Platelet rich gel can be used as an adjunct to homeostatic measures to control bleeding and aid in wound healing. The “Direct Draw,” intra-operative method of platelet sequestration can produce an autologous platelet rich gel that can eliminate disease associated with multiple donors. It is cost effective, easy to make and can be a useful surgical tool for selected patients.
Fibrin sealant has proven beneficial for many years in a wide variety of surgical procedures. Neurology, orthopedics and cardiac surgery are just a few examples. However, its use was limited because of the inherent risks associated with multiple donors of human plasma. Until recently, Fibrin Glue was made in the standard way by using heterologous blood components (cryoprecipitate), thus exposing the patient to multiple donors. Autologous platelet rich gel has eliminated the risk of disease (viral transmission) related to donor blood products. The platelet rich gel can be used by the surgeon to control unsuturable bleeding sites and the diffuse oozing associated with redo open-heart patients. It is easy to prepare and can be made with little advance notice. Using the Direct Draw method of platelet sequestration, a single donor platelet gel can be made successful intra-operatively.
PLATELET GEL BIOCHEMISTRY
Platelets are our primary mechanism for hemostasis. They circulate in our bodies looking for exposed endothelium. They then aggregate to the site of injury and further platelet degranulization occurs. The release various growth factors can also aid in the healing process. Platelet gel mimics the final stages in the clotting cascade. The platelet rich plasma in the presence of thrombin activates platelets, converts fibrinogen to fibrin and stimulates further platelet aggregation. Calcium chloride is added to counteract the anticoagulant citrate, rapidly forming a gelatinous, platelet-rich glue.
MATERIALS AND METHODS
In this evaluation, the Sequestra 1000 blood processing machine and the direct draw method of platelet sequestration was used. The sequestration “kit” from Medtronic came with all the necessary components to modify the standard wash set. The kit comes with a Y’d pigtail that attached to the waist outlet line of a 125ml or 225ml latham bowl. The two blood transfer bags found in the kit, labeled “platelet-rich” and “platelet-poor,” were attached to the pigtail. A separate anticoagulation drip line with buritrol was also included with the kit. This line was spiked to a 500ml CPD (citrate phosphate dextrose) bottle. One hundred milliliters (100ml) of CPD was allowed to fill the buritrol, then the anticoagulation is gravity primed to avoid any possibilities of air entrainment. The anticoagulation line was connected to an 8.5fr cordis in the internal jugular vein and to the inflow line to the centrifuge bowl. A drip rate from the buritrol was established at 70gtts/min to assure adequate anticoagulation. Note: There are alternative draw sites that can be used, but you must ensure that all connections are free flowing to avoid cavitation of air.
The concentrated platelet program (conplt) was then started. The initial flow rate was 50ml/min at 5600 rpm and then increased up to 100ml/min as the patient tolerated. Fluid replacement may become necessary in volume sensitive patients. The red blood cells can be re-infused if needed without penalty. The platelet poor plasma was collected into the transfer bag with the first hard spin at 5600 rpm’s and a flow rate of 50-100ml. The concentrated platelet program automatically sensed the level of the buffy-coat and stopped the centrifuge to allow a 60 second count down to help loosen platelets. After the 60-second countdown, the Sequestra prompted us to switch our clamps to the platelet rich plasma. A soft spin was begun at 2400 rpms and the platelet rich plasma was collected. This process was continued until an adequate amount of plasma had been collected. We found that 3 to 5 passes were sufficient to collect approximately 800ml of platelet poor plasma and 100ml of platelet rich plasma. A sample site coupling was spiked into the platelet rich bag and 21cc of plasma was drawn up in a separate syringe and transferred to a sterile specimen cup on the surgical field.
The Autologous platelet gel was produced in two parts. The platelet rich plasma was the first solution and stored in the sterile specimen cup labeled “PRP”. The second solution was a mixture of 1 gram 10% CaCl (Abbojet) used to dilute 10,000u/ml thrombin powder. Solution #2 was stored separately on the sterile field until ready for use. The ratio of solution #1 (platelet rich plasma) to solution #2 (thrombin diluent) was 7:1. We mixed 21cc of PRP to 3cc of thrombin diluent. Each solution was drawn up into a syringe and mixed into a separate sterile specimen cup at time of usage. The autologous glue was quickly drawn up into a 60cc syringe and injected onto the surgical sites that were bleeding. The gel set up in just a few seconds. The excess platelet poor plasma was re-infused after protomine had been given.
