fibrin sealants & components. fibrin sealants surgical haemostatic and adhesive agents derived...
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Fibrin sealants & components
Fibrin sealants
Surgical haemostatic and adhesive agents derived from plasma products
Designed to reproduce the final steps of the physiological coagulation cascade and form a stable fibrin clot
Fibrin clot arrests blood loss, seals physiological compartments and aids normal wound healing
Clot degraded by naturally occurring fibrinolytic enzymes over several days to weeks
Components of fibrin sealants
Fibrinogen
Thrombin
Factor XIII
Antifibrinolytic agent
Calcium chloride
Fibrinogen
Source: human plasma derived
Concentration range: 65–115 mg/mL
Structure: soluble monomeric form of fibrin
Function: forms basis of clot along with platelets – forms covalent cross-links with factor XIII which stabilizes the clot
Thrombin
Human plasma derived
4–1000 IU/mL
Enzymatically cleaves fibrinogen to initiate polymerisation
Cleaves 2-subunits and -chain of factor XIII
Initiates fibroblast division in wound healing
Factor XIII
Source: human plasma derived
Concentration range: 0–80 U/mL
Function: activated by thrombin in the presence of Ca2+ to factor XIIIa. Factor XIIIa participates in fibrin cross-linking and stabilisation
Aprotinin
Source: bovine lung derived
Concentration range: 0–3000 KIU/mL
Function: inhibits plasmin, preventing fibrinolysis – prevents clot degradation
Calcium chloride
Concentration: 40 mmol/L
Function: Ca2+ ions are required for thrombin and factor XIIIa activity
Fibrinogen
Fibrin degradation
Thrombin
Cross-linked fibrin clot
Fibrin clot
Mechanism of action
Factor XIIIa
Anti-fibrinolytic [Aprotinin,
tranexamic acid]
X
Beriplast® P safety & tolerability
Clinical safety of Beriplast® P
Beriplast® P has been shown to be clinically useful across a range of surgical procedures, and has an excellent safety and tolerability profile
Rigorous donor selection and testing on all plasma used in Beriplast® P is designed to ensure an extremely low risk of pathogen transmission
Safety of Beriplast® P
Worldwide safety record – many years’ experience with Beriplast® P – more than 6 million milliliters applied to date
Data from post-launch period (July 1991-Dec 2002) show:– no confirmed reports of HIV or hepatitis transmission
attributable specifically to Beriplast® P – only 1 in 156264 uses was associated with a suspected
adverse drug reaction in most cases the adverse reaction was not related to
Beriplast® P
Beriplast® P: integrated safety system
Safety at source
Controls/plasma verification and testing
Effective virus inactivation and elimination steps in production
Final product testing
Beriplast® P ISS: safety at the source
Safety at the source– plasma collection– donor centre selection– qualified donor selection– donation testing– plasma inventory hold
Careful selection of plasma donors meeting or exceeding regulatory requirements– viral marker rates lower than other plasma suppliers
Beriplast® P ISS: controls
Controls– plasma verification system– plasma pool testing
Rigorous testing of donated blood by serology and sensitive NAT/PCR techniques
Beriplast® P ISS: safety at the source
Careful donor selection– screening criteria more rigorous than non-
paid donors
Rigorous testing of donated blood or plasma by serology and sensitive NAT/PCR techniques
Beriplast® P: NAT/PCR used to test plasma donations
Hepatitis viruses– hepatitis C virus (HCV)– hepatitis B virus (HBV)– hepatitis A virus (HAV)
Retrovirus– human immunodeficiency virus-1 (HIV-1)
Parvovirus– parvovirus B19
Beriplast® P: window period reduction by PCR
HIV
HBV
HCV
Reduction
11
31
23
50
45
72
11
25
59
22
56
82
Window period (days)
%DaysPCRSerologyVirus
Beriplast® P ISS: virus inactivation and elimination
Effective virus inactivation and elimination steps in production– pasteurisation– purification methods
