RAPID Biodynamic PRP Haematogel Chronic Wound Care Treatment

Transcription

1 RAPID Biodynamic PRP Haematogel Chronic Wound Care Treatment USING THE CE CERTIFIED ANGEL CONCENTRATED PRP BLOOD PROCESSING SYSTEM WITH ACTIVAT AUTOLOGOUS THROMBIN KIT INSTRUCTIONS FOR USE Biotherapy Services Ltd Gainsborough House Thames Street Windsor SL4 1TX

2 Specialist Wound Care Therapies BS1074 SPa

3 THE RAPID BIODYNAMIC HAEMATOGEL CHRONIC WOUND CARE TREATMENT Contents PART 1: THE RAPID BIODYNAMIC HAEMATOGEL CHRONIC WOUND CARE TREATMENT 1.1 RAPID Biodynamic Haematogel Chronic Wound Care Treatment Indications for Use Treatment Duration Contraindications Precautions and Warnings Clinical Investigations Background to use of Autologous PRP for Chronic Wounds: 5 Aurix [previously Autologel ] PRP System RAPID Biodynamic Haematogel Chronic Wound Care Treatment 7 Case Series treating Chronic, Hard-to-Heal Wounds including Diabetic Wounds, Venous & Arterial Ulcers, Decubitus Ulcers and Sternal Wounds, and Femoral Popliteal Wounds following Coronary Artery Bypass Surgery RAPID Pilot Study: Chronic Diabetic Wounds Applications for Use of the Angel Concentrated PRP System and 9 its associated single use kits. PART 2: PREPARATION 2.1 Determining the volume of blood and Platelet Concentration 10 [x baseline] required for the RAPID Biodynamic Haematogel Chronic Wound Care Treatment PRP. 2.2 Prepare the Angel Concentrated PRP Blood Processing Device Prepare Supplies from the Angel System Processing Set Kit i Angel Processing Set 12 PART 3: THE RAPID BIODYNAMIC HAEMATOGEL CHRONIC WOUND CARE TREATMENT PROCEDURE 3.1 Phlebotomy Step Centrifugation Step Processing Step 1: Making the Autologous Thrombin using the ActivAT Kit 14 PART 4: COMPOSITION, STORAGE AND HANDLING OF THE ANGEL CONCENTRATED PRP SYSTEM FOR THE PRODUCTION OF THE RAPID BIODYNAMIC HAEMATOGEL CHRONIC WOUND CARE TREATMENT 4.1 Angel Whole Blood Seperation Processing Set Instructions for use Cat No Description Indications for Use Contraindications Warnings Precautions Instructions for Use Preoperative Blood Collection Angel Blood Access Kit Instructions for use Cat No Description Indications for Use Contraindications Warnings Precautions Instructions for Use ActivAT Autologous Thrombin Processing Kit Cat No Instructions for Use Indications for Use Contraindications Warnings Precautions Procedure for Use Specifications Processing Step 2: Adding the Ascorbic Acid and Autologous Thrombin to the PRP Application of the RAPID Biodynamic Haematogel Chronic Wound Care Treatment Documentation 16 3

4 REGENERATIVE BIOTHERAPIES PART 1: THE RAPID BIODYNAMIC HAEMATOGEL CHRONIC WOUND CARE TREATMENT 1.1 RAPID Biodynamic Haematogel Chronic Wound Care Treatment The RAPID Biodynamic Haematogel Chronic Wound Care Treatment is processed using the following: CE Marked Arthrex Angel Concentrated PRP Blood Processing System CE Marked Arthrex Angel Blood Processing Kit CE Marked Arthrex Angel Blood Access Kit for phlebotomy CE Marked Arthrex ActivAT Autologous Thrombin Kit for the production of autologous thrombin The addition of ascorbic acid to the autologous PRP 1.2 Indications for Use The RAPID Biodynamic Haematogel Chronic Wound Care Treatment, using the CE Marked Arthrex Angel Concentrated PRP Blood Processing System and dedicated kits (as above) including the Arthrex ActivAT Autologous Thrombin Kit, is a totally autologous process intended to be used at point-of-care for the safe and rapid preparation of platelet-rich plasma (PRP) gel from a small sample of the patient s own blood. Under the supervision of a healthcare professional, the RAPID PRP produced by the Arthrex Angel Blood Processing System is suitable for the treatment of chronic wounds, where devitalised and necrotic tissue has been fully debrided, including diabetic, traumatic and decubitus (pressure sores). The totally biological status makes it particularly appropriate for wounds which have been previously hampered by repeated infection. Evidence from the RAPID Pilot Study suggests that the RAPID Biodynamic Haematogel Chronic Wound Care Treatment is particularly useful in the treatment of wounds with large areas of tissue exposure including exposed bone and tendon, including those where major limb amputation would otherwise be considered. 1.3 Treatment Frequency The length of treatment using the RAPID Biodynamic Haematogel Chronic Wound Care Treatment will vary by the area and depth of wound, with four weeks being typical for a chronic diabetic foot wound measuring upto 7cm 3. The RAPID Biodynamic Haematogel Chronic Wound Care Treatment should be used in conjunction and in combination with standard of care procedures for comprehensive wound management such as: Removal of necrotic or infected tissue Off-loading Blood sugar control in diabeties Use of negative pressure suction dressing Compression therapy for venous stasis ulcers 4

5 THE RAPID BIODYNAMIC HAEMATOGEL CHRONIC WOUND CARE TREATMENT Establishment of adequate blood circulation Maintenance of a moist wound environment Management of wound infection Wound cleansing Nutritional support, blood glucose control for subjects with diabetic ulcers Bowel/bladder care for subjects with pressure ulcers at risk for contamination Management of underlying disease 1.4 Contraindications The RAPID Biodynamic Haematogel Chronic Wound Care Treatment is contraindicated in the following patients or wounds: patients on chemotherapeutic agents patients with the following abnormal laboratory test levels: haemoglobin <10.5 g/dl platelet count <100 x 109/L known or suspected current malignancy wounds remaining necrotic or infected tissue 1.5 Precautions and Warnings The RAPID Biodynamic Haematogel Chronic Wound Care Treatment is provided on the order of a physician. Precautions: Throughout the processing procedure and application of the RAPID Biodynamic Haematogel Chronic Wound Care Treatment, use Universal Precautions as defined by the facility policy and procedure manual. All parts of the procedure shall be performed in such a manner to minimie splashing, spraying, spattering, and generation of potential droplets. Because of thrombin s action in the clotting mechanism, RAPID Biodynamic Haematogel Chronic Wound Care Treatment must never be injected into or otherwise allowed to enter large blood vessels. Extensive intravascular clotting and even death may result. Patients undergoing renal dialysis should not have the RAPID Biodynamic Haematogel Chronic Wound Care Treatment within 6 hours of haemodialysis. 1.6 Clinical Investigations Background to use of Autologous PRP for Chronic Wounds: Aurix [previously Autologel ] PRP System The Aurix PRP System, available in the USA, has been unique in obtaining the Centers for Medicaid and Medicare CMS 11 reimbursement in the United States due to its clear benefits over best standard treatment for chronic wounds. The Aurix PRP System consists of a centrifuge system designed to isolate near-pysiological concentrations of platelets from the patients whole blood. These platelets are activated to form a clot that releases its wound healing factors by the addition of thrombin of bovine origin. Vitamin C is also added to improve both clot stability and the cross-linking of the newly forming connective tissue matrix. 1,2,3 1 Lui PP, Wong OT, Lee YW Transplantation of tendon-derived stem cells pre-treated with connective tissue growth factor and ascorbic acid in vitro promoted better tendon repair in a patellar tendon window injury rat model. Cytotherapy Jan;18(1): doi: /j.jcyt Mohammed BM1,, Fisher BJ, Kraskauskas D, Ward S, Wayne JS, Brophy DF, Fowler AA, Yager DR, Natarajan R Vitamin C promotes wound healing through novel pleiotropic mechanisms. nt Wound J Aug;13(4): doi: /iwj Epub 2015 Aug Stumpf U, Michaelis M, Klassert D, Cinatl J, Altrichter J, Windolf J, Hergenröther J, Schol M Selection of proangiogenic ascorbate derivatives and their exploitation in a novel drugreleasing system for wound healing. Wound Repair Regen Sep-Oct;19(5): doi: /j X

