick Georgoff: Yeah.

John Mclellan: incision, so you're

Patrick Georgoff: Peaking up

John Mclellan: it up

into the, the

left to like

'Cause then now you're debating whether you're gonna extend the incision, take out a spleen, or are you gonna get by with hemostatics.

But to back to your question, I think, you know, one of the things that does work well is a

hemostatic agent like SURGICEL or something like that. I think, uh, SURGICEL on the spleen does

Patrick Georgoff: Yeah. So for the most part, you, you would start a Surgicel,

um, maybe even less than a hundred bucks

depending on what your, your, your, uh, a hundred bucks, two hundred bucks, something, you know, you're in that price range depending on what your, um, agreement is with whoever's, you know, uh, selling that stuff to your institution.

You put it in there, you hold it for two minutes, you pack. That's gonna take care of most of these. Um, now there are some that can be a little more aggressive, maybe that, um,

laceration or, or, or the splenic capsule tear extends a little farther up. If you're getting to the point where you're thinking about a splenectomy, you could put an Everest patch, for example, on there.

I've done that before too, and when I've truly tried everything else, including Surgicel, the cheaper option, time, everything else, and it made the bleeding stop.

So I think that's a great example of that, this vague non-stitchable, non-clippable, non-staplable, uh, we tried packing type of bleeding, strong venous bleeding from that, uh, high blood flow spleen where this is an agent that can, you know, work pretty well

John Mclellan: Yeah, it's interesting with the-- especially with EVERS and kind of the more advanced hemostatics. I would put, you know, SURGICEL into that kinda category that still has a very strong role in all, you know, general surgery at least. But, you know, when you're going through like oral boards or stuff like that, you're never gonna say, "I'm gonna put a hemostatic up

there, and, and then that's what I'm gonna do.

You're gonna fix it." But, you know, I, I do see because we're having these... EVERS is an amazing instrument if you know how to use it right. Like, I do see that moving into the realm where we're now managing some liver, uh, spleen injuries outside of

EGS with EVERS patches as like spleni-splenic preservation.

Patrick Georgoff: glad you brought

up this on the boards. You know, collectively, I think we would say,

uh, you would-- i-if you were to mention a topical hemostatic agent as an answer to your question, you would have had to really gone through a lot of pains to talk about good surgical technique and decision-making before you would say, "Let me put a topical hemostatic agent on it."

I'm not saying it's wrong, and it may

fit into certain things, but you'd wanna, you'd wanna couch that answer, you'd wanna formulate that answer so it shows the, uh, examiner what you're r-- you know, you're thinking about other things that go beyond just that, that agent. Um, so Kevin, let's do, let's do, uh, some vascular surgery, uh, cases.

Kevin Kniery: Yeah. So, um, I'll talk through a recent case actually, um, where I r-you know, relied on, uh, on some help, um, from topical hemostatic. So we had an open triple A, um, everything's going great. We decided to transect, uh, the infrarenal neck, um, to do an end-to-end anastomosis for that proximal anastomosis. As we're sewing the

proximal, a little lumbar bleeder starts, a little artery bleeder starts from the kind of remai-- the, the, the sac, um, that's remaining in the body, um, right at the cut edge. And so said, "No big deal. Let me get a, a 5-0. Let me just put a stitch in that, uh, lumbar artery that's kinda bleeding." And we-- I, I tie down the, the artery

and then brisk venous bleeding comes from behind the aorta, between the aorta and the spine. Um, and, um, in this situation, we held pressure, uh, held pressure.

Um, of course, the patient is anticoagulated at this point in time 'cause we have in-- we have an infrarenal clamp on. Um, we tried placing stitches from every which

angle, but there's really not a lot of tissue to grab behind the aorta 'cause you're basically on the spine. every time you take a peek, it's like three hundred ccs of blood loss somehow.

Um, it's one of these just really frustrating venous bleeders. Um, and so, uh, after trying kind of everything we could, um, we put a, a patch of,

um, the, you know, Everest Tacosil-type things, and, um, two minutes of pressure,

that three hundred cc gush was completely gone. it was, it was a-absolutely, um,

Patrick Georgoff: to You tried all the, the surgical things. You tried suturing, of course. You put your sutures in, tied down, tied down, it wasn't working, and then,

um, an answer here in the form of, uh, a topical that gets into that, that type space. You could consider things like Flowseal and SurgiFlow too, right, into the space.

We should mention that you do... So, uh, in terms of the IFUs, the indications for use for these products, like the flowable gelatin agents, uh, with thrombin, like Flowseal, SurgiFlow,

there is a risk of embolization. So you would never use any of these agents inside or immediately adjacent to an open vessel.

