Topical hemostatic agents.
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These books synthesize perspectives of renowned scientists from the world’s most prestigious institutions - from Fukushima Renewable Energy Institute in Japan to Stanford University in the United States, including Columbia University (US), University of Sidney (AU), University of Miami (USA), Cardiff University (UK), and many others.
\\n\\nThis collaboration embodied the true essence of Open Access by simplifying the approach to OA publishing for Academic editors and authors who contributed their research and allowed the new research to be made available free and open to anyone anywhere in the world.
\\n\\nTo celebrate the 50 books published, we have gathered them at one location - just one click away, so that you can easily browse the subjects of your interest, download the content directly, share it or read online.
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IntechOpen and Knowledge Unlatched formed a partnership to support researchers working in engineering sciences by enabling an easier approach to publishing Open Access content. Using the Knowledge Unlatched crowdfunding model to raise the publishing costs through libraries around the world, Open Access Publishing Fee (OAPF) was not required from the authors.
\n\nInitially, the partnership supported engineering research, but it soon grew to include physical and life sciences, attracting more researchers to the advantages of Open Access publishing.
\n\n\n\nThese books synthesize perspectives of renowned scientists from the world’s most prestigious institutions - from Fukushima Renewable Energy Institute in Japan to Stanford University in the United States, including Columbia University (US), University of Sidney (AU), University of Miami (USA), Cardiff University (UK), and many others.
\n\nThis collaboration embodied the true essence of Open Access by simplifying the approach to OA publishing for Academic editors and authors who contributed their research and allowed the new research to be made available free and open to anyone anywhere in the world.
\n\nTo celebrate the 50 books published, we have gathered them at one location - just one click away, so that you can easily browse the subjects of your interest, download the content directly, share it or read online.
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Raytheon Fellow, Aerospace Associate/Interim Director and Principal Engineer/Scientist, NASA Representative at CCSDS. Holder of 17 US patents. Recipients of numerous awards from NASA, Raytheon, Aerospace.",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"210657",title:"Dr.",name:"Tien M.",middleName:"Manh",surname:"Nguyen",slug:"tien-m.-nguyen",fullName:"Tien M. Nguyen",profilePictureURL:"https://mts.intechopen.com/storage/users/210657/images/system/210657.png",biography:"Dr. Tien Nguyen serves as an Adjunct Research Professor in Mathematics at CSUF, where he is also a visiting scholar and advisor at the Center of Computational and Applied Mathematics. He works full-time as a Sr. Project Leader at The Aerospace Corporation. Prior to this position, he was Associate Director, Interim Director, and Principal Technical Staff. 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Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"72",title:"Ionic Liquids",subtitle:"Theory, Properties, New Approaches",isOpenForSubmission:!1,hash:"d94ffa3cfa10505e3b1d676d46fcd3f5",slug:"ionic-liquids-theory-properties-new-approaches",bookSignature:"Alexander Kokorin",coverURL:"https://cdn.intechopen.com/books/images_new/72.jpg",editedByType:"Edited by",editors:[{id:"19816",title:"Prof.",name:"Alexander",surname:"Kokorin",slug:"alexander-kokorin",fullName:"Alexander Kokorin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"314",title:"Regenerative Medicine and Tissue Engineering",subtitle:"Cells and Biomaterials",isOpenForSubmission:!1,hash:"bb67e80e480c86bb8315458012d65686",slug:"regenerative-medicine-and-tissue-engineering-cells-and-biomaterials",bookSignature:"Daniel Eberli",coverURL:"https://cdn.intechopen.com/books/images_new/314.jpg",editedByType:"Edited by",editors:[{id:"6495",title:"Dr.",name:"Daniel",surname:"Eberli",slug:"daniel-eberli",fullName:"Daniel Eberli"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"57",title:"Physics and Applications of Graphene",subtitle:"Experiments",isOpenForSubmission:!1,hash:"0e6622a71cf4f02f45bfdd5691e1189a",slug:"physics-and-applications-of-graphene-experiments",bookSignature:"Sergey Mikhailov",coverURL:"https://cdn.intechopen.com/books/images_new/57.jpg",editedByType:"Edited by",editors:[{id:"16042",title:"Dr.",name:"Sergey",surname:"Mikhailov",slug:"sergey-mikhailov",fullName:"Sergey