6 REGENERATIVE BIOTHERAPIES Aurix PRP System registry data demonstrates that chronic, non-healing wounds, are quickly kick-started back into healing, with high degrees of success 4. Various International clinical studies have demonstrated the efficacy of the Aurix [AutoloGel ] PRP System [Driver 5 Carter 6 et al] as well as the Sakata 7 longitudinal study from Japan, for the treatment of diabetic and chronic wounds. Table 1. Summary of Aurix PRP System US Post-Marketing Registry Data Number of Patients Mean Number of Treatments Mean Volume at Commencement cm 3 Mean % change Volume Mean number of weeks to outcome All Chronic Wounds (-63.6%) 2.2 Chronic Diabetic (-61%) 2.0 Surgical Trauma (-63.3%) 1.8 Venous Ulcer (-56.6%) 2.1 Dehiscence (-68.5%) 1.7 Spinal Cord Injury (-68.6%) 2.8 An independent Japanese Registry 8 also shows high healing rates for Aurix in chronic non-healing wounds. See Table 2. Table 2. Tokyo Wound Care Centre Aurix Experience Number Mean Number of Treatments Mean Volume at Commencement Proportion Completely Healed Mean Treatment Days All Wounds As a result of these as well as other clinical studies (de Leon 9, Frykberg 10, et al) The Aurix PRP System has been unique in obtaining the Centers for Medicaid and Medicare CMS 11 reimbursement in the United States due to its clear benefits over best standard treatment for chronic wounds. However, the Aurix PRP System uses bovine thrombin [derived from cattle), to activate the platelets in the PRP gel, and therefore the Aurix was not sanctioned for use by the MHRA. Therefore, using the CE marked Angel Concentrated PRP Blood Processing System and associated kits, including the CE marked ActivAT autologous thrombin kit; the RAPID Biodynamic Haematogel Chronic Wound Care Treatment was developed. This ensures a totally autologous approach to the production of an autologous PRP gel. Ascorbic Acid will be added to the autologous RAPID biodynamic PRP haematogel in the precise ratio of PRP volume to Ascorbic Acid, that is used in the Aurix PRP System. Refer to (Table 7 p16). 4 de Leon JM, Driver VR, Fylling CP, et al. The clinical relevance of treating chronic wounds with an enhanced near-physiological concentration of platelet-rich plasma gel. Adv Skin Wound Care.2011;24: Driver VR, Fabbi M, Lavery LA. Gibbons G. The costs of diabetic foot: the economic case for the limb salvages team. J Am Podiatr Med Assoc. 2010;100: Carter MJ, Fylling CP, Li WW, et al. Analysis of run-in and treatment data in a wound outcomes registry: clinical impact of topical platelet-rich plasma gel on healing trajectory. Int Wound J. 2011;8: Sakata J, Sasaki S, Handa K, et al. A retrospective, longitudinal study to evaluate healing lower extremity wounds in patients with diabetes mellitus and ischemia using standard protocols of care and platelet-rich plasma gel in a Japanese wound care program. Ostomy Wound Management.2012;58: Sakata J, Sasaki S, Handa K, et al. A retrospective, longitudinal study to evaluate healing lower extremity wounds in patients with diabetes mellitus and ischemia using standard protocols of care and platelet-rich plasma gel in a Japanese wound care program. Ostomy Wound Management.2012;58: de Leon JM, Driver VR, Fylling CP, et al. The clinical relevance of treating chronic wounds with an enhanced near-physiological concentration of platelet-rich plasma gel. Adv Skin Wound Care.2011;24: Frykberg RF, Driver RV, Carman D, Lucero B, Borris-Hale C, Fylling CP, Rappl L, Clausen P, Chronic Wounds Treated With a Physiologically Relevant Concentration of Platelet-rich Plasma Gel: A Prospective Case Series Ostomy Wound Management 2010;56(6): CMS.gov 6

7 THE RAPID BIODYNAMIC HAEMATOGEL CHRONIC WOUND CARE TREATMENT The RAPID-1 12 Diabetic Foot Ulcer Multi-centre RCT is planned to commence 4th Quarter 2016 in NHS hospitals at The Barts Health NHS Trust, Ninewells Hospital, Dundee University Scotland and Kings College Diabetic Foot Centre RAPID Biodynamic Haematogel Chronic Wound Care Treatment Case Series treating Chronic, Hard-to-Heal Wounds including Diabetic Wounds, Venous & Arterial Ulcers, Decubitus Ulcers as well as Cardio Thoracic Sternal Wounds, and Femoral Popliteal Wounds following Coronary Artery Bypass Surgery. Various Wound Care case series were conducted from in NHS hospitals [University Hospital Birmingham NHS Foundation Trust, Queen Eliabeth Hospital; King s College Hospital NHS Foundation Trust, Diabetic Foot Clinic; University Hospital Ayr NHS Aryshire and Arran, Scotland; James Cook Hospital South Tees NHS Foundation Trust; Wrightington, Wigan and Leigh NHS Foundation Trust; The Royal Free London NHS Foundation Trust and The Barts Health NHS Trust, The Royal London Hospital. The objective was to evaluate the safety and efficacy of a totally autologous approach to the use of PRP in Chronic Wound Care using the CE marked Angel Concentrated PRP Blood Processing System and the CE marked ActivAT autologous thrombin kit, plus ascorbic acid RAPID Pilot Wound Care Study 13 : Chronic Diabetic Wounds The RAPID Pilot Study published November 2014 treated consecutive patients with diabetic foot sepsis, ulceration and gangrene judged to be at high risk of limb loss or with factors predicting slow wound healing. All patients were managed using the standard diabetic multi-disciplinary approach. In addition, autologous RAPID Biodynamic Haematogel Chronic Wound Care Treatment PRP gels and direct platelet injections were given every 4-7 days. Serial volumetric measurements were undertaken using a 3D wound measurement camera. Results 18 wounds were treated in 15 patients. 5 had extensive tissue loss with exposed bone/tendon/cartilage; 3 were on renal replacement therapy; 4 had severe peripheral neuropathy; 4 had deep osteomyelitis. 1 had severe nutritional deficiency related to an eating disorder. Wound volume at commencement of treatment averaged mm 3 (range mm 3 ). At completion of PRP treatment mean wound volume was mm 3 (range mm 3 ). The average reduction in volume of wound at completion of treatment was 75.5%. Total number of days to >90% wound healing after commencing treatment was 17.9 days (range 6 40 days). The average number of PRP treatments given was 4.8 Post treatment surgical intervention was required in 1 patient who went on to a major amputation; the rest were discharged without further intervention. The addition of PRP to the standard multi-disciplinary care of patients with diabetic foot wounds is associated with rapid wound closure and low amputation rates. The scientific basis revolves around the shift from the inflammatory phase of wound healing into the proliferative phase and beyond, including rapid re-epithelialisation. In the case series Clinical Investigators demonstrated a significant decrease in wound volume using the PRP treatment, with an average reduction in sie of 75.5% and achieving wound closure in all but 1 patient. The average time taken to almost complete wound closure was 17.9 days, therefore rapidly reducing the risk of proceeding to major amputation and shortening hospital admission. The routine use of PRP in this group of patients represents a novel approach to a longstanding problem with potential significant morbidity, time and cost savings to the NHS. 12 Platelet Rich Plasma Biotherapies Project RAPID [Restorative Autologous Platelet biotherapies for Injuries & Delayed wound healing]. A Randomised Controlled Trial of Platelet Rich Plasma biotherapies in the management of adult patients with recalcitrant and slow healing diabetic ulcers. RAPID-1 Diabetic Foot Ulcer Study. 13 T Martin, CK Kyriakides, S Sarkar (2014) RAPID Biodynamic Haematogel Chronic Wound Care Treatment Autologous PRP Pilot Study. The Royal London Hospital, Barts Health NHS Trust. 7