Beriplast® P: virus elimination and inactivation steps
Elimination Inactivation
Cryoprecipitation
Adsorption
Ammonium sulphate precipitation
Ion exchange chromatography
Pasteurisation
Validation of virusInactivation/elimination
Demonstrates inactivation/elimination of certain viruses potentially present in donated plasma
Beriplast® P: viruses used in validation studies
Test Virus Relevant virus or Model virus for
HIV-1
Bovine viral diarrhoea virus (BVDV)
Herpes simplex virustype-1 (HSV-1)
Hepatitis A virus (HAV)
Canine parvovirus (CPV)
Relevant virus, specific model for Retroviruses
Specific model for HCV, HGV and non-specific model for other medium-sized enveloped RNA viruses
Non-specific model for enveloped DNA viruses
Relevant virus and non-specific model for other non-enveloped small RNA viruses
Specific model for Parvovirus B19
Viral reduction in Beriplast® P production
Pasteurisation process
Between 1.2 and 9 log10 reduction
Overall
Between 12 and 20 log10 reduction of HIV-1
Between 11 and 13 log10 reduction of model enveloped RNA virus
Between 5 and 9 log10 reduction of HAV
Between 9 and 20 log10 reduction of model enveloped DNA viruses (herpes simplex 1)
Between 4.3 and 5.5 log10 reduction of model parvovirus
Beriplast® P log10 viral reduction factors: human thrombin
Ion exchange chromatography
Pasteurisation
Precipitation, absorption
Activation of prothrombin
Mean overallreduction factor
2.7
6.9
6.5
3.5
19.6
-
8.5
1.9
2.2
12.6
1.7
7.0
6.6
5.0
20.3
-
4.0
1.7
2.6
8.3
1.1
(0.5)*
1.2
3.2
5.5
*Data not used in overall reduction factor calculation
Production step HIV-1 BVDV HSV-1 HAV CPV
Cryoprecipitation
Adsorption,precipitation
Pasteurisation
Precipitation
Lyophilisation
Mean overallreduction factor
-
2.8
5.7
3.9
-
12.4
-
(1.5)*
9.0
2.0
-
11.0
-
(0.9)*
8.0
1.0
-
9.0
1.4
-
4.1
(0.8)*
(2.2)*
5.5
1.7
-
1.2
1.6
-
4.5
Beriplast® P log10 viral reduction factors: human fibrinogen
Production step
*Data not used in overall reduction factor calculation
HIV-1 BVDV HSV-1 HAV CPV
Adsorption,defibrination
Ion exchange chromatography
Pasteurisation
Lyophilisation
Mean overallreduction factor
5.6
4.6
7.0
-
17.2
2.8
2.6
7.9
-
13.3
7.4
-
7.2
-
14.6
1.3
3.1
4.2
(2.3)*
8.6
(0.4)*
3.3
1.0
-
4.3
Beriplast® P log10 viral reduction factors: human factor XIII
Production step
*Data not used in overall reduction factor calculation
HIV-1 BVDV HSV-1 HAV CPV
Aprotinin and transmissible spongiform encephalopathy (TSE) risk
Derived from bovine lungs– class III organ
Cattle from countries with no reported cases of BSE according to WHO information
Reduction of scrapie agent (causative agent of TSE in sheep and goats) during the manufacture of aprotinin
Beriplast® P ISS: final product testing
Sterility
Activity / Identity
pH
Appearance, colour and solubility
Beriplast® P: adverse reactions
Basic prescribing information for Beriplast® P lists:– rare reports of hypersensitivity or allergic reaction
(dyspnoea, flushing/rash) – isolated cases of anaphylactic shock
Repeated exposure or hypersensitivity to bovine proteins (or other product constituents) can contribute to an adverse event
Thromboembolic complications
Risk for tissue adhesion at undesired sites
Transmission of infective agents
Beriplast® P: drug surveillance
>6 million mL of Beriplast® P distributed worldwide
41 cases of drug reactions have been reported with Beriplast® P - approximately 1 suspected adverse reaction per 156264 applications of Beriplast® P in the reporting period from Jul 1991 to Dec 2002
No confirmed reports of transmission of viral hepatitis or HIV related to use of Beriplast® P
Aronson, 1996
Estimated risks of adverse events in clinical practice
10-20% of hospital patients suffer an adverse reaction to therapy
0.24-2.9% of deaths in hospital inpatients are due to adverse reactions to drugs
0.3-5.0% of hospital admissions are due to adverse drug reactions
