The clinical use and immunologic impact of thrombin in surgery

Thrombin is a naturally derived enzyme that has been widely characterized for its roles in hemostasis, inflammation, and cell signaling. Thrombin has been purified from numerous sources and used as a clinical aid for topical hemostasis for more than 60 years. Due to both its ease of use and apparent effectiveness, thrombin has become used routinely as an aid for topical hemostasis in nearly all types of surgical procedures, including but not limited to cardiovascular, orthopedic, neurologic, general, gynecologic, and dental procedures. Due to the widespread acceptance of thrombin in the surgical setting, it is conservatively estimated that at least 1 million patients in the United States are treated with topical applications of thrombin each year. Although the U.S. Food and Drug Administration (FDA) has approved a wide array of topical and biologic products to stop surgical bleeding, the only thrombin that is currently FDA approved as a stand-alone hemostatic product in the United States is derived from bovine sources. Bovine-derived thrombin has potent biologic activity in its ability to convert fibrinogen to fibrin, activate platelets, and induce vascular contraction. However, it has also been shown to induce a robust immune response following human exposure. Numerous reports have documented an array of clinical events that follow bovine thrombin exposure, which include the development of antibodies against thrombin, prothrombin, factor V, and cardiolipin. In some well-described cases, these antibodies have led to clinical syndromes that range from severe postoperative bleeding to high rates of vascular bypass graft thrombosis. Furthermore, experimental applications of bovine thrombin to various strains of mice have induced a postexposure autoimmune syndrome that was pathologically identical to lupus. Thrombin-derived products are wen accepted by the surgical community for use as an aid for hemostasis, but the bovine-derived products have an unacceptably high and unnecessary association with immunologic side effects. If a nonimmunologic and effective thrombin were developed, one would expect it to be rapidly adopted by the clinical community.