8 REGENERATIVE BIOTHERAPIES PRP is associated with rapid coverage of bone, tendon and fascia as well as wound closure. This contributes to limb salvage in cases where major amputation would be the traditional management as well as faster healing of chronic diabetic wounds. Table 3. Synopsis of Wound Sies and Number of Treatments Conducted in the RAPID Pilot Study. Area of Wound at Commencement of Treatment mm 3 Number Treatments Sie of Wound at Completion of PRP Treatment mm 3 Reduction of Wound at Completion of Treatment % Change Total Number of Day to >90% Wound Closure ( ) (-70.5%) ( ) (-78.5%) (-216.2) (-50.1%) ( ) (-69.82%) ( ) (-72.2%) (139.4) (-98.65%) ( ) (-61.6%) (-756.1) (-99.9%) ( ) (-98.7%) ( ) (-96%) ( ) (-77.6%) (-95.5) (-98.6%) (-229) (-98.9%) (-1943) (-80.6%) (-412.4) (-72.7%) ( ) (-73.4%) ( ) (-77.5%) ( ) (-83.9%) 26 All data on file. 8

9 THE RAPID BIODYNAMIC HAEMATOGEL CHRONIC WOUND CARE TREATMENT Applications for Use of the Angel Concentrated PRP System and its associated single use kits, for the production of the RAPID Biodynamic Haematogel Chronic Wound Care Treatment. The Angel Concentrated PRP System and its associated single use kits, including the CE marked Angel Processing Kit and the ActivAT Autologous Thrombin Kit, that are used to make the RAPID Biodynamic Haematogel Chronic Wound Care Treatment, have been commercially available since Over 36,000 patients are being treated globally on an annual basis, using the CE marked Angel Concentrated PRP System and its associated single use kits, which are used for the safe and effective production of autologous PRP treatments for a range of tissue regeneration and wound healing applications. Table 4. Complex chronic wounds treated with the RAPID Biodynamic Haematogel PRP using the CE marked Angel Concentrated PRP System and its associated single use kits. Area of Wound at Commencement of Treatment mm 3 Number Treatments Sie of Wound at Completion of PRP Treatment mm 3 Reduction of Wound at Completion of Treatment % Change Total Number of Day to >90% Wound Closure ( ) (-99.0%) ( ) (-88.2%) (-1721) (-99%) (-845.7) (-99%) ( ) (-72.5%) ( ) (-85.9%) ( ) (-78%) ( ) (-98.7%) (-495.6) (-52.4%) ( ) (-93.6%) ( ) (-93.5%) 23 All data on file. 9

10 REGENERATIVE BIOTHERAPIES PART 2: PREPARATION 2.1 Determining the volume of blood and Platelet Concentration [x baseline] required for the RAPID Biodynamic Haematogel Chronic Wound Care Treatment using the Angel Concentrated PRP System. Platelet concentration is central to the RAPID Biodynamic PRP Haematogel Chronic Wound Care Treatment and uses the Angel concentrated PRP Blood Processing System that provides an accurate and reproducible concentration of platelets and leucocytes, allowing the specialist clinician to adjust the cellularity of the PRP based upon the type of wound or clinical application. Specific emission of LED light is used to specifically detect, distinguish and separate the cellular components of the fractionated autologous blood. These constituent components are determined by the haematocrit setting of the Angel Concentrated PRP Blood Processing System. Using this detection platform, the Angel Concentrated PRP Blood Processing System will produce a highly concentrated platelet sample that can range from 7x to greater than 18x platelet concentration over baseline of the patient s input blood sample. The concentration will vary dependent upon the amount of the amount of the sample of blood processed, as well as the distribution of platelet sie and density in the individual patient. The Angel Concentrated PRP system platelet concentration algorithm for wound care requires a platelet concentration of approximately 4-6 X baseline platelet concentration. Table 5 is intended to guide the appropriate dilution of the platelet rich plasma [PRP] concentrate with autologous platelet poor plasma to achieve a wide range of desired platelet concentrations. Values presented in the table are mathematical extrapolations based on the data from experiments processing 40mls, 50mls, 100mls and 180mls of blood. The amount of autologous blood required for the RAPID Biodynamic Haematogel Chronic Wound Care Treatment, is in direct relation to the wound sie. The average wound treatment requires 50mls of autologous blood and large wounds of over 7000 mm 3 require 100mls of autologous blood per treatment. The treating clinician may determine to treat selected areas within the wound if the amount of PRP is limited. Complete coverage of wound surface is recommended, however it is not required. 10

