Science of Hemostasis

Transcription

1 Educational Series Science of Hemostasis The third-party trademarks used herein are trademarks of their respective owners Ethicon US, LLC

2 Educational Series Module 1 Burden of Bleeding Module 2 Clarifying the confusion in the adjunctive hemostat marketplace Module 3 Science of Hemostasis Module 4 Hemostasis Optimization Program Module 5 Resident Training

3 Patient factors contribute to the increased risk of surgical bleeding The new normal Patients suffer from a growing number of comorbidities, which increases surgical bleeding risk 1,2 Comorbidities such as uncontrolled diabetes and obesity can affect the natural clotting process 2 Aging demographics have led to increasingly complex and extensive surgeries 2,3,4 1. Parekh AH, Barton MB. The Challenge of Multiple Comorbidity for the US Health Care System. JAMA. 2010; 303: MedMarket Diligence (2012) Worldwide surgical sealants, glues, wound closure, and anti-adhesion markets, Report #S Department of Economic and Social Affairs Population Division (Web Page) World Population Ageing: Updated Available from: ( Accessed Mar Levy JH, Dutton RP, Hemphill JC, et.al. Multidisciplinary approach to the challenge of hemostasis. Anesth Analg. 2010; 110 (2):

4 Patient medications and conditions increase the risk for surgical bleeding Several patient medications and conditions may lead to surgical bleeding in approximately 10% to 25% of procedures 1,2,3 Growing incidence of cardiovascular disease increases use of anticoagulants and antiplatelets 4,5,6 Patient medications: Aspirin Warfarin (COUMADIN) Clopidogrel (PLAVIX) Novel oral anticoagulants 1. Shander A (2007) Financial and clinical outcomes associated with surgical bleeding complications. Surgery 142 (4 Suppl):S Voils SA (2009) Thrombin products: economic impact of immunemediated coagulopathies and practical formulary considerations. Pharmacotherapy 29 (7 Pt 2):18S-22S. 3. Marietta M, Facchini L, Pedrazzi P, Busani S, Torelli G (2006) Pathophysiology of bleeding in surgery. Transplant Proc 38 (3): Millennium Research Group Inc (2011) US Markets for Surgical Hemostats, Internal Tissue Sealants, and Adhesion Barriers In. 5. Shireman TI, Howard PA, Kresowik TF, Ellerbeck EF. Combined anticoagulant-antiplatelet use and major bleeding events in elderly atrial fibrillation patients. Stroke. 2004;35(10): Anderson FA, White K (2002) Prolonged prophylaxis in orthopedic surgery: insights from the United States. Seminars in Thrombosis and Hemostasis 128 (3):

5 Types of Bleeding There are different types of bleeding (eg, capillary, venous, or arterial). Each type may require different methods to achieve hemostasis. Capillary Slow-flow Broad or diffuse oozing Venous Slow-steady flow Broad or diffuse oozing Arterial Spurting, pulsating flow Small Artery Large Artery Dark-red Bright-red Primary Methods and Adjunctive Hemostats Primary Methods Hemostasis Primary methods of hemostasis may not always allow achievement of complete hemostasis. Using an adjunctive hemostat may result in faster time to achieve and sustain hemostasis. 5

6 Different bleeding situations require different solutions Primary Methods Mechanical Energy Sutures Monopolar and Ligating clips Bipolar Electrosurgery Staples Ultrasonic Clamps Advanced Bipolar Manual compression Adjunctive Methods Topical Hemostats and Sealants Oxidized regenerated cellulose Flowable gelatin Fibrin sealants Fibrin patches Bone wax Collagen based 6

7 Primary Hemostasis Methods Alone May Be Ineffective or Impractical in Some Bleeding Situations Surgical Situations Uneven tissue topography in bone or tumor bed Difficult to control compression at sites of diffuse bleeding Difficult to access to bleeding source Bleeding near critical structures (ureters, nerves, and blood vessels) Patient Groups Comorbidities, such as uncontrolled diabetes, obesity, and certain chemotherapies Anticoagulant and antiplatelet therapies source Aging population with more complex surgeries and comorbidities Obstructed visualization by blood or anatomic structures Minimizing charring from monopolar energy 7

8 There are multiple points of intervention along the coagulation cascade 8

9 There are multiple points of intervention along the coagulation cascade Disrupted endothelium Platelet Vessel Injury Red Blood Cell 9

10 There are multiple points of intervention along the coagulation cascade Vasoconstriction 10

11 There are multiple points of intervention along the coagulation cascade Activated Platelet Platelet Plug Formation 11

12 There are multiple points of intervention along the coagulation cascade Fibrin Fibrin Clot Formation 12

13 There are multiple points of intervention along the coagulation cascade Fibrinolysis 13

14 There are multiple points of intervention along the coagulation cascade Antithrombotic medications disrupt the body s ability to form a clot 14

15 There are multiple points of intervention along the coagulation cascade 15

16 The Confusion in the Marketplace Number of choices & lack of standardization has led to suboptimal use of adjunctive hemostats 16

