Intracorporeal Use of Advanced Local Hemostatics in a Damage Control Swine Model of Grade IV Liver Injury

Background: The purpose of this study was to evaluate the efficacy of zeolite- and chitosan-based local hemostatic agents for the control of intracorporeal bleeding in a damage control swine model of grade IV liver injury. Methods: Anesthetized pigs (weight, 40 kg) had a controlled 35% total blood volume bleed from the right jugular vein. A laparotomy was performed and the animals were cooled to 35 degrees C. Ringer's lactate was titrated to achieve a three to one blood withdrawal resuscitation. The liver was injured with a standardized 10 cm x 3 cm avulsion. After 2 minutes of uncontrolled hemorrhage, the animals were randomized to application of gauze control (GC, n = 11), Celox (CX, n = 11) (5AM Medical, Newport, OR), or QuikClot ACS(+) (QC, n = 11) (7-Medica, Wallington, CT) and packed in a standardized manner. At 10 minutes, the packs were removed to calculate amount of shed blood. The animals then underwent damage control closure with packing in place. Forty-eight hours after initial damage control packing, the animals were returned to the operating room for pack removal and killing. The need for repacking of the liver was assessed and tissue samples were collected from the liver edge and adjacent small bowel for histopathology. Results: There was no difference in the amount of uncontrolled bleeding at 2 minutes (GC: 4.0 mL/kg +/- 0.4 mL/kg, CX: 3.5 mL/kg +/- 0.5 mL/kg, QC: 4.0 mL/kg +/- 0.6 mL/kg; one-way analysis of variance: p = 0.715). Compared with GCs, the blood loss at 10 minutes was significantly lower in the CX and QC arms (GC: 8.3 mL/kg +/- 0.9 mL/kg, CX: 3.7 mL/kg +/- 0.7 mL/kg, QC: 4.6 mL/kg +/- 0.8 mL/kg; one-way analysis of variance: p = 0.001). A total of 27.3% of control animals died compared with 18.2% of CX and 0.0% of QC. All GC and QC animals required repacking, compared with one (9.1%) of those in the CX arm. There was no difference between groups in the extent of necrosis. Conclusion: Celox and QuikClot ACS(+) are effective adjuncts to standard intracavitary damage control packing for the control of bleeding. Celox provided durable control allowing packing removal at the time of take-back laparotomy. Further evaluation of their long-term effects is warranted.