fibrin sealants & components. fibrin sealants surgical haemostatic and adhesive agents derived...

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