11 THE RAPID BIODYNAMIC HAEMATOGEL CHRONIC WOUND CARE TREATMENT Table 5. Dilution Table for Achieving Desired Platelet Concentrations Whole Blood Volume [mls] Final Volume of PRP [mls] 50mls mls Platelet concentration [x over whole blood input] Platelet concentration [x over whole blood input] NB. An App is available to download to calculate the Angel Platelet Concentration. After the following process the RAPID Biodynamic Haematogel Chronic Wound Care Treatment is applied as a contact layer to the wound surface. 2.2 Prepare the Angel Concentrated PRP Blood Processing Device 1. Place the Angel Concentrated PRP Blood Processing device on a smooth, secure surface near an electrical point. 2. Plug the Angel into an electrical socket. 3. Switch on the Angel and it will self-calibrate and the touch screen will display. 4. Set the haematocrit setting and the blood volume setting on the touch screen display. 4.i For Chronic Wounds: Set Angel Heamatocrit setting to 8% Prepare to take blood draw 50mls for wounds in sie of <7000 mm 3 Prepare to take blood draw 100mls for wounds in sie >7000 mm Prepare Supplies from the Angel System Processing Set Kit The Angel System Processing Kit contains phlebotomy/ blood collection supplies and the sterile Angel processing set. Always use aseptic techniques when working with syringes and needles. Exercise caution to avoid injury. 11

12 REGENERATIVE BIOTHERAPIES 2.3.i Angel Processing Set: Load the Angel Processing Set into the Angel System as per the following instructions: 1. Open the Angel centrifuge lid cover, and lift the centrifuge stator arm [the brake], to lock the rotating centrifuge adapter within the centrifuge. 2. Remove the Angle Separation Set Processing Set from the sterile tray and lay it on top of the machine. 3. Insert the variable volume separation chamber into the centrifuge adapter by aligning the notches in the separation chamber plate with the matching features on the centrifuge adapter. 4. Once aligned, press the separation chamber down and twist the separation chamber clockwise to the right, so that it locks into place. The Angel centrifuge will not rotate or start up if improperly loaded. 5. Lower the centrifuge stator arm and align it with the raised tab on top of the variable volume separation chamber. 6. Place the tube leading from the variable volume separation chamber, through the centrifuge well slot. 7. Close the centrifuge lid, ensuring that the tubing in the slot is not occluded 8. Place the pump loop tubing over the pump rotor. The pump loop will automatically load when the processing cycle is initiated. 9. Set the platelet cuvette/valve assembly by aligning the platelet cuvette and the valve assembly with the platelet sensor body and the valve assembly driver. Press down firmly on the rear side of the platelet cuvette/valve assembly, nearest to the pump loop, until the assembly is clicked into place. 10. NB. It is essential that the platelet cuvette /valve assembly seats fully on the machine to obtain proper sensing of the blood constituent components. 11. Hang the three compartment reservoir bag on the two support pins located on the side of the Angel Concentrated PRP System. 12. Remove the breather cap from the PRP valve port located on the valve assembly. Attach the 20ml luer lock syringe to the valve port. 13. After setup, inspect the circuit to make sure that there are no kinks in the tubing and that the lid of the centrifuge is sealed. 12

13 THE RAPID BIODYNAMIC HAEMATOGEL CHRONIC WOUND CARE TREATMENT PART 3: THE RAPID BIODYNAMIC HAEMATOGEL CHRONIC WOUND CARE TREATMENT PROCEDURE 3.1 Phlebotomy Step The individual responsible for blood collection should be trained in venipuncture including aseptic technique, proper skin preparation and continued protection of the site. 1. Preload the 60ml luer lock syringe with 8mls of ACDA anticoagulant. 2. Attach the Safety-Multifly [butterfly] needle to the syringe. 3. Wrap tourniquet proximal to the puncture site. 4. Cleanse venipuncture site with alcohol prep. 5. Palpate the vein then insert the Safety-Multifly needle through the skin into a vein. (Alternately, a PICC line adaptor may be used to access blood). 6. Draw 50mls blood per 60ml syringe. 7. Release the tourniquet and remove the Safety-Multifly needle from the vein. 8. Holding onto the Safety-Multi-fly wings, slide the protective tubing over the needle to prevent sharps injury. 9. Apply pressure to vein with the sterile 2 x 2 gaue and then apply band-aid dressing to venipuncture site. 10. Detach the safety multifly needle from the syringe and dispose of it into the clinical waste sharps bin. 11. Place a sterile cap, contained in the Angel processing set, onto the syringe filled with blood and gently invert the syringe to mix the blood with the anticoagulant. 3.2 Centrifugation Step 1. Remove the cap on the input valve to the whole blood chamber and insert the blood. 2. Close cap and discard the syringe in the clinical waste. 3. Ensure that the correct haematocrit setting is displayed on the Angel System touch screen. 4. Set the haematocrit setting and the blood volume setting on the touch screen display. 4.i For Chronic Wounds: Set Angel Heamatocrit setting to 8%: RAPID Acute Wound Setting 5. Press the Green Start button to start the 18minute spin and separation cycle. 6. Once the centrifuge stops, the Angel System will automatically separate the constituent components of the blood into: PRP, PPP and packed red cells. 13

14 REGENERATIVE BIOTHERAPIES 3.3 Processing Step 1: Making the Autologous Thrombin using the ActivAT Kit. 1. Open the sterile ActivAT kit and take out the 20ml luer lock syringe for the collection of the Platelet Poor Plasma [PPP]. 2. Draw 12mls of Platelet Poor Plasma [PPP] from the Angel processing set PPP chamber, after the Angel Device has processed the autologous PRP from the 50mls of the patient s blood. 3. Connect the transfer connector. 4. Remove cap from the prefilled ActivAT reagent syringe and attach to the syringe containing the 12mls of PPP. 5. Inject the ActivAT reagent into the PPP and mix by gently rotating the syringe. 6. Remove the ActivAT reagent syringe from the transfer connector. 7. Remove cap from the ActivAT processing syringe and break the seal by drawing back the plunger to release the contents of the processing syringe. 8. Connect the ActivAT processing syringe to the PPP syringe via the connector. 9. Inject the PPP containing the reagent into the processing chamber which contains glass beads to increase the surface area. 10. Mix well by vigorously shaking the syringe processing chamber containing the PPP and 11. Leave for minutes. 12. Depress the plunger of the ActivAT processing syringe and express out the autologous thrombin. 13. Average yield of 3mls of autologous thrombin. 14

15 THE RAPID BIODYNAMIC HAEMATOGEL CHRONIC WOUND CARE TREATMENT 3.4 Processing Step 2: Adding the Vitamin C and Autologous Thrombin to the PRP to make the RAPID Biodynamic Haematogel Chronic Wound Care Treatment. 1. Remove the syringe from the Angel Concentrated PRP Whole Blood Processing System containing the Platelet Rich Plasma after diluting the concentrated PRP with the required amount of PPP to achieve the necessary platelet concentration. See Dilution Table below: Table 6. Dilution Table for Achieving Desired Platelet Concentrations Whole Blood Volume [mls] Final Volume of PRP [mls] 50mls mls Platelet concentration [x over whole blood input] Platelet concentration [x over whole blood input] NB. An App is available to download to calculate the Angel Platelet Concentration. 2. Determine the amounts of autologous thrombin and ascorbic acid needed based on the volume of PRP drawn into the mixing chamber (Table 6). 3. Add the ascorbic acid, to the Autologous PRP based on the following Reagent Mix Table (Table 7). Table 7. Ascorbic Acid and Autologous Thrombin Mix Table for RAPID Biodynamic Haematogel Chronic Wound Care Treatment PRP (ml) Ascorbic acid (ml) Autologous Thrombin (ml) Before adding the Autologous Thrombin check to insure: Patient positioning is appropriate for gel application. Wound preparation, debridement has been properly completed. Application of skin protectant film or barrier cream, such as Cavalon to peri wound intact skin as needed. Caregiver is ready to perform the RAPID Biodynamic Haematogel application. 5. Add the autologous thrombin - Use the same 20 ml syringe with needle to draw the appropriate (Table 7) amount of autologous thrombin into the syringe. 6. Gently invert the syringe several times to mix the reagents with the PRP. 7. Discard the needle into clinical sharps container. 8. Within 18 seconds the RAPID Biodynamic Haematogel Chronic Wound Care Treatment is ready for application to the cleaned and debrided wound surface. 9. The RAPID Biodynamic Haematogel Chronic Wound Care Treatment can be applied using the syringe, by directly applying this to the wound surface. 15