17 Surgeon s decisions rely predominately on site and situation 17

18 Five bleeding situations emerge from the sites and situations that surgeons encounter Continuous Oozing Problematic Difficult to Access Potential Re- Bleeding Risk High-Pressure Vessel Bleeding Will not stop with compression/ simple packing. The solution for this bleeding is more time consuming than it is difficult. 1 Even though the bleeding is accessible, it could be trouble. It is more than routine, likely to be resistant to conventional means, requires immediate attention, and causes disruption to the normal progression of surgery. 1 Bleeding that occurs in tight and irregular spaces; you cannot see the exact source of the bleed. You are concerned that accessing a tight space will cause more harm. 1 Bleeding may be addressed intraoperatively but could later develop into more serious complications, especially in highrisk patients. 1 A leak in a highpressure vessel (aortic or peripheral vascular suture line) that has been stopped, but if it leaks post-op, could be catastrophic S-Factors Insight Research and Next Steps Meeting. 18

19 Comprehensive Bleeding Management Solution Mechanical Sutures/Ligatures Dissection/ Transection PRIMARY Methods of Hemostasis GOAL: Prevent/ minimize bleeding Energy Ligating Clips Staplers Monopolar and bipolar electrosurgery Ultrasonic Advanced bipolar Important Risk Information: Adjunctive hemostats (shown above) are not intended for use on nonbleeding tissue or for prophylactic use. The bleeding situations identified reflect customer insights/market research on optimal adjunctive hemostat utilization. The product solutions should only be used in accordance with their instructions for use. Product recommendations should not supplant medical judgment. Surgeon preference, experience, and patient needs may dictate alternate technique. Review all relevant precautions, especially the indications, contraindications, warnings, and information for use. Please see package inserts for Full Prescribing Information. The visual does not reflect any sequential order in use. Reference: 1. Hemostasis Optimization Program and Next Steps Meeting.

20 Comprehensive Bleeding Management Solution Mechanical Sutures/Ligatures Hemostasis Achieved Yes Dissection/ Transection PRIMARY Methods of Hemostasis GOAL: Prevent/ minimize bleeding Energy Ligating Clips Staplers Were Primary methods of hemostasis effective or practical in achieving complete hemostasis? No Monopolar and bipolar electrosurgery Ultrasonic Advanced bipolar ADJUNCTIVE Methods of Hemostasis GOAL: To achieve complete intraoperative hemostasis & reduce risk of postoperative bleeding Important Risk Information: Adjunctive hemostats (shown above) are not intended for use on nonbleeding tissue or for prophylactic use. The bleeding situations identified reflect customer insights/market research on optimal adjunctive hemostat utilization. The product solutions should only be used in accordance with their instructions for use. Product recommendations should not supplant medical judgment. Surgeon preference, experience, and patient needs may dictate alternate technique. Review all relevant precautions, especially the indications, contraindications, warnings, and information for use. Please see package inserts for Full Prescribing Information. The visual does not reflect any sequential order in use. Reference: 1. Hemostasis Optimization Program and Next Steps Meeting.

21 Comprehensive Bleeding Management Solution Intraoperative Bleeding ADJUNCTIVE Methods of Hemostasis Can you see the source of bleeding and apply hemostat? GOAL: To achieve complete intraoperative hemostasis & reduce risk of postoperative bleeding Is there intraoperative bleeding with a concern of postoperative re-bleeding? Important Risk Information: Adjunctive hemostats are not intended for use on nonbleeding tissue or for prophylactic use. The bleeding situations identified reflect customer insights/market research on optimal adjunctive hemostat utilization. The product solutions should only be used in accordance with their instructions for use. Product recommendations should not supplant medical judgment. Surgeon preference, experience, and patient needs may dictate alternate technique. Review all relevant precautions, especially the indications, contraindications, warnings, and information for use. Please see package inserts for Full Prescribing Information. The visual does not reflect any sequential order in use. Reference: 1. Hemostasis Optimization Program and Next Steps Meeting, dated 06/30/2014.

22 Comprehensive Bleeding Management Solution Intraoperative Bleeding Continuous oozing Will not stop with compression/ simple packing. The solution for this bleeding is more time consuming than it is difficult. 1 ADJUNCTIVE Methods of Hemostasis GOAL: To achieve complete intraoperative hemostasis & reduce risk of postoperative bleeding Can you see the source of bleeding and apply hemostat? Yes No Problematic Even though the bleeding is accessible, it could be trouble. It is more than routine and likely to be resistant to conventional means, and requires immediate attention causing disruption to the normal progression of surgery. 1 Difficult to access Bleeding that occurs in tight and irregular spaces and you cannot see the exact source of the bleed. You are concerned accessing a tight space will cause more harm. 1 Is there intraoperative bleeding with a concern of postoperative re-bleeding? Yes Potential rebleeding risk Bleeding may be addressed intraoperatively, but could later develop into more serious complications, especially in high-risk patients. 1 High-pressure vessel bleeding A leak in high-pressure vessel (aortic or peripheral vascular suture line) that has been stopped, but if it leaks post-op, could be catastrophic. 1 Important Risk Information: Adjunctive hemostats are not intended for use on nonbleeding tissue or for prophylactic use. The bleeding situations identified reflect customer insights/market research on optimal adjunctive hemostat utilization. The product solutions should only be used in accordance with their instructions for use. Product recommendations should not supplant medical judgment. Surgeon preference, experience, and patient needs may dictate alternate technique. Review all relevant precautions, especially the indications, contraindications, warnings, and information for use. Please see package inserts for Full Prescribing Information. The visual does not reflect any sequential order in use. Reference: 1. Hemostasis Optimization Program and Next Steps Meeting, dated 06/30/2014.