For Beriplast® P the estimated reporting rate of suspected adverse event is 1 case for every 156264 standard applications (0.0000063%)
Safety of Beriplast® P
Greatly reduced risk of viral transmission compared with blood transfusion
Safer than blood bank produced sealants– reduced risk of virus transmission– reduced risk of antibody response with human
thrombin compared with bovine thrombin– consistency of product
Beriplast® P: conclusions
The manufacturer’s integrated safety system confers a high degree of clinical safety to Beriplast® P
Beriplast® P is a safe, valuable and reliable adjunct to surgery supported by:– virus validation studies– clinical trials data– long-term drug surveillance reports
Preclinical uses of fibrin sealant
Experimental models
Used to determine the mechanical and biochemical properties of fibrin sealants
Mechanical properties– support strength of seal– evaluate bursting pressure of wound closure
Biochemical properties– models of haemostasis– studies of the viscosity of fibrin sealants
Fibrin sealants enhance tensile strength of intraocular wounds
Day 0 Day 4 Day 28
Shigemitsu and Majima, 1997
0
50
100
150
200
250
300
350
Mean tensilestrength
gf/mm2
Vertical suture
Infinity suture
Self-sealing sutures
Fibrin sealant
Cyanoacrylate closure
Postoperative days
Fibrin sealants increase the tensile strength of ruptured membranes in vitro
Fibrin sealant increases the strength of punctured chorioamniotic membrane in vitro but does not restore tissue strength to pre-puncture levels
0
20
60
100
140
180
40
80
120
160
Rupture tension
(g/cm)
Intact Punctured Fibrin sealant
Harmanli et al, 1998
*
*
*p<0.05
Human plasma derived fibrin sealants produce strong wound closure
Human fibrin sealant provides a stronger cutaneous wound closure than sutures alone (controls) or bovine fibrin sealant
Scardino et al, 1999
0
2
4
6
8
10
12
14
Day 10 Day 30 Day 10 Day 30
Human fibrin sealant Bovine fibrin sealant
Treated
Control Control
Breakingstrength
(kg)
Treated
Fibrin sealants strengthen colonic anastomoses
Byrne et al, 1992
Bursting pressure of colonic anastomoses closed with fibrin sealant and sutures is significantly (p<0.05) higher than with sutures alone
0
20
40
60
80
100
120
Burstingpressure
cm H2O
Sutures Sutures +fibrin sealant
*
*p<0.05
Fibrin sealants strengthen watertight sutures
Oosterlinck et al, 1993
Hydrostatic leak pressure is significantly higher (p<0.1) after skin tube closure with sutures and fibrin sealant compared with sutures alone
Burstingpressure
cm H2O
Day 0 Day 3 Day 6
Postoperative days
Fibrin sealant
Control
0
25
50
75
100
*
*
*
*p<0.1
Fibrin sealants strengthen vascular anastomoses
Isogai et al, 1992
Fibrin sealant significantly (p<0.01) reduces bleeding following vascular anastomoses even in hypertensive animals
0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
Bleedingg/30 s
Normotensive 150 mmHg 200 mmHg 250 mmHg
Blood pressure
Treated
Control
Effect of fibrin sealant in a femoral artery
injury model
Jackson et al, 1997
Meanblood loss
(mL)
Meanblood flow
(mL/min)
0
25
50
75
100
Treated
Control
0
20
40
60
80
100
120
*
*p=0.0005
Fibrin sealant reduces suture hole bleeding in a pig vascular graft model
Dickneite et al, 2000
0
50
100
150
200
Mean blood loss
(mL)
ControlFibrinsealant
*
* p=0.016
Effective haemostasis in experimental atrial rupture
Right atrium
Left atrium
Mean atrial pressureprior to clamp release
(cmH2O)
Haemostasis
10.4
10.8
5/5
5/5
Kjaergard et al, 1995
Hot aircoagulation
Tovar et al, 1998
Effective haemostasis with fibrin sealant in experimental liver injury
Suture
Fibrinsealant
Time tohaemostasis (s)
100 200
300
400
0
Viscosity and delivery of fibrin sealants
Used increasingly in minimally invasive surgical techniques such as endoscopy– repair damaged tissue– haemostasis
– promoting healing process
Delivered through twin-lumen injection catheters– <180 cm in length