16 REGENERATIVE BIOTHERAPIES 10. Alternatively for large wounds, the gel can be formed into sheets by using a sterile receiver or gallipot to pre-shape the gel for application to the wound surface. 3.5 Application of the RAPID Biodynamic Haematogel Chronic Wound Care Treatment PRP usually gels rapidly, within seconds from the addition of autologous thrombin. To prevent difficulty expelling from the mixing chamber of the syringe, prepare to apply the RAPID Biodynamic Haematogel Chronic Wound Care Treatment promptly following processing and activation. 1. Apply RAPID Biodynamic Haematogel Chronic Wound Care Treatment onto the wound area by first filling any undermined areas, tunnels, or sinus tracts using the blunt needle. Apply using Mepitel or similar non adherent dressing or a gloved hand to spread a thin layer directly in contact with viable tissue. 2. Apply the selected primary dressing (non absorbent, non cytotoxic) over the contact layer interface. Apply a secondary dressing (absorbent) to further secure and protect the primary dressing. 3. These dressings may be left in place until the next RAPID Biodynamic Haematogel Chronic Wound Care Treatment. If the secondary dressing becomes soiled, it should be changed. However, the primary dressing should be undisturbed for hours post application. 4. If the primary dressing is changed between RAPID Biodynamic Haematogel Chronic Wound Care Treatment applications, the wound bed may be carefully cleaned using extreme care to avoid disturbing new granulation tissue. No cytotoxic cleansers, topical anti-infectives or pressuried cleansing should be used. Appropriate moist wound dressings may then be applied until the next RAPID Biodynamic Haematogel Chronic Wound Care Treatment application. 3.6 Documentation 1. All RAPID Biodynamic Haematogel Chronic Wound Care Treatments to be carefully recorded in the RAPID Biodynamic Haematogel Patient Care Pathway in terms of best clinical practice and conformance with the Human Tissue Act requirements and all device kits recorded. 2. Document RAPID Biodynamic Haematogel Chronic Wound Care Treatment application and patient care as per facility policy. 3. Ensure confidentiality of patient details and only use patient hospital number as the primary mode of patient identification. 16

17 THE RAPID BIODYNAMIC HAEMATOGEL CHRONIC WOUND CARE TREATMENT PART 4: COMPOSITION, IFU S, STORAGE AND HANDLING OF THE ANGEL CONCENTRATED PRP SYSTEM FOR THE PRODUCTION OF THE RAPID BIODYNAMIC HAEMATOGEL CHRONIC WOUND CARE TREATMENT 4.1 Angel Whole Blood Seperation Processing Set Instructions for use Cat No Platelet Cuvette / Valve Assembly Clip Platelet Cuvette 3. Rotating Valve 4. Pump Loop Tubing 5. Whole Blood Compartment 6. RBC Compartment 7. PPP Compartment Three-Compartment Reservoir Bag 9. Variable Volume Separation Chamber ml Specimen Cups 11. Syringe Activated PRP Valve ml Luer Lock Syringe 13. Male-Female Luer Lock 14. Whole Blood Spike Adapter 14. Figure 1. Angel Whole Blood Separation Processing Set Variable Volume Separation Chamber: The Angel Whole Blood Separation Processing Set utilies a variable volume separation chamber that can process from 40 ml ml of anticoagulated autologous whole blood in a single cycle. Platelet Cuvette/Valve Assembly: The platelet cuvette/valve assembly contains three major components: (1) the platelet cuvette, (2) the pump loop tubing and (3) the rotating valve. The top half of the variable volume separation chamber (Figure 1) is the separation chamber plate. The separation chamber plate is used to seat the variable volume separation chamber in the centrifuge. The platelet cuvette/valve assembly has been designed so that the operator can easily install the platelet cuvette/valve assembly while insuring that the platelet cuvette is properly seated in the platelet sensor and that the rotating valve is properly seated on the valve assembly driver. 17

18 REGENERATIVE BIOTHERAPIES PRP Valve Port: A luer lock syringe is attached to the PRP valve port to collect PRP. At the end of a processing cycle, the PRP valve port can also be used to collect PPP. A Syringe Activated Valve is included as an accessory and can be attached for more convenient collection of PRP and PPP. Three-Compartment Reservoir Bag: The three-compartment reservoir bag is used to collect anticoagulated whole blood and separated blood components. The whole blood compartment is used as a reservoir for collected anticoagulated whole blood from a patient. The clinician may use syringes or whole blood bags to collect anticoagulated whole blood from a patient. The RBC Compartment is used to collect the concentrated red cells at the end of the processing cycle. The PPP Compartment is used to collect platelet poor plasma; the PPP is the first blood component collected after separation has been completed. Syringe activated valves are used to access the PPP, and whole blood compartments of the threecompartment reservoir bag. Other accessory items in the Angel Whole Blood Separation Processing Set are: 20 ml Luer Lock Syringe: The 20 ml luer lock syringe is used for the collection of platelet rich plasma. However, the syringe activated PRP valve will accommodate most luer fitting syringes. 60 ml Wrapped Specimen Cups (2 ea.): For use in a sterile field. Male/Female Luer Plug: The male/female luer plug can be used during and at the end of the procedure to seal open luer lock connections. Whole Blood Bag Spike Adapter: The whole blood spike adapter is used to transfer blood from a whole blood bag to the whole blood compartment of the three-compartment reservoir bag. Labels: Appropriate labels to label collected whole blood and separated components Description The Angel Whole Blood Separation Processing Set consists of a pre-connected variable volume separation chamber, a tubing set with a platelet sensor/valve assembly, and a three-compartment reservoir bag for the collection of blood products (whole blood, red blood cells, and platelet poor plasma). The Angel Whole Blood Separation Processing Set also contains a 20ml luer lock syringe for the collection of platelet rich plasma (PRP), two 60 ml specimen cups for use in a sterile field, a whole blood bag spike adapter, a male-female luer plug, and labels for collected blood components. Contents of this set have been sterilied by ethylene oxide gas and have non-pyrogenic fluid pathway Indications For Use The Angel Whole Blood Separation Processing Set is intended for use with the Angel Whole Blood Separation System to separate and collect an autologous plasma fraction rich in platelets and white cells from the patient s whole blood perioperative to a surgical procedure Contraindications The Angel Whole Blood Separation Processing Set is not intended to wash blood salvaged from the surgical site, nor is it intended for direct connection to the patient. The risk/benefit ratio of autologous sequestration must be determined on a case by case basis by the qualified medical personnel in charge of the patient s care; the responsibility for the use of this device belongs solely to the physician in charge Warnings 1. Only Angel Whole Blood Separation Processing Sets are approved for patient use with the Angel Whole Blood Separation System. 18