Mikhailov"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"1373",title:"Ionic Liquids",subtitle:"Applications and Perspectives",isOpenForSubmission:!1,hash:"5e9ae5ae9167cde4b344e499a792c41c",slug:"ionic-liquids-applications-and-perspectives",bookSignature:"Alexander Kokorin",coverURL:"https://cdn.intechopen.com/books/images_new/1373.jpg",editedByType:"Edited by",editors:[{id:"19816",title:"Prof.",name:"Alexander",surname:"Kokorin",slug:"alexander-kokorin",fullName:"Alexander Kokorin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"54974",title:"Markers for Sperm Freezability and Relevance of Transcriptome Studies in Semen Cryopreservation: A Review",doi:"10.5772/intechopen.68651",slug:"markers-for-sperm-freezability-and-relevance-of-transcriptome-studies-in-semen-cryopreservation-a-re",body:'Cryopreservation of semen allows the preservation of good genetic resources and the protection of endangered species [1–5]. While a great deal of efforts has been done over the last several years to improve the semen cryopreservation technology, effective cryosurvival of spermatozoa from various animal species, including the boar and stallion, still remains elusive and a cryobiological enigma [1]. Cryo-induced oxidative stress is associated with excess production of reactive oxygen species (ROS), resulting in biochemical and physical damage to the sperm membrane structures and subsequently leading to reduced fertilizing ability of spermatozoa [4–6]. In the artificial insemination (AI) industry, there is a need to optimize the selection strategy for individuals with good freezability, so as to incorporate this information in the breeding program to improve the fertility of post-thaw semen [2, 3, 7]. Moreover, selection of animals with good semen freezability for cryopreservation and AI is a crucial step to improve the fertility levels of frozen-thawed semen [9, 10]. Furthermore, in some animal species, despite satisfactory results of fertility in liquid-stored semen, frozen-thawed semen does not give acceptable fertility results in AI practice in the commercial industry [2, 3, 9].
Accumulating evidence has indicated that inherent male variability in semen freezability is one of the factors responsible for marked differences in the sperm cryosurvival [2, 5, 7–10]. With regard to boar semen, studies have reported that differences in sperm freezability might be due to a genetic origin [7, 8]. Even though the underlying mechanisms responsible for the genetic differences associated with poor or good semen freezability are yet unknown, it has been suggested that the identification of sperm freezability markers might be the most efficient approach to improve the technology of semen cryopreservation.
Recent technological advances have confirmed that the spermatozoon carries epigenetic factors that constitute their epigenome, such as proper packaging of the chromatin with protamines, modifications of histones, and a large population of messenger ribonucleic acid (mRNA) and microRNA (miRNA) transcripts [11–13]. The diversity of the RNA constellation in the seminal plasma (SP) and spermatozoa has been used as a pattern for the genomic analysis of semen quality characteristics, particularly for the estimation of the fertility potential of spermatozoa [12–17]. Moreover, high-throughput sequencing demonstrates that several stable full-length mRNA transcripts are useful markers for sperm functions in fresh and frozen-thawed semen [17]. It has been hypothesized that transcriptome analysis of sperm RNA-Sequencing (RNA-Seq) data is required to explore the potential links between semen freezability and the transcript profiles of spermatozoa [18–20]. This review discusses recent accomplishments in molecular markers for the assessment of post-thaw sperm quality and exemplifies the significant relevance of transcriptome profiling by RNA-Seq in semen cryopreservation.
Subjective motility evaluation is one of the most commonly used parameters to determine the quality of frozen-thawed semen for AI. Even though post-thaw sperm motility is a good indicator of viability, it is not always an accurate fertility predictor of an AI-semen dose [9]. Evaluations of sperm motility characteristics have been improved by the incorporation of the computer-assisted semen analysis (CASA) system, which measures several motility and motion parameters of spermatozoa that are closely related to fertility compared with subjective motility measurements [21–24]. Besides motility analysis, studies have confirmed that the velocity parameters, such as velocity straight line (VSL), velocity curvilinear (VCL), and velocity average path (VAP), are associated with the fertilizing capacity of frozen-thawed spermatozoa [21, 24].