Think like a big vein. Now, you know, John and I were just talking about liver stuff, you know, that you can have open veins in the liver, uh, uh, and, and you, you may be compressing it. That could be an issue. You gotta think

about that. Really, though, these are, uh... So you have to think about embolization from especially these gelatin flowable products.

Um, there's no... That doesn't seem to be a super high risk for something like packing. Uh, but again, big open vessels, uh, you don't wanna be just injecting stuff in it or around it 'cause that'd be, could be catastrophic.

And you have another one, right?

Kevin Kniery: Yeah, the-- more common scenario that we deal with, uh, you know, on a weekly basis is just your suture line oozing, um, right? And so I think the, the important concepts to remember here are, um, the patient's only transiently,

um, coagulopathic, right? So at this point in time, you're going to be giving your protamine, um, to reverse the heparinization.

And you can start with the inactive compounds such as your Surgicel and Gel Foam. Um, and, and so typically that's what we do. Uh, we, we kind of place Surgicel or Gel Foam around the, the suture line, uh, give the

protamine, hold pressure for two minutes, sometimes five minutes. I had an-- Darren Schneider at, uh, Cornell, he would always-- we would-- No matter how much it was bleeding, we'd pack it, reverse the protamine, wait five minutes, and almost a hundred percent of the times it was completely not bleeding. Um, and so, um, but yeah. So in this kind of situation, um, you know, you're reversing the

coagulopathy.

You know it's just sort of, uh, needle hole bleeding. Um, starting off with some of the inactive compounds can be,

Patrick Georgoff: I think that's key. I mean, you're talking about a heparinized patient, right?

Like they're gonna bleed, right? You just cut them open and put them on heparin. Nick, you have your cases here in a minute for CT world. You know, this is very-- this is quite a bit different, I think, than John and I dealing with a trauma or, or a, or a

frustrating spleen, right?

These are patients who are anti-- actually anticoagulated. So Kevin, good points, right? Time, reversal, pressure are the keys here, uh, before you go wild just slapping things on on a, uh, universal basis, right? All right, Nick, let's talk about a,

type A repair

Nick Teman: Yeah, so, so similar to, to Kevin

talking about, uh, vascular surgery, you know, all, all of our patients

in cardiac surgery are, are

bleeding. You know, we don't even quantify A blood loss. Uh, a-and so, uh, but, you know, most of them are going to, uh, stop bleeding after you reverse, uh, with protamine, uh,

after you hold some pressure, and, and you shouldn't need products in the, in the majority of patients.

But, you know, I do wanna highlight a couple scenarios in which case we commonly do need to use hemostatic agents. So, so the first, yes, is a kind of emergent type A aortic dissection repair. Uh, and so let's say you do your repair, you do a, a hemi-arch and

a valve resuspension, and after rewarming and you reverse the heparin with protamine, uh, you see some diffuse oozing coming up from behind the aorta. Uh, you kinda peek back there. Uh, you can see the suture lines. It doesn't seem like anything is, is pumping. Um, it's just kind of diffuse. Um, and, and so I think, you know,

one, one thing that's we didn't talk about, one class of hemostatic agents that we didn't mention that are kind of unique to vascular and cardiac surgery are vessel sealants.

Um, uh, and, and some surgeons use these basically on an anastomosis before you even have bleeding. So it's not a treatment for bleeding. It's more of a preventative thing. Uh, commonly, uh, used products include

Prevaleak, Tredine, BioGlue. Those are some of the trade names of, uh, of products that some people use. Uh, a-and these aren't gonna fix poor surgical technique, um, but they can help prevent needle hole bleeding and, and oozing just relating to- related to patients being coagulopathic. You know, we- when we talk about dissection repairs, these are patients that have longer bypass runs.

They're patients that are cooled down more than normal, and so these patients are all coagulopathic and, and these products can help kind of, um, prevent, uh, leaking from the anastomosis in that situation. The other thing that I find really useful, especially if you can get circumferential around the anastomosis, is to basically cut a strip of Everest, uh, hot dog, not hamburger, and, and, uh, and

basically wrap it around the anastomosis and then, uh, sometimes we'll even kinda clip it on top just to hold it tightly around there, and that can really help, uh, deal with some of that just medical bleeding.

You know, it's not, it's not bleeding that a suture is gonna fix. Sutures often will make it worse in that situation because the

Patrick Georgoff: Nick, I got one question for you and one point to make about this other... You threw in a whole nother type of, uh,

product, right? We didn't talk about specifically 'cause they're not in essence hemostatic agents. So you mentioned something like PrevaLeak or BioGlue. These are glues, gels essentially, that chemical...