19 THE RAPID BIODYNAMIC HAEMATOGEL CHRONIC WOUND CARE TREATMENT 2. Do not use the Angel Whole Blood Separation Processing Set if sterile packaging barrier has been broken. 3. Carefully examine the Angel Whole Blood Separation Processing Set for damage prior to use. Should any evidence of damage to the Processing Set be e vident, do not use the Processing Set. 4. Carefully observe the Angel Whole Blood Separation Processing Set for leaks during use. Leakage may result in loss of sterility or loss of blood product. 5. Use of this product for pediatric patients is at the discretion of a physician. Blood withdrawal from a pediatric patient should be performed in the presence and at the direction of a physician to prevent significant reduction of the circulating blood volume. 6. When collecting and processing autologous blood products it is recommended that the following precautions be followed to insure that the autologous product is not contaminated. Use sterile technique when setting up the Angel Whole Blood Separation Processing Set Thoroughly clean and disinfect the donation site Use sterile technique whenever handling autologous blood products 7. Whole blood must be anticoagulated before it can be processed for separation. Inadequate anticoagulation may result in clotting, interfering with the processing of the blood products. Blood containing clots will not pass through the syringe-activated valve located on the Whole Blood compartment of the three-compartment reservoir bag. Do not over anticoagulate collected whole blood. The Angel Whole Blood Separation System does not having a processing cycle to remove excess anticoagulant. Excess anticoagulant administered to a patient could result in coagulopathies. 8. If centrifugation is discontinued before the completion of a processing cycle, the variable volume separation chamber is pressuried and presents the risk for exposure to blood and blood borne pathogens if the variable volume separation chamber is not properly removed. Please refer to the Angel Whole Blood Separation System Operator s Manual for unloading a variable volume separation chamber containing blood. 9. Failure to properly secure the luer lock syringe to the syringe-activated valve on the valve assembly may result in a leakage of fluids. 10. Do not directly connect the patient to the three-compartment reservoir bag. Direct connection to the patient could lead to vascular damage, shock or air embolism. 11. Disposal of Angel Whole Blood Separation Processing Sets should be in accordance with federal, state, and local regulations. These materials should be considered biohaardous. Universal precautions for blood borne pathogens should be practiced when disposing of these items. 12. The responsibility for the use of this device in all cases belongs solely to the physician in charge. 13. Place the Angel Whole Blood Separation System on a flat, stable surface. Never try to move the Angel Whole Blood Separation System while the device is in operation Precautions 1. Carefully read these Instructions for Use before using this product. Refer to the Angel Whole Blood Separation System Operator s Manual for complete instructions. 2. Due to the possibility of operator exposure to blood borne pathogens (such as HIV, hepatitis viruses, bacteria, etc.), Universal Precautions for blood borne pathogens should be practiced. 3. The Angel Whole Blood Separation Processing Set is intended for single patient use. Do not resterilie any part of this Processing Set. 19

20 REGENERATIVE BIOTHERAPIES 4. Failure to properly load the Angel Whole Blood Separation Processing Set per the enclosed instructions may affect the performance of the system. 5. Luer lock syringes should be used with the Angel Whole Blood Separation Processing Set. 6. This product is intended for use by trained personnel only. 7. The physician ordering the collection of PRP shall use discretion when any of the following conditions exist: Presence of sepsis Preoperative hematocrit less than 30% Preoperative platelet count less than 195,000 per microliter Hemodynamic instability Prolonged clotting times Recent use of anti-platelet drugs Inability to maintain stable oncotic pressure Instructions For Use Turning on the Angel 1. Turn on the Angel Whole Blood Separation System by pressing the power switch on the back of the machine (see Figure 2). The message Self test in progress. Please stand by. will be displayed on the Angel s touch screen display, and the machine will orientate the valve assembly driver to the loading position. Initial Setup With the Angel turned on, do the following: 1. Open the centrifuge lid cover and lift the centrifuge stator arm to lock the centrifuge adapter within the centrifuge well. 2. Remove the Angel Whole Blood Separation Processing Set from the tray Power Switch Figure 2 - Rear-view of Angel Whole Blood Separation System 20

21 THE RAPID BIODYNAMIC HAEMATOGEL CHRONIC WOUND CARE TREATMENT 3. Lay the Angel Whole Blood Separation Processing Disposables on the top of the machine. Insert the variable volume separation chamber into the centrifuge adapter by aligning the notches in the separation chamber plate with the mating feature on the centrifuge adapter. Once aligned, press the separation chamber plate down near the location of the position indicator and turn clockwise until the position indicator snaps into place (see Figure 3). The centrifuge adapter has an interlock mechanism that will stop the centrifuge rotation if the variable volume separation chamber is not properly loaded. 4. Place the tube leading from the variable volume separation chamber through the slot on the rim of the centrifuge well Separation Chamber Plate 2. Separation Chamber Plate Interlock Mechanism 3. Position Indicators Figure 3 - Mounting the Separation Chamber 5. Lower the centrifuge stator arm and align it with the raised tab on the top of the rotating seal of the variable volume separation chamber (see Figure 4). 1. Centifuge Stator Arm 1. Figure 4 - Centrifuge stator arm aligned with the variable volume separation chamber 21

22 REGENERATIVE BIOTHERAPIES 6. Close the centrifuge lid. After closing the centrifuge lid, make sure that the tubing remains in the slot on the rim of the centrifuge and is not occluded by the centrifuge lid. 7. Place the pump loop tubing over the pump rotor. The pump loop will automatically load when the processing cycle is initiated. Seat the platelet cuvette/valve assembly by aligning the platelet cuvette and the valve assembly with the platelet sensor body and the valve assembly driver. Press down firmly on the back side of the platelet cuvette/valve assembly, at position A near the pump loop, until the assembly is snapped in place (see label A, figure 5). Note: It is essential that platelet cuvette/valve assembly seats fully on machine to obtain proper sensing of blood components. A Platelet Cuvette 2. Valve Assembly 3. Valve Assembly Driver 4. Syringe Activated PRP Valve Figure 5 - Valve Assembly Hang the three-compartment reservoir bag on the two support pins located on the side of the Angel Whole Blood Separation System. 9. Remove breather cap from PRP valve port located on the valve assembly. If desired, attach the Syringe Activated Valve to the PRP valve port. Attach the 20 ml luer lock syringe (or alternate syringe, if desired), to the PRP valve port. Note: The luer on the PRP valve port will accommodate most luer lock syringes. 10. After set-up, inspect the circuit to make sure there are no kinks or occlusions Preoperative Blood Collection The Angel Whole Blood Separation System utilies a variable volume separation chamber that is capable of processing between 40 ml and 180 ml of anticoagulated whole blood in a single cycle. The Angel Whole Blood Separation System can accommodate anticoagulated whole blood that has been collected from a patient in either syringes or blood collection bags. In either situation, the patient s whole blood should be collected in a citrate anticoagulant (ACD-A) in a 7:1 ratio (seven parts whole blood to one part citrate anticoagulant). 22