Spermatozoa comprise several compartments enclosed within the acrosome, plasma membrane, and mitochondrial membranes, which act as physiological barriers that must remain intact to permit cell viability, particularly after cryopreservation [1, 2, 6, 10]. In recent years, several fluorescent probes have shown that the cryopreservation process compromises the sperm plasma membrane integrity (PMI), resulting in reduced fertilizing capacity of post-thaw semen [3–5, 23–29]. Post-thaw sperm PMI has been assessed with different fluorescent membrane probes, such as the dual SYBR-14 and propidium iodide (PI) assay [25, 28] or membrane-permeable substrate carboxyfluorescein diacetate (CFDA), a nonspecific esterase substrate [24]. The chlortetracycline (CTC) fluorescence assay has been used to detect capacitation-like changes in frozen-thawed spermatozoa, which may compromise their fertilizing ability [6, 10, 22–24, 29]. Cryo-induced changes in the acrosome membrane integrity (AMI) have been monitored by specific Giemsa-staining technique [25] or with fluorescent dyes, such as fluorescein isothiocyanate (FITC)-conjugated PNA (peanut agglutinin) or conjugated PSA (
Cryopreservation affects the lipid composition and organization of the sperm plasma membranes, resulting in leakage of valuable intracellular enzymes, such as antioxidants [4], acrosin [31], aspartate aminotransferase (AspAT) [32], or energy substrates, such as adenosine triphosphate (ATP) [33], which ultimately lead to cell death. Another measure of membrane damage to frozen-thawed spermatozoa is the degree of lipid peroxidation (LPO) of polyunsaturated fatty acids in sperm cell membranes, induced by the production of reactive oxygen species during cryopreservation. It has been confirmed that frozen-thawed boar spermatozoa are susceptible to FeSO4/ascorbate-induced LPO, measured by the production of malondialdehyde (MDA), which is capable of triggering apoptotic-like changes that could result in the sublethal sperm cryodamage [24, 30, 32]. Furthermore, the extent of LPO-induced damage to frozen-thawed spermatozoa can be analyzed by monitoring the colorimetric measurements of lipid peroxide formation with a fluorescent membrane probe, BODIPY581/591-C11 [26, 30].
The sperm mitochondrial membrane potential is necessary for ATP production, which is the main energy support for several functions [25, 32]. Several studies showed that cryo-induced damage to the MMI of spermatozoa is one the major causes of their reduced fertilizing capacity [4, 5, 10, 24, 25, 29, 33]. These studies detected a marked deterioration in the sperm mitochondrial function following cryopreservation, as reported by the fluorescent staining with rhodamine 123 (R123), the lipophilic cationic compound 5,5′,6,6′-tetrachloro-1,1′,3,3′ tetraethylbenzymidazolyl carbocyanine iodine (JC-1), or with ATP measurements by the bioluminescence assay. The percentages of frozen-thawed spermatozoa with functional mitochondria, as assessed by either the R123/PI or JC-1/PI assay, are highly correlated to motility [5, 29, 33]. Besides the R123/PI and JC-1/PI assays, there are a plethora of fluorescent dyes that can be used to microscopically or cytometrically assess the sperm mitochondrial membrane function (MMF). Some fluorescent MitoTracker probes, such as MitoTracker Deep Red, MitoTracker Red, MitoTracker Orange, and MitoTracker Green, have been used effectively to assess the MMF on frozen-thawed spermatozoa [23, 26]. Boars with good and poor semen freezability ejaculates were identified using several sperm function parameters, including total and progressive motility (TMOT and PMOT, respectively), and rapid movement (RAP) analyzed by the computer-assisted semen analysis system, mitochondrial membrane function, MMF (JC-1/PI assay) and PMI (SYBR-14/PI assay) (Figure 1). Post-thaw analysis of the sperm parameters showed that boars with good semen freezability were characterized by significantly higher sperm cryosurvival (Boars 1–6) compared with those with poor semen freezability (Boars 7–10; Figure 1), suggesting the importance of these sperm parameters in the assessment of post-thaw semen quality (unpublished results).