23 Comprehensive Bleeding Management Solution Intraoperative Bleeding Continuous oozing Will not stop with compression/ simple packing. The solution for this bleeding is more time consuming than it is difficult. 1 Oxidized regenerated cellulose (ORC) ADJUNCTIVE Methods of Hemostasis GOAL: To achieve complete intraoperative hemostasis & reduce risk of postoperative bleeding Can you see the source of bleeding and apply hemostat? Yes No Problematic Even though the bleeding is accessible, it could be trouble. It is more than routine and likely to be resistant to conventional means, and requires immediate attention causing disruption to the normal progression of surgery. 1 Difficult to access Bleeding that occurs in tight and irregular spaces and you cannot see the exact source of the bleed. You are concerned accessing a tight space will cause more harm. 1 Fibrin patch Flowable gelatin Is there intraoperative bleeding with a concern of postoperative re-bleeding? Yes Potential rebleeding risk Bleeding may be addressed intraoperatively, but could later develop into more serious complications, especially in high-risk patients. 1 High-pressure vessel bleeding A leak in high-pressure vessel (aortic or peripheral vascular suture line) that has been stopped, but if it leaks post-op, could be catastrophic. 1 Fibrin sealant Vascular sealant Important Risk Information: Adjunctive hemostats are not intended for use on nonbleeding tissue or for prophylactic use. The bleeding situations identified reflect customer insights/market research on optimal adjunctive hemostat utilization. The product solutions should only be used in accordance with their instructions for use. Product recommendations should not supplant medical judgment. Surgeon preference, experience, and patient needs may dictate alternate technique. Review all relevant precautions, especially the indications, contraindications, warnings, and information for use. Please see package inserts for Full Prescribing Information. The visual does not reflect any sequential order in use. Reference: 1. Hemostasis Optimization Program and Next Steps Meeting, dated 06/30/2014.

24 Comprehensive Bleeding Management Solution Intraoperative Bleeding Continuous oozing Will not stop with compression/ simple packing. The solution for this bleeding is more time consuming than it is difficult. 1 Oxidized regenerated cellulose (ORC) SURGICEL Absorbable Hemostats ADJUNCTIVE Methods of Hemostasis GOAL: To achieve complete intraoperative hemostasis & reduce risk of postoperative bleeding Can you see the source of bleeding and apply hemostat? Yes No Problematic Even though the bleeding is accessible, it could be trouble. It is more than routine and likely to be resistant to conventional means, and requires immediate attention causing disruption to the normal progression of surgery. 1 Difficult to access Bleeding that occurs in tight and irregular spaces and you cannot see the exact source of the bleed. You are concerned accessing a tight space will cause more harm. 1 Fibrin patch Flowable gelatin EVARREST Fibrin Patch SURGIFLO Hemostatic Matrix Is there intraoperative bleeding with a concern of postoperative re-bleeding? Yes Potential rebleeding risk Bleeding may be addressed intraoperatively, but could later develop into more serious complications, especially in high-risk patients. 1 High-pressure vessel bleeding A leak in high-pressure vessel (aortic or peripheral vascular suture line) that has been stopped, but if it leaks post-op, could be catastrophic. 1 Fibrin sealant Vascular sealant EVICEL Fibrin Sealant (Human) Important Risk Information: Adjunctive hemostats are not intended for use on nonbleeding tissue or for prophylactic use. The bleeding situations identified reflect customer insights/market research on optimal adjunctive hemostat utilization. The product solutions should only be used in accordance with their instructions for use. Product recommendations should not supplant medical judgment. Surgeon preference, experience, and patient needs may dictate alternate technique. Review all relevant precautions, especially the indications, contraindications, warnings, and information for use. Please see package inserts for Full Prescribing Information. The visual does not reflect any sequential order in use. Reference: 1. Hemostasis Optimization Program and Next Steps Meeting, dated 06/30/2014.

25 Validation of HOP 1 >350-Bed Teaching Hospital >30 ORs 1-year study >100 HCPs trained A systematic approach to surgical hemostat use supports standardization and cost efficiencies by: Nicole Ferko MSc, Cornerstone Research Group, Burlington, ON, Canada Walt Danker III PhD and Gaurav Gangoli PharmD, Ethicon Inc., Somerville, NJ, USA, Healthcare Purchasing News, November, Cornerstone Research Group Inc. Hemostasis Optimization Program RWE Study: Quantitative and Qualitative Results. November 02, 2018.