– force needed to inject fibrin sealant increases with increasing catheter length
Comparison of two commercially available fibrin sealants
Beriplast® P Competitor
Component 1
Human fibrinogen 65–115 mg
Human factor XIII 40–80 U
Human albumin 5–15 mg
Bovine aprotinin 1000 KIE
Amino acids, salts
Component 2
Human thrombin 400–600 IU
CaCl2 dihydrate 5.88 mg
NaCl, Sodium citrate
Component 1
Human fibrinogen 70–110 mg
Human factor XIII 10–50 U
Human fibronectin 2–9 mg
Bovine aprotinin 3000 KIE
Glycine, albumin, heparin, creatine, triton, salts
Component 2
Human thrombin 500 IU
CaCl2 dihydrate 5.88 mg
NaCl, glycine
Human plasminogen 0.02–0.08 mg
Nagelschmidt, 1999
Viscosity of fibrin sealants
Nagelschmidt, 1999
0
150
300
450
600
750
900Beriplast® P Competitor
18ºC 25ºC 37ºC 25ºC 37ºC18ºC
Viscosity(mm2/s)
Batch 1
Batch 2
Batch 3
Less force needed to deliver low viscosity fibrin sealants through delivery devices
Nagelschmidt, 1999
0
1000
2000
3000
4000
Short Long Short Long
Force(g)
Batch 1
Batch 2
Batch 3
Catheter length
Beriplast® P Competitor
Fibrin sealant reduces rate of adhesion formation in a rat model
Harris et al, 1995
0
25
50
75
100
Control Interceed® Fibrin sealant
Rate ofadhesionformation
(%)
2% carboxy-methylcellulose
Strength of adhesion is inversely related to treatment viscosity
Harris et al, 1995
0
45
90
135
180
Adhesionstrength
(g)
Control Interceed® Fibrin sealant
2% carboxy-methylcellulose
Moro, 1999
Fibrin sealant inhibits pericardial adhesions after cardiac surgery in dogs
No. of animals
0
1
2
3
4
5
6
7
8
Adhesion to epicardiump<0.001
Adhesion to patchp<0.001
0 1 2 3 0 1 2 3
Adhesion score
Adhesion score
ControlFibrin sealant
Delivery devices
Fibrin sealants
Fibrin sealants are used in a variety of surgical procedures including:– open surgery– minimal invasive surgery– endoscopy– microsurgery
A range of delivery devices are used to ensure that fibrin sealant can be applied to the surgical site efficiently and effectively
Pantajet® dual syringe in open surgery
Uses:
– local haemostasis
– suture support
– tissue adhesion
– assisting closure of small lung fistulae
– sealing of body cavities
Application of fibrin sealant through spray tip in open surgery
Pantaject® with spray tip can be used in:– cardiovascular surgery– thoracic surgery– visceral surgery– plastic and reconstructive
surgery– maxillofacial surgery– trauma surgery
0.5 mL Beriplast® P covers 25–50 cm2; 1.0 mL covers 50–100 cm2; 3.0 mL covers 150–300 cm2
Application of fibrin sealant in minimal invasive surgery
Endoflex® spray catheter with Endoflex® spray tip (syringes with Luer Lok® connector needed)
Uses:
– laparoscopy
– thoracoscopy
– video-assisted thoracic surgery
CE 0538
Application of fibrin sealant in minimal invasive surgery
The Catheject™ dual lumen endoscopic catheter (parallel channels)
Uses:– minimal invasive
surgery
Pantaject ® 3 mL or Endoscopic Application Set
Application of fibrin sealant through double-lumen probe in endoscopy
Endoflex® double-lumen probe ‘Neumühl’ and syringes with Luer Lok® connector
Use:
– bleeding peptic ulcers
Application of fibrin sealant throughdouble-lumen probe in endoscopy
Endoflex® double-lumen probe ‘Neumühl’ (syringes with Luer Lok® connector needed)
Use:
– bleeding peptic ulcers
Double-lumen probe (no needle) for use in endoscopy
The Catheject™ dual lumen catheter (parallel channels)
Uses:– Fistulae - anastomotic
insufficiencies of the gastrointestinal tract
Pantaject ® 0.5/1 mL, 3 mL or Endoscopic Application Set
Application of fibrin sealant with double-lumen cannulae in microsurgery
The Catheject™ dual lumen cannula (parallel channels, malleable)
Flexible catheter for spray delivery
Flexible PvB catheter, triple-lumen
Thrombin solution in one lumen, fibrinogen solution in one lumen
Compressed sterile gas delivered via large lumen
Flexible catheter
Single-lumen plastic catheter
Pantaject ® 0.5/1 mL, 3 mL