Distribution of the characteristics of frozen-thawed boar spermatozoa for: (A) Total sperm motility (TMOT). (B) Progressive sperm motility (PMOT). (C) Rapid moving (RAP) spermatozoa. (D) Mitochondrial membrane function (MMF). (E) Plasma membrane integrity (PMI) (
Sperm chromatin and DNA integrity is an uncompensable trait because abnormalities in the male genome, characterized by damaged chromatin/DNA structure, may be manifested until the sperm-oocyte fusion, or at early embryo development [34]. Accumulating evidence has shown that sperm DNA integrity is one of the parameters of semen quality assessment that has paramount importance in the prognosis of fertility and the outcome of assisted reproductive procedures [5, 34, 35,]. Among the most frequently used sperm DNA integrity assays are the Comet assay (SCGE), which quantifies double-stranded DNA (dsDNA) and single-stranded DNA (ssDNA) breaks under neutral or alkaline electrophoresis [8, 32, 35], the sperm chromatin structure assay (SCSA) measures the susceptibility of sperm chromatin to acid-induced denaturation in situ [34], and the terminal deoxynucleotidyl transferase-mediated dUDP nick end-labeling assay (TUNEL), which quantifies the incorporation of deoxyuridine triphosphate (dUTP) at ssDNA and dsDNA breaks [24, 34]. These DNA integrity assays have confirmed that the cryopreservation process increases the sperm susceptibility to DNA damage, irrespective of the extender or the protocol type [4, 5, 8, 21, 24, 32, 34, 35]. It is worth noting that sperm DNA fragmentation is associated with differential expression of proteins in the viable sperm populations [36]. Intasqui et al. [36] postulated that the overexpression of the sperm proteins in the viable sperm population from ejaculates with high-sperm DNA fragmentation might indicate proteome alterations to compensate defects in sperm motility.
Recently, seminal plasma and sperm proteins became an integral part of the reproductive area development. It is worth noting that proteins that are involved in the energy metabolism of spermatozoa play key roles in glycolysis, the citric acid cycle, and oxidative phosphorylation, which are required to provide sufficient energy for the sperm physiological functions [37]. The protein constellation of the SP and sperm cells, and their distinct subcompartments have been well documented in a numerous animal species, using a plethora of proteomic-based techniques [6, 37, 38]. While some specific sperm protein markers facilitating good semen freezability have been identified [10, 24, 39, 40], their function depends on the presence of mRNA that can be translated into proteins in the spermatozoa. Moreover, the differential expression patterns of certain classes of SP and sperm proteins following cryopreservation have been used as markers for semen freezability [3, 6, 10, 39–44]. Regarding boar semen, the physiological functions of SP and sperm proteins and their associations with freezability have been summarized in recent reviews by Yeste [3, 10]. In the bull, higher concentrations of a 26-kDa SP protein, known as lipocalin-type prostaglandin D synthase (L-PGDS), and a 13-kDa acidic seminal fluid protein (aSFP) were associated with high-fertility bulls, suggesting the importance of these proteins as freezability markers [41]. Moreover, a fertility-associated protein, osteopontin (OPN), an acidic glycoprotein occurring in the bovine SP, has been shown to induce capacitation and improve viability of spermatozoa by inhibiting the apoptotic pathways [39, 41]. Bovine SP proteins, collectively known as binder of sperm (BSP) proteins (BSP1, BSP 3, and BSP 5), bind to choline phospholipids in the sperm plasma membrane and are implicated in semen freezability [22, 39, 41, 42]. Recently, it has been confirmed that BSP1, one of the most abundantly expressed BSP proteins (representing approximately 25–47% of the total proteins in bovine SP), consists of four molecular forms that have varying cryoprotective effects on the bull spermatozoa [42]. According to Sarsaifi et al. [22], approximately 52% of the SP protein spots detected after cryopreservation were represented by four major protein fractions with different molecular weights, and 10 proteins, identified by mass spectrometry, were major bovine SP proteins. It is worth noting that two of these proteins, defined as phosphoglycerate kinase (PGK, 37–45 kDa) and phospholipase A2 (PLA2, 50–55 kDa), are implicated in glycolysis and the fertilization-associated processes, respectively [22]. More recently, it has been reported that the presence of fertility-associated 28–30-kDa heparin-binding proteins (HPBs) in bovine SP exerted better cryoprotective effects on the sperm structural and functional membrane integrity, which resulted in 13% higher conception rate than the bulls lacking the proteins in their SP [24]. Ledesma et al. [23] postulated that the decrease in phosphotyrosine signal of 45-, 40-, or 30-kDa protein in the presence of SP was concurrent with an inhibition of cryo-induced capacitation of ram spermatozoa, suggesting the relevance of these proteins as markers for the capacitation status of frozen-thawed spermatozoa.