23 THE RAPID BIODYNAMIC HAEMATOGEL CHRONIC WOUND CARE TREATMENT The following table defines the appropriate mixture of whole blood and citrate anticoagulant: Whole Blood vs. Citrate Anticoagulant Mixture (7:1 ratio; seven parts blood to one part citrate anticoagulant) Total Volume of Anticoagulated Whole Blood (ml) Volume of ACD-A (ml) Total Volume of Whole Blood Drawn (ml) ml anticoagulated whole blood volumes require a patient hematocrit of 30% or greater. The recommended minimum patient hematocrit for anticoagulated whole blood volumes of 50 ml or greater is 28%. During and after collection, gently mix the whole blood with the citrate anticoagulant for a thorough distribution of the anticoagulant. Failure to properly mix collected blood with anticoagulant may cause blood clot formation. Blood clot formation may interfere with the loading of blood into the Whole Blood compartment of the three-compartment reservoir bag and/or may interfere with the processing of the blood. If a syringe is used to collect blood, attach the syringe to the syringe-activated valve located on the Whole Blood compartment of the three-compartment reservoir bag and inject the blood. If using a whole blood collection bag to collect blood, ensure that the blood-citrate ratio is correct by weighing the bag as the blood is collected according to AABB standard methods. 14 Place the citrated blood bank bag on a standard metric scale and ero it prior to beginning to withdraw the blood. Refer to the instructions for the specific bag that you are using and allow the blood to gravity drain into the bag until its weight equals the volume of the bag (1 ml of blood weighs approximately grams). Use the Whole Blood Bag Spike Adapter to transfer blood to the whole blood compartment of the threecompartment reservoir bag. Connect the Whole Blood Bag Spike Adapter to the syringe activated valve located on the Whole Blood compartment of the three-compartment reservoir bag and spike the blood collection bag to drain the blood into the whole blood compartment. After the blood has drained into the Whole Blood compartment of the three-compartment reservoir bag, remove the Whole Blood Bag Spike Adapter and recap the syringe-activated valve. Refer to the Angel Whole Blood Separation System Operator s Manual for processing instructions. 14 Method 9.3 Phlebotomy and Collection. Technical Manual. American Association of Blood Banks. AABB Press. Bethesda, MD

24 REGENERATIVE BIOTHERAPIES 4.2 Angel Blood Access Kit Instructions for use Cat No Blood Access Kit Contents 2ea - 60 cc syringes 1ea - 17 gauge needle fistula set 1ea - 30 ml vial of ACD-A 1ea - IV Prep Kit 1ea - Skin prep single swab 2ea - 18 gauge needles Description The Angel Blood Access Kit consists of the following sterile components: two each 60 cc syringes, one each 17 gauge needle fistula set, one each 30 ml vial of ACD-A anti-coagulant, an intravenous blood prep kit, a skin prep single swab, and two each 18 gauge needles for the aspiration of ACD-A Indications For Use The Angel Blood Access Kit is intended for the collection of anticoagulated whole blood for further processing using the Angel Whole Blood Separation System Contraindications There are no known contraindications for this product Warnings The health care professional responsible for blood collection should be trained in the practice of venipuncture and the inherent risks. Aseptic technique, proper skin preparation and continued protection of the venipuncture site are essential. Do not use the skin prep swabs included in this kit on patients allergic to Iodine. Carefully examine the Angel Blood Access Kit for damage prior to use. Should any evidence of damage to any kit components or their sterile packaging be evident, do not use for collection. For single use and for single-patient use only. During use the device is in contact with human blood, body fluids, liquids or gases for the purpose of eventual infusion, administration or introduction into the body and due to its specific design it cannot be fully cleaned and disinfected at the end of use. Therefore, reuse on other patients might cause cross-contamination, infection and sepsis. In addition, reuse increases the probability of product failure (integrity, functionality and clinical effectiveness). If used on children, pregnant or nursing women, be aware that this device contains di(2-ethylhexyl) phthalate (DEHP) that is presently classified in the European Union as toxic to reproduction. The amount of phthalate which might be released from the device does not raise specific concerns about residual risks. Further information is available on request. When collecting and processing autologous blood products it is recommended that the following precautions be followed to insure that the autologous product is not contaminated: Use sterile technique when setting up the Angel Blood Access Kit Thoroughly clean the donation site Use sterile technique whenever handling autologous blood products 24

25 THE RAPID BIODYNAMIC HAEMATOGEL CHRONIC WOUND CARE TREATMENT Whole blood must be anticoagulated before it can be processed for separation. Inadequate anticoagulation may result in clotting, interfering with the processing of the blood products Precautions The Angel Blood Access Kit is intended for single patient use. Do not resterilie or reuse any part of this kit. This product is intended for use by trained personnel only. Carefully read the Instructions for Use before using this product. The physician ordering the procedure to collect and process autologous blood should consider the following patient conditions prior to ordering the procedure: Presence of sepsis Pre-procedure hematocrit Pre-procedure platelet count Hemodynamic stability Clotting times Use of anti-platelet therapies Stable oncotic pressure Do not collect whole blood from same limb where IV is inserted. This kit contains sterile components. Practice Universal Precautions due to the possibility of operator exposure to blood borne pathogens (such as HIV, hepatitis viruses, bacteria, etc.). Discard all blood collection materials in biohaard containers approved for their disposal. The ACD-A anticoagulant is not for infusion. Discard the unused portion Instructions for Use Syringe Set-Up and Preparation of Syringes The Angel Whole Blood Separation System utilies a variable volume separation chamber that is capable of processing between 40 ml and 180 ml of anticoagulated whole blood in a single cycle. The Angel Blood Access Kit contains 2 60 cc syringes for collection of up to 120 cc whole blood. If more than 120 cc of whole blood is to be processed using the Angel Whole Blood Separation System, the user must supply a third sterile syringe or blood bag containing the appropriate quantity of citrate anticoagulant (ACD-A) to achieve a 7:1 blood:citrate anticoagulant ratio. STEP 1: Locate and open the IV Prep Kit. Clean the ACD-A bottle with the alcohol wipe provided in the IV Prep Kit. STEP 2: Using the 18 gauge needle, slowly draw the appropriate amount of citrate anticoagulant (ACD-A) into a 60 ml syringe to achieve a 7:1 ratio of blood to ACDA (Column B). 25