26 Results Results Not including contractual savings A systematic approach to surgical hemostat use supports standardization and cost efficiencies by: Nicole Ferko MSc, Cornerstone Research Group, Burlington, ON, Canada Walt Danker III PhD and Gaurav Gangoli PharmD, Ethicon Inc., Somerville, NJ, USA, Healthcare Purchasing News, November, 2017

27 EVARREST Fibrin Sealant Patch Important Safety Information Indications and Usage EVARREST is a fibrin sealant patch indicated for use with manual compression as an adjunct to hemostasis in adult patients undergoing surgery, when control of bleeding by conventional surgical techniques (such as suture, ligature, and cautery) is ineffective or impractical. Limitations for Use Cannot be used in place of sutures or other forms of mechanical ligation in the treatment of major arterial or venous bleeding. Not for use in children under one month of age Laparoscopic and other minimally invasive surgeries where manual compression would be difficult to achieve. Important Safety Information For topical use only. Apply immediate manual compression over the entire surface of the patch and maintain contact pressure for 3 minutes to control the bleeding. Do not apply intravascularly. This can result in life threatening thromboembolic events. Do not use to treat bleeding from large defects in arteries or veins where the injured vascular wall requires conventional surgical repair and maintenance of vessel patency or where there would be persistent exposure of EVARREST to blood flow and/or pressure during absorption of the product. Thrombosis can occur if absorbed systemically. Do not use in individuals known to have anaphylactic or severe systemic reaction to human blood products. EVARREST can cause hypersensitivity reactions including anaphylaxis. Avoid application to contaminated areas of the body or in the presence of active infection. Infection can occur. EVARREST contains oxidized regenerated cellulose which adheres to bleeding surfaces. Inadvertent adhesions can occur. Avoid use in, around, or in proximity to, foramina in bone or areas of bony confines where swelling may cause compression. Use the least number of patches required to cover the entire bleeding area. Portions of excess patch material can become dislodged and migrate to other areas of the body. Do not use more than eight 2x4 inch (5.1 x 10.2 cm) or more than four 4x4 inch (10.2 x 10.2 cm) patches. Use in patients who have been previously exposed to EVARREST has not been studied. May carry a risk of transmitting infectious agents, e.g., viruses, the variant Creutzfeldt-Jakob disease (vcjd) agent and, theoretically, the Creutzfeldt- Jakob disease (CJD) agent. The adverse reactions reported during clinical trials occurred in less than 1% of all cases and included deep venous thrombosis, pulmonary embolism, blood fibrinogen increase, anastomotic hemorrhage, post procedural and intra-abdominal hemorrhage, abdominal distension, anemia, gastrointestinal hemorrhage, thoracic cavity drainage, pleural effusion, abdominal abscess, ascites, localized intra-abdominal fluid collection, cardiac failure, operative hemorrhage, and ischemic bowel. Pediatrics: Safety and effectiveness in pediatric patients have not been established. Use in children under the age of one month may be unsafe or ineffective due to small size and limited ability to apply the patch as recommended. Please see package insert for EVARREST Full Prescribing Information. To report SUSPECTED ADVERSE REACTIONS, contact ETHICON Customer Support Center at or FDA at FDA-1088 or

28 EVICEL Fibrin Sealant (Human) IMPORTANT SAFETY INFORMATION Indication EVICEL Fibrin Sealant (Human) is indicated as an adjunct to hemostasis for use in patients undergoing surgery, when control of bleeding by standard surgical techniques (such as suture, ligature, or cautery) is ineffective or impractical. Contraindications Do not inject directly into the circulatory system. Intravascular application of EVICEL may result in life-threatening thromboembolic events. Do not use in individuals known to have anaphylactic or severe systemic reaction to human blood products. Do not use for the treatment of severe or brisk arterial bleeding. Do not use EVICEL for spraying in endoscopic or laparoscopic procedures where the minimum recommended distance from the applicator tip to the target site cannot be ensured. Warnings and Precautions Life-threatening air or gas embolism has occurred with the use of spray devices employing a pressure regulator to administer EVICEL. This event appears to be related to the use of the spray device at pressures higher than recommended and/or at distances closer than recommended to the surface of the tissue. Monitor changes in blood pressure, pulse, oxygen saturation, and end-tidal CO2 when spraying EVICEL because of the possibility of gas embolism. To reduce the risk of potentially life-threatening gas embolism, spray EVICEL using only pressurized CO2 gas at the pressures and distances recommended for the specific tips. Use EVICEL spray application only if it is possible to accurately judge the spray distance, especially during endoscopic or laparoscopic procedures. Prior to applying EVICEL, dry surface areas of the wound by standard techniques (e.g. intermittent application of compresses, swabs, use of suction devices). Prepare and administer EVICEL according to the instructions and with only devices recommended for this product. May carry a risk of transmitting infectious agents, e.g. viruses, the variant Creutzfeldt-Jakob disease (vcjd) agent and theoretically, the Creutzfeldt-Jakob disease (CJD) agent. The most common adverse reactions reported in clinical trials are peripheral edema, abdominal abscess, infection, hematoma, incision site hemorrhage, vascular graft occlusion, postoperative wound complication and decreased hemoglobin. For complete indications, contraindications, warnings, precautions, and adverse reactions, please reference full package insert.