Spermatozoa have a repertoire of distinct proteins localized in different subcellular structures that are associated with post-thaw semen quality [3, 6, 10, 40, 43]. In boar sperm extracts, the levels of outer dense fiber 2 (ODF2), A-kinase-anchoring protein 3 or 4 (AKAP3; AKAP4), heat-shock protein 90 (HSP90AA1), voltage-dependent anion channel 2 (VDAC2), acrosin-binding protein (ACRBP), and triosephosphate isomerase 1 (TP1) activities were associated with semen freezability [10, 40]. Furthermore, ODFs provide a stable and elastic structure to the flagellum of the spermatozoon, supporting its movement and protecting it during the epididymal transit and ejaculation [36, 39, 40]. The ODF2 seems to be essential to ODF assembly, and its overexpression in frozen-thawed boar spermatozoa was associated with reduced post-thaw semen quality [40]. Moreover, AKAP4 and AKAP3 occur in the fibrous sheath of sperm flagellum and are involved in sperm motility and morphology [36]. It has been confirmed that an increase in the expression of either AKAP4 or AKAP3 in frozen-thawed spermatozoa might be associated with their premature capacitation [40]. In another study, it has been demonstrated that greater levels of HSP90AA1 and VDAC2 in high-freezability boars might confer increased sperm cryotolerance [10]. Furthermore, greater expression levels of a fertility-associated protein, 90-kDa HSP (HSP90), were detected in bull spermatozoa with high cryotolerance and motility, indicating that the protein can be used as a marker for semen freezability [44]. The concept that HSPs supplementation to the freezing extender could protect spermatozoa against cryo-induced damage is supported by a report indicating that the HSPA8, a highly conserved member of the HSP70 family, exerted beneficial effects on post-thaw bull semen quality, as reflected by the reduced proportions of spermatozoa with apoptotic-like changes [45]. According to Chen et al. [40], higher levels of mRNA expression of the membrane proteins cytosolic SOD (Cu/Zn SOD1) in frozen-thawed boar semen might be due to the protective response of the sperm cells to cold stimulation and oxidation stress to prevent cryo-induced damage and also probably due to the toxicity of the components of the cryoprotectants. Recently, the application of high-throughput proteomics to the study of cryopreserved human semen showed substantial changes in the sperm proteome at every stage of the freezing-thawing processes [43]. Irrespective of the thawing procedure of frozen semen, it was reported that there was an increase in the expression levels of a few proteins, such as clusterin (CLU), histone H4 (HIST1H4A), and L-xylulose reductase (DCXR), whereas there was a decrease in the expression levels of several proteins, including apoptosis-inducing factor 1-mitochondrial (AIFM1), carbonic anhydrase 2 (CA2), acrosin (ACR), phosphoglycerate mutase 2 (PGAM2), inositol monophosphatase 1 (IMPA1), calmodulin (CALM1), cytochrome (CYC2), and NADH-cytochrome b5 reductase2 (CYB5R2) [43]. Besides the effect upon the sperm membrane protein P25b, an acrosome membrane-coating protein, cryopreservation causes a significant loss of several sperm-coating proteins, resulting in reduced post-thaw semen quality [10, 22–24, 39–45]. It appears that the cryo-induced decrease in the levels of sperm proteins is probably attributed to protein degradation, membrane damage due to osmotic stress, and the subsequent freezing-thawing causing the efflux of intracellular sperm constituents [6, 43]. Presently, the mechanism responsible for the cryo-induced increase in levels of protein expression is not fully understood, even though it has been suggested that enhanced phosphorylation might be a possible cause for abundance in some of the proteins following cryopreservation [23, 43]. Even though changes in the SP or sperm proteome could predict the cryotolerance of spermatozoa, they do not provide relevant information about possible associations of sperm transcript profiling with semen freezability.