TABLE 1. INDICATIONS VS. CONTRAINDICATIONS
|REOPERATIONS||SEVERE HYPOVOLEMIC STATES|
|DACRON TUBE AND PATCH REPAIRS ( AS IN ANEURYSMS )||UNSTABLE ANGINA WITH IABP|
|PREXISTING COAGULOPATHY||PATIENTS WITH HEMATOCRITS UNDER 30%|
|ACUTE MYOCARDIAL ISCHEMIA|
|FIBRINALITIC DRUG THERAPY ,TPA, STREPTOKINASE|
|LEFT MAIN CORONARY ARTERY DISEASE|
|PLATELET COUNT BELOW 100|
TABLE 2. COST COMPARISON ANALYSIS
|FIBRIN GLUE||PLATELET GEL|
|1 UNIT(15CC) CRYOPRECIPITATE: $43/UNIT. AVERAGE 4 UNITS FOR SUFFICIENT AMOUNT OF GLUE||MEDTRONICS SEQUESTRA KIT: 3-4 PASSES OBTAIN A THERAPUTIC DOSE OF PLATELETS/PLASMA : $25 ABOVE DISPOSABLE WASH SET.|
|PREOPERATIVE SINGLE DONOR PHERESIS: $500||TIME REQUIREMENT: CAN BE COMPLETEDWITHIN 20 MIN. INTRAOPERATIVE|
|2 FFP: $55/UNIT|
|6 PLT: $50/UNIT|
|TIME REQUIREMENT: HOMOLOGOUS: 20-30 MIN THAW TIME – AUTOLOGOUS: 5-7 DAYS PREOP||(using current cost known at our institution)|
Using platelet rich gel can provide significant cost savings, aid in the treatment of persistent coagulopathies and eliminate the risk of disease and viral transmission associated with heterologous blood products. Platelet rich gel can be made with minimal and can be a great benefit to the patient. The Medtronic Sequestra 1000 blood processing machine and the direct draw method of platelet sequesteration are an effective system that can be used to procure platelet rich gel.
- Hartman AR, Galanakis DK, Honig MP, Seifert FC, Anag-nostopoulos CE. Autologous Whole Plasma Fibrin Gel- Intraoperative Procurement. Arch Surg 1992; 127:357-9
- Boldt J, Zickman B, Ballesteros M. etal. Influence of Acute Preoperative Plasmapheresis on Platelet Function in Cardiac Surgery. J Cardiothorac Vasg Anesth 1993; 7(1): 4-9.
- Quigley Rl, Perkins JA, Gottner RJ, Curran Rd, Kuehn Be, Hoff WJ, Wallock ME, Arentzen CE, Alexander JC. Intraoperative Procurement of Autologous Fibrin Glue. Ann Thorac Surg 1993; 56:387-9.
- Mehmet Oz, Jeevanandam V, Smith CT, Williams MR, Kaynar AM, Frank RA, Mosca R, Reiss R, Rose EA. Autologous Fibrin Glue from Intraoperatively collected Platelet-Rich Plasma. Ann Thorac Surg 1992; 53: 530-1.
- Stechison MT. Rapid Polymerizing Fibrin Glue From Autologous or Single Donor Blood: Preperation and Indications. J Neurosurg 76:626-628, 1992.
- Rouso J, Gonzalez L, Cosgrove D, Weldon C, Hess P, Joyce L, Bergsland J, Gazzaniga A. Randimized Clinical Trial of Fibrin Sealant in Patients Undergoing Resternotomy or Reoperation After Cardiac Operations. J Thorac Cardiovascular Surg 1989;97:194-203.
- Spotnitz WD, Mintz PD, Avery N, Bithell TL, Kaul S, Nolan SP. Fibrin Glue from stored Human Plasma- an Inexpensive and Efficient Method for Local Blood Blank Preparation. The American Surgeon 1987;53:460-462.
- Sierra DH. Fibrin Sealant adhesive Systems: A Review of their Chemistry, Material Properties and Clinical Applications. Journal of Biomaterial and Applications 1993 vol.7:309-338.
- Gibble JW, Ness PM. Fibrin Glue: The Perfect Operative Sealant? Transfusion 1990:30(8):7417
Catch the latest Perfusion news or peruse our article archive.