29 SURGICEL Essential Product Information INDICATIONS SURGICEL Absorbable Hemostat (oxidized regenerated cellulose) is used adjunctively in surgical procedures to assist in the control of capillary, venous, and small arterial hemorrhage when ligation or other conventional methods of control are impractical or ineffective. SURGICEL ORIGINAL, SURGICEL FIBRILLAR and SURGICEL NU-KNIT Hemostats can be cut to size for use in endoscopic procedures. PRECAUTIONS Use only as much SURGICEL Absorbable Hemostat as is necessary for hemostasis, holding it firmly in place until bleeding stops. Remove any excess before surgical closure in order to facilitate absorption and minimize the possibility of foreign body reaction. In urological procedures, minimal amounts of SURGICEL Absorbable Hemostat should be used and care must be exercised to prevent plugging of the urethra, ureter, or a catheter by dislodged portions of the product. Since absorption of SURGICEL Absorbable Hemostat could be prevented in chemically cauterized areas, its use should not be preceded by application of silver nitrate or any other escharotic chemicals. If SURGICEL Absorbable Hemostat is used temporarily to line the cavity of large open wounds, it should be placed so as not to overlap the skin edges. It should also be removed from open wounds by forceps or by irrigation with sterile water or saline solution after bleeding has stopped. Precautions should be taken in otorhinolaryngologic surgery to assure that none of the material is aspirated by the patient. (Examples: controlling hemorrhage after tonsillectomy and controlling epistaxis.) Care should be taken not to apply SURGICEL Absorbable Hemostat too tightly when it is used as a wrap during vascular surgery (see Adverse Reactions). ADVERSE EVENTS Encapsulation of fluid and foreign body reactions have been reported. There have been reports of stenotic effect when SURGICEL Absorbable Hemostat has been applied as a wrap during vascular surgery. Paralysis and nerve damage have been reported when SURGICEL Absorbable Hemostat was used around, in, or in proximity to foramina in bone, areas of bony confine, the spinal cord, and/or the optic nerve and chiasm. Blindness has been reported in connection with surgical repair of a lacerated left frontal lobe when SURGICEL Absorbable Hemostat was placed in the anterior cranial fossa. Possible prolongation of drainage in cholecystectomies and difficulty passing urine per urethra after prostatectomy have been reported. For more information, please consult your doctor or for product quality and technical questions, call

30 SURGICEL Powder Absorbable Hemostat Essential Product Information INDICATIONS SURGICEL Powder (oxidized regenerated cellulose) is used adjunctively in surgical procedures to assist in the control of capillary, venous, and small arterial hemorrhage when ligation or other conventional methods of control are impractical or ineffective. CONTRAINDICATIONS Do not inject or place SURGICEL Powder into an open blood vessel. SURGICEL Powder should not be used to control hemorrhage from large arteries. When SURGICEL Powder is used to help achieve hemostasis in, around, or in proximity to foramina in bone, areas of bony confine, the spinal cord, or the optic nerve and chiasm, it must always be removed after hemostasis is achieved since it will swell and could exert unwanted pressure. SURGICEL Powder should not be used for implantation in bone defects, such as fractures, since there is a possibility of interference with callus formation and a theoretical chance of cyst formation. WARNINGS Closing with SURGICEL Powder in a contaminated wound without drainage may lead to complications and should be avoided. SURGICEL Powder should not be impregnated with anti-infective agents or with other materials such as buffering or hemostatic substances. SURGICEL Powder is dry and there may be difficulties in precise delivery under certain circumstances. Unintentional device placement may result in powder scattering and device migration that may increase the risk of adhesion formation. Although SURGICEL Powder is bactericidal against a wide range of pathogenic microorganisms, it is not intended as a substitute for systemically administered therapeutic or prophylactic antimicrobial agents to control or to prevent postoperative infections. Do not attempt to trim the applicator tip. PRECAUTIONS SURGICEL Powder should not be used in conjunction with autologous blood salvage circuits, because its fragments may pass through the transfusion filters of blood-scavenging systems. Use only as much SURGICEL Powder (oxidized regenerated cellulose) as is necessary and apply only where needed for hemostasis. Remove any excess before surgical closure in order to facilitate absorption and to minimize the possibility of foreign body reaction. In urological procedures, minimal amounts of SURGICEL Powder should be used and care must be exercised to prevent plugging of the urethra, ureter, or a catheter by dislodged portions of the product. 30

31 SURGICEL Powder Absorbable Hemostat Essential Product Information (continued) PRECAUTIONS (continued) Since absorption of SURGICEL Powder could be prevented in chemically cauterized areas, its use should not be preceded by application of silver nitrate or any other escharotic chemicals. If SURGICEL Powder is used temporarily to line the cavity of open wounds, it should be removed by irrigation with sterile water or saline solution after bleeding has stopped. Precautions should be taken in otorhinolaryngologic surgery to ensure that none of the material is aspirated by the patient (e.g., controlling hemorrhage after tonsillectomy and controlling epistaxis). This applicator tip is not intended for laparoscopic or other endoscopic use. ADVERSE EVENTS Paralysis and nerve damage have been reported when other SURGICEL products were used around, in, or in proximity to foramina in bone, areas of bony confine, the spinal cord, and/or the optic nerve and chiasm. Blindness has been reported in connection with surgical repair of a lacerated left frontal lobe when other SURGICEL products were placed in the anterior cranial fossa (see WARNINGS and PRECAUTIONS). Foreign body reactions have been reported with other products from the SURGICEL Family of Absorbable Hemostats. Burning has been reported when other SURGICEL products were applied after nasal polyp removal. Headache, burning, stinging, and sneezing in epistaxis and other rhinological procedures, and stinging when SURGICEL product was applied on surface wounds (varicose ulcerations, dermabrasions, and donor sites) have also been reported. For more information and technical questions, call