They're chemical cross-linking mechanisms to form a essentially an elastic mechanical seal

around whatever you're, you're working on. It doesn't have fibrin in it, it doesn't have, uh, or fibrinogen, it doesn't have, uh, uh, thrombin in it, et cetera. Uh, but it's a just a, a true mechanical agent. So we did not add that to this, this mental model that we've shared and, and this table that we've created, um,

uh, because these are not in- in...

One might look at them as not being truly hemostatic, right? Uh, they're not hemostatic. They're independent of the coagulation cascade, so I think that's important. Uh, adds to the confusion, right? There, there's... Right? It's just there's more and more of these products that are more confusing, but, but do keep that in mind that there's a whole, a whole glue category that are not

hemostatic.

Uh, the second thing I would ask is, so what, what, what did the cardiac surgeons do 10 or 15 years ago when you couldn't hot dog a piece of Everest around your anastomosis? And did that patient do worse than

today if you hot dog a piece of Everest around an anastomosis? 'Cause

y-

because you will see it, the, the bleeding decrease.

You will

Nick Teman: Yeah, I mean, it's a great question. I, I've, uh, I've asked that because, uh, Everest came out while I was a fellow, so I, I, I, uh, saw, uh, you know, Everest kinda take over and really kinda change the game for a lot of what we do. Uh, there were other products, uh,

that have since kind of gone out of the, out the market.

Um, uh, we, we do use TacaSeal. The problem with TacaSeal is that it, it's very hard to conform to an irregular surface, or certainly you'd never be able to kinda wrap it around the aorta. It would just kind of, uh, shrivel up and, and, and you'd never really get that to work. So, so I think it's just there was a lot more packing, temporary closures, things like

that.

I mean, I've, I've definitely seen an impact of

Patrick Georgoff: Now there's-- You talked about the data.

Anecdotally, would you go as far to say that these things decrease take backs?

Nick Teman: Uh, anecdotally, I don't know that they decrease take backs. I think they decrease the time you spend in the operating room. I think that you can get out of the

operating room faster, and I think that I sleep

Patrick Georgoff: Your, your sl- your sleep is very important, and it is-- and your sleep is worth the, uh, the cost of an Everest patch, so we'll, we'll leave it at that.

Nick Teman: 100%. All right, and then so moving on to, uh, my second case, which, uh, is, is also a difficult case. So this is a, a redo heart

transplant or a redo sternotomy with a heart transplant, uh, and explanting an LVAD. And, and this is just, you know, these cases are just a mess. There's oozing from everywhere. The patients are all coagulopathic.

You, you're basically sitting there regretting every decision that you've made in life up to that point. And, and at that point, you're just kinda throwing the kitchen sink at, at all of the diffuse bleeding from

every kinda surface area. So you're using flowables, you're packing, uh, with Surgicel or QuickClot, you're putting Everest on anything that you can get Everest on. Uh, you, you sometimes you're, you know, spraying, uh, um, uh, you know, Tisseel or, or Evicel o- on, on surfaces. Oftentimes you've gotten into the lung, uh, at which point you're spraying Vista

Seal or something onto the lung to get that to stop bleeding and having an air leak. So, uh, I, I mean, I think you're really kinda just doing whatever you can, and, and there's certainly no science to this.

This is all just art. Um, I, I would caution, uh, just in general for, for, uh, budding cardiac surgeons, my personal bias is to not use any of the powder-based hemostatic agents in cardiac surgery. I

think that these tend to, uh, kinda clump up and form kind of a sludge, uh, that can occlude, uh, the chest tubes that we routinely use after cardiac surgery.

Um, Fibrilar also, I don't mind wrapping Fibrilar in, uh, Surgicel. I think that's fine, but exposed Fibrilar, same thing, kind of you get this sludge that blocks off the chest tubes. And the key to hemostasis in cardiac surgery is

tissue apposition, right? So you get tissues touching tissues, and that provides y- a little bit of tamponade that, that, uh, helps bleeding to stop.

And so the moment your chest tubes clot off and you start having blood building up in the chest, you're-- you've lost. There's nothing you can do. You're gonna have to take the patient back to the operating room. So keeping the chest tubes patent, I think, is the single most important thing in, in cardiac surgery.

Uh, another unique thing about cardiac surgery is that we have a very low threshold, uh, to just pack. And we talked about it for liver, uh, lacerations, but, you know, we pack patients in cardiac surgery all the time and just do temporary closures. Uh, every center does this a little bit differently in terms of how they approach this. [00:4