The records of transcription of the late stages of sperm differentiation are easily accessible through sperm transcript fragments, which have the potential to be used as markers for fertility [13]. Among others, increasing focus has been given to the examination of the biological functions of mRNAs in spermatozoa of different animal species. It has been suggested that the analysis of the sperm-derived RNAs might provide potential links between the sperm proteome and semen freezability [17, 18, 20, 46–48]. It should be underlined that the isolation of high-quality RNAs from fresh or frozen-thawed semen is important to assess the sperm gene expression [19, 46, 49, 50]. However, to optimize the isolation protocol of total RNA from spermatozoa of different animal species, the procedure has to be modified, and should incorporate a quality control reverse transcription polymerase chain reaction (RT-PCR) to avoid somatic cell contamination [17, 19, 46, 49]. Presently, human sperm transcripts are the best characterized among all mammals with respect to RNA sequence profiling. Even though microarray techniques, coupled with either quantitative real-time qPCR or qRT-PCR, have revealed limited features of the transcriptome and global patterns of gene expression in spermatozoa, these techniques have revealed that sperm transcripts affecting different metabolic pathways are related to semen fertility [48, 49, 51–54]. A study based on the evaluation of sperm capacitation status provides evidence, indicating that the sperm-derived RNAs can be translated
Recently, the utilization of advanced molecular genetics tools has led to a rapid development of high-throughput RNA-Seq techniques, which have been used to explore the relationship between sperm functions with the transcript profiles of raw fresh or frozen-thawed spermatozoa [12, 50]. The resolution of RNA population has been optimized with the utilization of next-generation sequencing (NGS) technology, to uncover complete transcript profiles of mammalian spermatozoa [12], making significant contributions to elucidate the physiological roles of sperm-derived RNAs. Moreover, the wider adaption of RNA-Seq has revealed a complex RNA repertoire in spermatozoa from different animal species, including the bull [17, 51–53, 55, 56], boar [46–48], and stallion [54]. However, despite the increasingly wide applications of RNA-Seq in the analysis of different cellular tissues, its application is limited to screening of the mRNA profiles of frozen-thawed spermatozoa to uncover candidate genes associated with semen freezability.
Despite its apparent transcriptionally inert state, a mature spermatozoon contains diverse populations of both small and large RNAs [11–13, 47, 55]. Since their discovery in 1989, sperm-derived RNAs were implicated in spermatogenesis and in fertilization and early embryonic development, suggesting that they are not merely the remnants of sperm cell development [11, 46, 54]. Notwithstanding the rich repertoire of coding and noncoding RNAs in mammalian spermatozoa, they are not a random remnant from spermatogenesis in testes, but a selectively retained and functionally coherent collection of RNAs [12, 54, 55]. Spermatozoa contain complex populations of RNAs, including several stable full-length RNAs and a variety of different RNAs, such as ribosome RNAs (rRNA), mitochondrial RNAs (mtRNAs), miRNAs (18–24 nucleotides), piwi-interacting RNAs (piRNAs, 26–31 nucleotides), and small interfering RNAs (siRNAs), which originate from double-stranded RNAs (dsRNAs) [11–17, 55]. The precise population of mRNAs in spermatozoa is unknown, but has been estimated to be about 3000–7000 transcripts [17, 54]. It has been established that a majority of sperm mRNAs are located in the nucleus, and a limited number of mRNAs are located in other areas, such as the mid-piece region and flagella fibrous sheath [11]. Individual identified sperm transcripts include mRNAs for ribosomal and mitochondrial proteins, protamines, and proteins involved in signal transduction and cell proliferation [13].