32 SURGIFLO Hemostatic Matrix Kit Essential Product Information (Made from Absorbable Gelatin Sponge, USP) with Thrombin DESCRIPTION SURGIFLO with Thrombin (SURGIFLO Hemostatic Matrix Kit) is intended for hemostatic use by applying to a bleeding surface. ACTIONS When used in appropriate amounts SURGIFLO is absorbed completely within 4 to 6 weeks. INTENDED USE/INDICATIONS SURGIFLO, mixed with thrombin solution, is indicated in surgical procedures (other than ophthalmic) as an adjunct to hemostasis when control of bleeding by ligature or other conventional methods is ineffective or impractical. CONTRAINDICATIONS Do not use SURGIFLO in intravascular compartments because of the risk of embolization. Do not use SURGIFLO in patients with known allergies to porcine gelatin. Do not use SURGIFLO in closure of skin incisions because it may interfere with the healing of skin edges. This interference is due to mechanical interposition of gelatin and is not secondary to intrinsic interference with wound healing. WARNINGS SURGIFLO should not be used in the presence of infection and should be used with caution in contaminated areas of the body SURGIFLO should not be used in instances of pumping arterial hemorrhage. SURGIFLO will not act as a tampon or plug in a bleeding site. SURGIFLO should be removed from the site of application when used in, around, or in proximity to foramina in bone, areas of bony confine, the spinal cord, and/or the optic nerve and chiasm because it may swell resulting in nerve damage. Excess SURGIFLO should be removed once hemostasis has been achieved. The safety and effectiveness of SURGIFLO for use in ophthalmic procedures has not been established. SURGIFLO should not be used for controlling post-partum intrauterine bleeding or menorrhagia. The safety and effectiveness of SURGIFLO has not been established in children and pregnant women. The blue flexible applicator tip should not be trimmed to avoid exposing internal guidewire. The white straight applicator tip should be trimmed away from the surgical area. Cut a square angle to avoid creating a sharp tip. 32

33 SURGIFLO Hemostatic Matrix Kit Essential Product Information (Made from Absorbable Gelatin Sponge, USP) with Thrombin (CONTINUED) PRECAUTIONS Safe and effective use of SURGIFOAM Sponge has been reported in a published neurologic retrospective study involving 1700 cases in Europe. Safe and effective use in neurosurgery has not been proven through randomized, controlled clinical studies in the United States. SURGIFLO is supplied as a sterile product and cannot be resterilized. SURGIFLO should not be used for packing unless excess product that is not needed to maintain hemostasis is removed. SURGIFLO may swell up to 20% upon contact with additional fluid. SURGIFLO should not be used in conjunction with autologous blood salvage circuits. SURGIFLO should not be used in conjunction with methylmethacrylate adhesives. In urological procedures, SURGIFLO should not be left in the renal pelvis or ureters to eliminate the potential foci for calculus formation. ADVERSE EVENTS A total of 142 patients received SURGIFOAM Sponge during a clinical trial comparing SURGIFOAM Sponge to another absorbable gelatin sponge. In general, the following adverse events have been reported with the use of absorbable porcine gelatin-based hemostatic agents: Gelatin-based hemostatic agents may serve as a nidus for infection and abscess formation and have been reported to potentiate bacterial growth. Giant cell granulomas have been observed at implant sites when used in the brain. Compression of the brain and spinal cord resulting from the accumulation of sterile fluid have been observed. Multiple neurologic events were reported when absorbable gelatin-based hemostatic agents were used in laminectomy operations, including cauda equina syndrome, spinal stenosis, meningitis, arachnoiditis, headaches, paresthesias, pain, bladder and bowel dysfunction, and impotence. The use of absorbable gelatin-based hemostatic agents during the repair of dural defects associated with laminectomy and craniotomy operations, has been associated with fever, infection, leg paresthesias, neck and back pain, bladder and bowel incontinence, cauda equina syndrome, neurogenic bladder, impotence, and paresis. The use of absorbable gelatin-based hemostatic agents has been associated with paralysis, due to device migration into foramina in the bone around the spinal cord, and blindness, due to device migration in the orbit of the eye, during lobectomy, laminectomy, and repair of a frontal skull fracture and lacerated lobe. Foreign body reactions, encapsulation of fluid, and hematoma have been observed at implant sites. Excessive fibrosis and prolonged fixation of a tendon have been reported when absorbable gelatin-based sponges were used in severed tendon repair. Toxic shock syndrome was reported in association with the use of absorbable gelatin-based hemostats in nasal surgery. Fever, failure of absorption, and hearing loss have been observed when absorbable hemostatic agents were used during tympanoplasty. 33