26 REGENERATIVE BIOTHERAPIES Whole Blood vs. Citrate Anticoagulant Mixture (7:1 ratio; seven parts blood to one part citrate anticoagulant) Column A Volume of Blood Drawn (ml) Column B Volume of ACD-A (ml) Column C Syringe Volume of Blood (ml) Preparation of the Venipuncture Site STEP 3: Follow your facility s policies and procedures for performing venipuncture for blood collection using the fistula 15. STEP 4: GENTLY draw desired amount of blood (Column A) from the patient into a 60 ml syringe. The maximum total volume in each syringe totals 60 ml (52 ml whole blood and 8 ml ACD-A). Note: Excessive force may activate platelets and hemolye red blood cells. STEP 5: During and after collection, gently mix the whole blood with the citrate anticoagulant for a thorough distribution of the anticoagulant. Whole blood may be kept for up to eight hours from collection time at room temperature. If processing is delayed, ensure mixing of anticoagulant with whole blood. Note: Failure to properly mix collected blood with anticoagulant may cause blood clot formation. Blood clot formation may interfere with the loading of blood into the Whole Blood compartment of the threecompartment reservoir bag, and/or may interfere with the processing of the blood. STEP 6: Inject the collected whole blood into the Whole Blood Compartment of the Angel Whole Blood Separation System Processing Set. 4.3 ActivAT Autologous Thrombin Processing Kit Cat No Kit Contents: Process Syringe Transfer Syringe Reagent Syringe-Contains Ethanol Calcium Chloride Solution Female Connector Wrapped 60ml Cup Instructions For Use Description The ActivAT Autologous Thrombin Processing Kit is designed to produce autologous thrombin serum from Platelet Poor Plasma. This product has been sterilied with gamma radiation and has non-pyrogenic fluid pathways Indications For Use The ActivAT Autologous Thrombin Processing Kit is intended for the production of an autologous thrombin serum derived from a patient s own platelet poor plasma. 15 FDA, Center for Biologics Evaluation and Research, Options for Arm Preparation, Updated January 29,

27 THE RAPID BIODYNAMIC HAEMATOGEL CHRONIC WOUND CARE TREATMENT Contraindications Undiluted autologous thrombin serum produced from this device contains approximately 17% ethanol by volume. Do not apply autologous thrombin serum directly to tissues sensitive to ethanol Warnings Because of its action in the clotting mechanism, thrombin serum must not be injected or otherwise allowed to enter large blood vessels. Extensive intravascular clotting, severe injury, and even death may result. Do not use the kit if any components are damaged or sterile package barrier has been broken. Do not apply autologous thrombin serum to patients that are known to be allergic to ethanol. Do not operate device if the PROCESS SYRINGE integral filter is detached or if materials have leaked out of the syringe Precautions Read Instructions For Use carefully before using this device. This device is intended for the production of one autologous thrombin serum batch and single patient use. Do not resterilie. This device is intended for use by trained personnel only. Do not use blood that is anticoagulated with warfarin sodium, heparin or any other means than citrate. The ActivAT Autologous Thrombin Processing Kit performance has not been tested for all possible blood conditions. Conditions may exist where the resulting autologous serum produced may have a low activity level. The autologous thrombin serum produced from this product has been tested for storage periods up to 6 hours Procedure For Use Caution: Failure to use prescribed volumes indicated in the procedure may result in autologous thrombin serum having low activity levels. Caution: PROCEDURE FOR USE operation steps must be performed with aseptic technique. Caution: Only use platelet poor plasma that is Citrate anticoagulated 7:1 by volume whole blood to citrate. Plasma (Platelet Poor Plasma) Preparation: 1. Remove the protective cap from the TRANSFER SYRINGE and aspirate 12.0cc of plasma (platelet poor plasma) into the syringe. 2. Attach the enclosed double female adapter to the tip of the TRANSFER SYRINGE. 3. Remove the tip plug from the REAGENT SYRINGE. 4. Connect the REAGENT SYRINGE to the TRANSFER SYRINGE with the double female adapter. 5. Hold the REAGENT SYRINGE above the TRANSFER SYRINGE and RAPIDLY inject its contents into the TRANSFER SYRINGE. 6. Detach the empty REAGENT SYRINGE from the double female adaptor. Make sure that the double female adaptor remains attached to the TRANSFER SYRINGE. 7. Pull 2-4cc of air into the TRANSFER SYRINGE. 27

28 REGENERATIVE BIOTHERAPIES Processing Procedure: 1. Remove the female plug from the PROCESS SYRINGE. 2. Attach the TRANSFER SYRINGE with the double female adaptor to the PROCESS SYRINGE. 3. Hold the TRANSFER SYRINGE and PROCESS SYRINGE horiontaly and inject contents into the PROCESS SYRINGE. 4. VIGOROUSLY shake the PROCESS SYRINGE to thoroughly mix the plasma with the processing materials. Continue shaking the PROCESS SYRINGE until its fluid contents thicken into a paste consistency. Make sure that processing materials are completely wet (slight tapping may be required). 5. Allow the PROCESS SYRINGE to sit for a minimum time of 30 minutes at room temperature. Additional incubation time up to 60 minutes may be required as, clinical environment and patient blood variation may influence the rate of thrombin formation. PROCESS SYRINGE contents should be visually inspected for solid clot formation by tilting the PROCESS SYRINGE. Sufficient thrombin serum activity is indicated by liquid PROCESS SYRINGE contents clotting and not flowing. 6. Prior to expressing autologous thrombin serum from the PROCESS SYRINGE, tap and agitate the PROCESS SYRINGE to remix its paste contents to facilitate flow. 7. Pull back TRANSFER SYRINGE plunger and turn clockwise. turn to lock in place. This will generate a vacuum that will pull thrombin serum into the TRANSFER SYRINGE (a secure connection between the PROCESS and TRANSFER SYRINGE is required to hold vacuum). PROCESS SYRINGE plunger may be pushed while lock is engaged to maximie thrombin serum yield. 8. Turn the TRANSFER SYRINGE plunger counterclockwise. Turn to disengage the lock. 9. To maintain the activity of unused autologous thrombin serum for periods longer than one hour, store the serum in the TRANSFER SYRINGE at 0-3 o C Specifications The ActivAT Autologous Thrombin Processing Kit produces 5-6ml of autologous thrombin serum with minimum activity of 50 International Units or 43 National Institute of Health Units from 12ml of citrated Platelet Poor Plasma. 1 International Unit = 1.15 National Institute of Health Unit Additional Safety Information: Approximately 2.4ml of ethanol is included in each ActivAT Autologous Thrombin Processing Kit. Ethanol is a Class III, flammable liquid. The following information provides its haardous identification and storage/handling. MSDS sheet is available by request. Haards Identification Substance Name: Ethyl Alcohol, USP/NF CAS #: Emergency Overview: Flammable (USA), Highly Flammable (EU), Irritant, Irritating to eyes, respiratory system, and skin. Target organs: nerves, liver, blood, and reproductive system NFPA Rating: Health:2, Flammability:3, Reactivity:1 Handling and Storage 28

29 THE RAPID BIODYNAMIC HAEMATOGEL CHRONIC WOUND CARE TREATMENT User Exposure: Avoid breathing vapor. Avoid contact with eyes, skin, and clothing. Avoid prolonged or repeated exposure. Storage, Suitable: Keep container closed. Keep away from heat, sparks, and open flame. Store in a cool, dry place between 0-60 o C). 29

30 30 REGENERATIVE BIOTHERAPIES

31