Hemostatic Agents
Topical hemostatic agents are adjuncts applied to the surgical field when bleeding control by sutures, cautery or pressure is ineffective or impractical, typically for diffuse oozing from raw surfaces, capillary bleeding, or venous bleeding on tissue that will not tolerate cautery.[1][2] They are divided by mechanism into passive matrices (mechanically enhance clot formation) and active agents (direct biochemical effect on the coagulation cascade).
Mechanistic Classification
Passive hemostatic matrices
Porous or fibrous matrices that physically contact blood and platelets, promoting fibrin deposition and mechanical clot formation. Depend on the patient's platelets and clotting substrate to differing degrees.
- Oxidized regenerated cellulose (Surgicel). Plant-cellulose-derived; contact activation of platelets
- Microporous polysaccharide hemospheres (Arista AH). Plant-starch-derived; absorbs water rapidly to concentrate clotting factors
- Gelatin matrices (Gelfoam sponge; Surgiflo flowable). Porcine gelatin; mechanical tamponade and platelet activation. Gelfoam and Surgiflo can be saturated with topical thrombin, which converts them into a thrombin-augmented matrix.
Active hemostatic agents
Contain thrombin or other active coagulation factors that directly catalyze fibrin formation. May assist local clot formation in some coagulation defects, but thrombin alone still requires fibrinogen.
- Topical thrombin (Evithrom, Recothrom). Bovine-, pooled-human-, or recombinant-sourced thrombin
- FloSeal. Flowable gelatin matrix combined with thrombin; supplied with human or recombinant (Recothrom) thrombin depending on kit (passive and active hybrid)
Systemic adjunct: desmopressin (DDAVP)
Desmopressin is a systemic, not topical, adjunct that has been used for uremic bleeding associated with platelet dysfunction, distinct from its use in von Willebrand disease; XGen’s US injection label contraindicates use at creatinine clearance <50 mL/min and carries a boxed warning for potentially fatal hyponatremia.[9][13] It is planned with the anesthesia or hematology team alongside dialysis timing and correction of anemia.
Agent comparison
| Agent | Composition | Mechanism | Absorption (per child pages/labeling) | Key warnings |
|---|---|---|---|---|
| Surgicel (ORC) | Plant cellulose | Passive; acidic pH activates platelets | Not fixed by label (amount, saturation, tissue bed); Ethicon comparison table: 7–14 days across listed forms[10] | Inactivates thrombin (do not combine); remove near spinal cord, optic nerve/chiasm and other vulnerable structures; not intravascular[3] |
| Arista AH (MPH) | Plant starch | Passive; absorbs water, concentrates clotting factors | 24–48 h (amylase-degraded; longer in neonates and infants) | Adjunct for capillary, venous or arteriolar bleeding when conventional control is ineffective or impractical; not for neurological or ophthalmic procedures, postpartum bleeding or menorrhagia; embolization/death if placed in a vessel; swells on contact, so remove excess; do not leave in the renal pelvis or ureters[2] |
| Gelfoam / Surgiflo | Porcine gelatin | Passive tamponade + platelet contact; active if thrombin-soaked | Gelfoam sponge: usually absorbed within 4–6 weeks in soft tissue, but liquefies within 2–5 days on bleeding nasal, rectal or vaginal mucosa; Surgiflo: absorbed within 4–6 weeks when used in appropriate amounts[4][8] | Swelling in confined spaces; Gelfoam contraindicated with known porcine-collagen allergy and Surgiflo with known porcine-gelatin allergy (anaphylaxis reported with gelatin hemostats); avoid infected fields; Surgiflo not for pumping arterial bleeding and not to be left in the renal pelvis or ureters[4][8] |
| FloSeal | Bovine gelatin granules + thrombin (human or recombinant Recothrom, by kit) | Hybrid passive + active | 6–8 weeks[11] | About 10–20% swelling (about 20% in the human-thrombin IFU); bovine allergy; hamster-protein hypersensitivity (Recothrom kit); human-plasma infectious-agent precautions (human-thrombin kit); not intravascular; not for infection[1] |
| Topical thrombin | Bovine, pooled human or recombinant | Active; fibrinogen to fibrin | Not applicable (liquid) | Never intravascular[12]; requires local fibrinogen; hypersensitivity |
Passive agents depend on the patient's own platelets and fibrinogen.