Screening of differentially expressed genes (DEGs) in spermatozoa has been explored mainly to investigate the associations of the gene expression levels with male fertility [11, 14]. Using microarray-based techniques, significant differences in the expression of two genes—testis-specific protein1 (
Significant differences were detected in the DEGs between fresh and frozen-thawed bull spermatozoa using microarray technique in conjunction with qRT-PCR analysis and that upregulations of several DEGs existed, such as ribosomal protein L31 (
Currently, the biological roles of small-nuclear RNAs (snRNAs)—miRNAs, piRNAs, and siRNAs—which are expressed specifically and abundantly in spermatogenic cells, have been documented by several authors [11–17]. Quantitative RT-PCR analysis on boar sperm RNA revealed that the mRNA targets of the differentially expressed miRNAs encode proteins previously described to play specific roles in sperm function, such as motility and capacitation [14]. According to Chang et al. [16], the differential expression of 15 miRNAs between the cauda epididymal spermatozoa and fresh ejaculate in the boar suggests that significant mRNA expression and miRNA regulation are implicated in apoptosis, and are associated with the sperm maturation processes. The authors postulated that the targeted gene, adrenoceptor beta 2 (
Even though proteins of the SP and spermatozoa have been used as semen freezability markers, these expectations are over-shadowed by the problems associated with the inherent male variability in sperm cryosurvival. The search for a new set of freezability markers using transcriptome studies on RNA-Seq data, bioinformatics study, and proteome characterization of protein expression patterns in frozen-thawed spermatozoa will offer new perspectives to enhance the marker-assisted selection programs in animal breeding. It is envisaged that such freezability markers will also help to unravel the biological functions of sperm-derived mRNA transcripts in the mechanism underlying cryotolerance of spermatozoa from various domestic animal species, and will have a significant impact in the technology of semen cryopreservation.
This study was supported by a research project from the National Science Centre, Poland (2015/19/B/NZ9/01333).
Control of bleeding wounds has always been a priority in managing injured patients, and providers have used numerous adjuncts to staunch bleeding for decades, with variable success. The earliest use of topical hemostatic agents dates from the end of the nineteenth century when thrombin was used by boxers and barbers to control bleeding from lacerations [1]. Almost a century before the clotting cascade was completely elucidated, in 1909 Bergel had described using topical fibrin to stop surgical bleeding [2, 3, 4]. Subsequently, surgeons utilized fibrinogen in plasma as well as bovine thrombin to assist in a variety of surgical scenarios, including nerve repair and skin grafting [5, 6]. Commercial products first became available in Europe in 1972, but the Food and Drug Administration did not approve fibrin sealants in the United States until 1998 [3]. Over the course of time, numerous other types of hemostatic agents have been developed, each unique in their load bearing capacity, biomechanical properties, handling, derivation, and application [7].
Cutaneous and mucous membrane bleeding are common presentations to emergency departments. Data from the National Hospital Ambulatory Medical Care Survey in 2002 estimated that there were 7.27 million emergency department visits for lacerations, representing approximately 6.6% of all emergency department visits [8], and data from HCUP National Emergency Department Survey in 2013 estimated about 7 million emergency department visits or 5.2% of all visits for lacerations [9]. There are no data to quantify how many of these visits are associated with uncontrolled or major bleeding. The mainstays of treating bleeding remain the simple application of direct pressure with a pressure bandage and application of tourniquet if hemostasis is unable to be obtained. However, there are times that application of hemostatic agents can assist in bleeding control. In the modern era, with widespread use of anticoagulant and antiplatelet agents, as well as physiologically induced coagulopathies from liver disease and uremia, development of topical hemostatic agents to assist in terminating complex bleeding scenarios has become important.
We will briefly review classes of tissue adhesives, topical hemostatic agents, and the best practice data regarding each in the setting of the emergency department. We will provide common clinical bleeding scenarios and the application of these materials in those situations.
Topical hemostatic agents generally fall into one of two categories: the physical agents that work by providing a physical substrate which promotes hemostasis and the biologically active agents that enhance coagulation at the site of action(Table 1). In the emergency department, topical hemostatic agents are primarily used as adjuvant therapy to direct pressure to stop persistent bleeding from lacerations and abrasions that are not amenable to suture control, such as distal fingertip avulsions, flap lacerations with avulsion of the flap, and skin tears in the elderly. As well, topical hemostatic agents can be used to assist with persistent bleeding from nasal mucosa, gingival tissue after tooth extraction, and from vascular bleeding sites such as persistently bleeding dialysis access sites or bleeding lower extremity varices.