34 EVITHROM Thrombin, Topical (Human) for Topical Use Only Lyophilized Powder for Solution EVITHROM is a topical thrombin indicated as an aid to hemostasis whenever oozing blood and minor bleeding from capillaries and small venules is accessible and control of bleeding by standard surgical techniques (such as suture, ligature or cautery) is ineffective or impractical. EVITHROM may be used in conjunction with an Absorbable Gelatin Sponge, USP. Important Safety Information For topical use only. Do not inject. Apply EVITHROM on the surface of bleeding tissue only. The amount of EVITHROM required depends upon the area of tissue to be treated and the method of application. In clinical studies, volumes up to 10 ml were used in conjunction with Absorbable Gelatin Sponge. Do not use for the treatment of severe or brisk arterial bleeding. Do not use in individuals known to have anaphylactic or severe systemic reaction to human blood products. Hypersensitivity reactions, including anaphylaxis, may occur. There is a potential risk of thrombosis if absorbed systemically. May carry a risk of transmitting infectious agents such as viruses and theoretically, the Creutzfeldt-Jakob disease (CJD) agent, despite manufacturing steps designed to reduce the risk of viral transmission. The most common adverse reactions during clinical trial (reported in at least 2% of subjects treated with EVITHROM ) were prolonged activated partial thromboplastin time, increased INR, decreased lymphocyte count, prolonged prothrombin time and increased neutrophil count. None of the patients treated with EVITHROM developed antibodies to human thrombin or to human Factor V/Va. The clinical significance of these findings is unknown. For complete indications, contraindications, warnings, precautions, and adverse reactions, please reference full package insert.

35 References Anderson FA, White K (2002) Prolonged prophylaxis in orthopedic surgery: insights from the United States. Seminars in Thrombosis and Hemostasis 128 (3): Beauregard K, Carper K (2009) Outpatient prescription anticoagulant utilization and expenditures for the U.S. civilian noninstitutionalized population, Age 18 and older, Medical Expenditure Panel Survey, Agency for Healthcare Research and Quality. SB #268. Briceno J, Naranjo A, Ciria R, Diaz-Nieto R, Sanchez-Hidalgo JM, Luque A, Rufian S, Lopez-Cillero P (2010) A prospective study of the efficacy of clinical application of a new carrier-bound fibrin sealant after liver resection. Arch Surg 145 (5): Corral M, Ferko N, Hollman S, Broder M, Chang E, Sun G (2014) Health and Economic Consequences of Controlled versus Uncontrolled Surgical Bleeding in Patients Treated with Haemostatic Agents: A Retrospective Analysis of the Premier Perspective Database. SABM(abstract # Houston,TX, USA. Sept 11-13, Comadoll, J, Comadoll S, Hutchcraft A, Krishnan S, Farrell K, Kreuwel HTC, Bechter M (2012 ) Comparison of hemostatic matrix and standard hemostasis in patients undergoing primary TKA. Helio.com/orthopedics 35 (6): e785. Dancey AL, Cheema M, Thomas SS (2010) A prospective randomized trial of the efficacy of marginal quilting sutures and fibrin sealant in reducing the incidence of seromas in the extended latissimus dorsi donor site. Plast Reconstr Surg 125 (5): Dasta JF, McLaughlin TP, Mody SH, Piech CT (2005) Daily cost of an intensive care unit day: the contribution of mechanical ventilation. Crit Care Med 33 (6): Department of Economic and Social Affairs Population Division (Web Page) World Population Ageing: Updated Available from: ( Accessed Mar Farnworth LR, Lemay DE, Wooldridge T, Mabrey JD, Blaschak MJ, DeCoster TA, Wascher DC, Schenck RC, Jr. (2001) A comparison of operative times in arthroscopic ACL reconstruction between orthopaedic faculty and residents: the financial impact of orthopaedic surgical training in the operating room. Iowa Orthop J

36 References Ferko, N., Danker, W., Fanfoli, G. A systematic approach to surgical hemostat use supports standardization and cost efficiencies. Healthcare Purchasing News. doi: Halpern NA, Pastores SM (2010) Critical care medicine in the United States : an analysis of bed numbers, occupancy rates, payer mix, and costs. Crit Care Med 38 (1): Joseph T, Adeosun A, Paes T, Bahal V (2004) Randomised controlled trial to evaluate the efficacy of TachoComb H patches in controlling PTFE suture-hole bleeding. Eur J Vasc Endovasc Surg 27 (5): Kahn JM, Rubenfeld GD, Rohrbach J, Fuchs BD (2008) Cost savings attributable to reductions in intensive care unit length of stay for mechanically ventilated patients. Medical care 46 (12): Kluba T, Fiedler K, Kunze B, Ipach I, Suckel A (2012) Fibrin sealants in orthopaedic surgery: practical experiences derived from use of QUIXIL(R) in total knee arthroplasty. Arch Orthop Trauma Surg 132 (8): Levy JH, Dutton RP, Hemphill JC, 3rd, Shander A, Cooper D, Paidas MJ, Kessler CM, Holcomb JB, Lawson JH (2010) Multidisciplinary approach to the challenge of hemostasis. Anesth Analg 110 (2): Liu L, Wang Z, Jiang S, Shao B, Liu J, Zhang S, Zhou Y, Zhou Y, Zhang Y (2013) Perioperative allogenenic blood transfusion is associated with worse clinical outcomes for hepatocellular carcinoma: a meta-analysis. PLoS One 8 (5):e Marietta M, Facchini L, Pedrazzi P, Busani S, Torelli G (2006) Pathophysiology of bleeding in surgery. Transplant Proc 38 (3): Massin P, Scemama C, Jeanrot C, Boyer P (2012) Does fibrin sealant use in total knee replacement reduce transfusion rates? A non-randomised comparative study. Orthop Traumatol Surg Res 98 (2): McMenamin P (Web Page) 2009 Registered nurses employment and earning. American Nurses Association. Updated Available from: ( Briefs/RN-Employment-Earnings.pdf). Accessed Aug. 20, MedMarket Diligence (2012) Worldwide surgical sealants, glues, wound closure, and anti-adhesion markets, Report #S190. Millennium Research Group Inc (2011) US Markets for Surgical Hemostats, Internal Tissue Sealants, and Adhesion Barriers In. 36