Combination / advanced sealing products
Discussed under Tissue Sealants & Adhesives:
- Fibrin sealants (Tisseel, Evicel), fibrinogen plus thrombin
- Collagen-fibrinogen patches (TachoSil, Evarrest), solid-phase fibrin sealant
Selection by Clinical Situation
| Situation | Possible adjunct after source control |
|---|---|
| Broad raw surface, diffuse oozing (renal bed or pelvic sidewall; avoid intraluminal placement) | FloSeal |
| Venous bleeding on a pelvic sidewall | Surgicel or FloSeal |
| Partial nephrectomy renal bed | Control the bleeding source with renorrhaphy first. In a randomized trial of robotic partial nephrectomy (178 analyzed), postoperative-day-1 hemoglobin fell 1.8 g/dL with an agent versus 1.7 g/dL without one; major bleeding occurred in 6/90 versus 4/88. A review of 15 partial-nephrectomy studies (2 randomized, 13 observational; 3,408 patients) found no statistically significant difference in transfusion or hemorrhagic complications; blood-loss estimates were too heterogeneous to pool. An adjunct remains an option for residual ooze.[1][5][6] |
| Bone bleeding (pubic bone, sacrum) | Bone wax (outside this section) or Gelfoam |
| Bleeding around a nerve where cautery is contraindicated | A carefully selected adjunct with a removal plan; swelling can injure nerves[2] |
| Diffuse capillary ooze from flap donor bed | Arista AH or Surgicel (in one small RCT of Arista at ALT donor sites, drain output, seroma and hematoma did not differ from controls)[7] |
| Bleeding in a patient on anticoagulation | FloSeal or a thrombin-augmented gelatin matrix, since passive matrices depend on native clotting; treat as a local adjunct alongside systemic correction |
| Bleeding peritoneal or serosal surface | Apply a thin Surgicel layer with gentle pressure.[3] |
| Urinary tract / mucosa | Avoid persistent foreign-body matrices in direct urinary contact and use active agents sparingly. Arista, FloSeal and Surgiflo labels warn against leaving product in the renal pelvis or ureters because of potential calculus foci; with Surgicel, use minimal amounts and prevent dislodged fragments from plugging a ureter, urethra or catheter.[1][2][3][8] |
Key Pitfalls
Urinary tract contact
- Gelatin matrices (Surgiflo, FloSeal) and Arista carry labeled warnings against leaving them in the renal pelvis or ureters because of potential foci for calculus formation. Surgicel labeling instead warns that dislodged fragments can plug the urethra, ureter or a catheter
- In partial nephrectomy, place hemostatic agents on the parenchymal renal bed rather than within the calyceal reconstruction
Nerve compression
- Gelatin matrices, FloSeal and Arista swell as they absorb fluid, and cellulose products carry labeled removal requirements. Packed against a nerve (e.g., lumbosacral trunk during pelvic dissection) they can cause focal compression injury.
- Follow product-specific removal requirements near confined or vulnerable structures such as bone foramina, the spinal cord and the optic nerve; do not simply pack around a nerve
- Do not combine Surgicel with topical thrombin. Its acidic environment inactivates thrombin.[3]
Mass-effect / foreign body reaction
- Large volumes of Surgicel or gelatin matrices left in the body can produce organized granuloma mimicking tumor on surveillance imaging
- Document the location and volume in the operative note
Thromboembolic risk from intravascular migration
- Do not place these hemostats in a vessel. Topical thrombin and FloSeal can cause extensive, potentially fatal intravascular clotting; Gelfoam, Surgiflo and Arista carry embolization warnings, and Surgicel Powder must not be placed into an open vessel.[1][2][3][4][8][12]
Cost Hierarchy (Approximate)
Prices vary by institution, contract and pack size.
| Agent | Relative cost |
|---|---|
| Gelfoam | Low |
| Surgicel | Low–moderate |
| Arista AH | Moderate |
| Topical thrombin (recombinant) | Moderate–high |
| FloSeal | High |
| Fibrin sealants | High |
| Collagen-fibrinogen patches | Very high |
See Also
References
1. Baxter. FloSeal current US risk information. Urologic safety/effectiveness have not been established through randomized clinical studies; source-control, vascular-entry, swelling and collecting-system precautions.
2. BD. Arista AH indications, warnings and application instructions. Label indication, amylase degradation, embolization and swelling warnings.
3. Ethicon / J&J MedTech. SURGICEL essential product information. Thrombin incompatibility, removal near vulnerable structures and intravascular warnings.
4. Pfizer. GELFOAM compressed sponge prescribing information. Application, excess removal and confined-space precautions.
5. Lazarovich A, Tremblay S, Nottingham C, et al. Randomized, Prospective Evaluation of Hemostatic Agents in Robotic-Assisted Laparoscopic Partial Nephrectomy. J Urol. 2026;215(5):526-534. doi:10.1097/JU.0000000000004889
6. Shiomi da Cruz JA, De Souza Almeida A, Terada BD, et al. Adjunctive topical hemostatic agents combined with renorrhaphy versus renorrhaphy alone during partial nephrectomy: a systematic review and meta-analysis. World J Urol. 2026;44(1):592. doi:10.1007/s00345-026-06679-5
7. David AP, Zebolsky AL, Park AM, et al. Effect of microporous polysaccharide hemospheres on anterolateral thigh free flap donor site complications. Laryngoscope Investig Otolaryngol. 2022;7(2):380-387. doi:10.1002/lio2.770
8. Ethicon. Hemostasis key-points booklet (Ethicon US, 2022), including SURGIFLO Hemostatic Matrix Kit with Thrombin and SURGICEL essential product information. Manufacturer material: absorption wording, swelling, urologic precautions.
9. Kaw D, Malhotra D. Platelet dysfunction and end-stage renal disease. Semin Dial. 2006;19(4):317-322. doi:10.1111/j.1525-139X.2006.00179.x
10. Ethicon / J&J MedTech. SURGICEL Family Comparison Table. Device specifications, p. 1; absorption time by product form.
11. Baxter. FLOSEAL Hemostatic Matrix US instructions for use. Resorption and swelling information.
12. U.S. FDA. RECOTHROM (thrombin topical, recombinant) package insert. Contraindications and thrombosis warning.
13. XGen Pharmaceuticals DJB, Inc. Desmopressin acetate injection prescribing information. Revised March 2024.