37 References Molloy DO, Archbold HA, Ogonda L, McConway J, Wilson RK, Beverland DE (2007) Comparison of topical fibrin spray and tranexamic acid on blood loss after total knee replacement: a prospective, randomised controlled trial. J Bone Joint Surg Br 89 (3): Notarnicola A, Moretti L, Martucci A, Spinarelli A, Tafuri S, Pesce V, Moretti B (2012) Comparative efficacy of different doses of fibrin sealant to reduce bleeding after total knee arthroplasty. Blood Coagul Fibrinolysis 23 (4): Pan HW, Zhong JX, Jing CX (2011) Comparison of fibrin glue versus suture for conjunctival autografting in pterygium surgery: a meta-analysis. Ophthalmology 118 (6): Parekh AK, Barton MB (2010) The challenge of multiple comorbidity for the US health care system. JAMA 303 (13): Randelli F, Banci L, Ragone V, Pavesi M, Randelli G (2013) Effectiveness of fibrin sealant after cementless total hip replacement: a double-blind randomized controlled trial. Int J Immunopathol Pharmacol 26 (1): Rousou JA (2013) Use of fibrin sealants in cardiovascular surgery: a systematic review. J Card Surg 28 (3): Sabatini L, Trecci A, Imarisio D, Uslenghi MD, Bianco G, Scagnelli R (2012) Fibrin tissue adhesive reduces postoperative blood loss in total knee arthroplasty. J Orthop Traumatol 13 (3): Schreiber M, Neveleff D (2011) Achieving hemostasis with topical hemostats: making clinically and economically appropriate decisions in the surgical and trauma settings. AORN Journal 94 (5): Shander A (2007) Financial and clinical outcomes associated with surgical bleeding complications. Surgery 142 (4 Suppl):S Shippert R (2005) A study of time-dependent operating room fees and how to save $ by using time-saving products. The American Journal of Cosmetic Surgery 22 (1): Shireman TI, Howard PA, Kresowik TF, Ellerbeck EF. Combined anticoagulant-antiplatelet use and major bleeding events in elderly atrial fibrillation patients. Stroke. 2004;35(10): Simon Kucher & Partners Strategy & Marketing Consultants (2012) Global Pricing and Positioning Strategy for Project Hercules. In. 37

38 References Spotnitz WD, Burks S (2012) Hemostats, sealants, and adhesives III: a new update as well as cost and regulatory considerations for components of the surgical toolbox. Transfusion 52 (10): The Henry J. Kaiser Family Foundation (Web Page) Hospital Adjusted Expenses per Inpatient Day. Updated Available from: ( Accessed Mar Toner RW, Pizzi L, Leas B, Ballas SK, Quigley A, Goldfarb NI (2011) Costs to hospitals of acquiring and processing blood in the US: a survey of hospital-based blood banks and transfusion services. Appl Health Econ Health Policy 9 (1): Voils SA (2009) Thrombin products: economic impact of immune-mediated coagulopathies and practical formulary considerations. Pharmacotherapy 29 (7 Pt 2):18S-22S. Wang GJ, Hungerford DS, Savory CG, Rosenberg AG, Mont MA, Burks SG, Mayers SL, Spotnitz WD (2001) Use of fibrin sealant to reduce bloody drainage and hemoglobin loss after total knee arthroplasty: a brief note on a randomized prospective trial. J Bone Joint Surg Am 83-A (10): Wang T, Luo L, Huang H, Yu J, Pan C, Cai X, Hu B, Yin X (2014) Perioperative blood transfusion is associated with worse clinical outcomes in resected lung cancer. Ann Thorac Surg 97 (5): Ye X, Rupnow MF, Hammond J, Shah M, Farrelly E (2012) Readmission rates and hospital costs associated with fibrin sealant use among patients undergoing orthopaedic surgery J Orthopardics. Zimlichman E, Henderson D, Tamir O, Franz C, Song P, Yamin CK, Keohane C, Denham CR, Bates DW (2013) Health care-associated infections: a meta-analysis of costs and financial impact on the US health care system. JAMA Intern Med 173 (22): Ethicon US, LLC