Product | Manufacturer | |
---|---|---|
Gelatin matrix | Gelfoam® | Pfizer Inc., New York, NY, USA |
Surgifoam® | Ethicon Inc., Somerville, NJ, USA | |
Floseal® | Baxter International, Deerfield, IL, USA | |
Oxidized regenerated cellulose | Surgicel® | Ethicon Inc., Somerville, NJ, USA |
SafeGauze® | Medicom, Montreal, QC, Canada | |
Microporous polysaccharide spheres | Arista® AH | CR Bard Inc., Murray Hill, NJ, USA |
Microfibrillar collagen | Avitene® | CR Bard Inc., Murray Hill, NJ, USA |
Chitosan | HemCon® | Tricol Biomedical Inc., Portland, OR, USA |
Chitoflex® | Tricol Biomedical Inc., Portland, OR, USA | |
TraumaStat® | Ore-Medix, LLC Company, Lebanon, OR, USA | |
Celox® | Medtrade Products LLC., Crewe, UK | |
ChitoSAM® | Sam Medical, Tualatin, OR, USA | |
Axiostat® | Axio Biosolutions PVT LTD. Gujarat, India | |
Topical thrombin | Thrombin JMI® | Pfizer Inc., New York, NY, USA |
Tranexamic acid (TXA) | Multiple generics | |
Cyklokapron® 100 mg/ml | Pfizer Inc., New York, NY, USA | |
Erfa Tranexamic® 100 mg/ml | Erfa Canada 2012, Inc., Montreal, QC, Canada | |
Kaolin | QuickClot® | Z-Medica LLC., Wallingford, CT, USA |
Topical hemostatic agents.
Little data exists to suggest superiority of a single agent over others, and often selection of an agent is based on availability, familiarity with its use, patient and wound characteristics, and cost.
Gelfoam® and Surgifoam® are porcine derived, non-soluble, gelatin matrices that are in a compressed sponge form [10, 11]. They can be cut to appropriate size for application and when applied to bleeding sites are able to absorb 45 times their weight in whole blood. Floseal® is a combination of bovine-derived, liquid gelatin matrix and human-derived thrombin that is supplied in a syringe with an applicator tip that assists with mixing the components and application at the site of bleeding [12]. The mechanism of action of gelatin matrix is poorly understood but is thought to be due to its physical properties, providing a structural support for clot formation rather than a direct effect on the clotting cascade. In clinical use, these agents are appropriate for topical application to persistently bleeding sites, such as dental extraction sites, in the management of epistaxis, and in fingertip avulsion injuries. These agents typically have minimal tissue reaction and are absorbed within 6 weeks when placed within soft tissues or liquified and absorbed within 2–5 days when applied to bleeding mucosal sites.
Little data exists studying the efficacy of gelatin matrices for bleeding complications in the emergency department setting. In a small prospective, randomized study of patients who failed anterior packing for epistaxis, Floseal® application demonstrated equal rates of hemostatic control as repeat anterior packing by a specialist, and lower, but not statistically significant, rates of hospitalization [13]. A larger, prospective randomized sample of patients with epistaxis managed initially with Floseal® versus anterior packing demonstrated that Floseal® was associated with improved patient satisfaction and less rebleeding [14]. In a small convenience sample of patients presenting with posterior epistaxis, Floseal® was successfully used to control bleeding in 80% of patients at a significantly reduced cost when compared to surgery, posterior packing with hospital admission, and embolization [15].
Complications from gelatin matrix applications are reported to be minimal but include the potential to form a nidus for infection or abscess formation, foreign body reactions with encapsulation of reactive fluid, and toxic shock when used in nasal application.
Surgicel® is a sterile, knitted, absorbable fabric produced from plant cellulose. The mechanism of action of Surgicel® is poorly understood, but is thought to produce a mechanical scaffolding for clot formation rather than have a direct effect on the clotting cascade [16]. In clinical use, these agents are appropriate for topical application to persistently bleeding sites, such as dental extraction sites and in the management of epistaxis. As opposed to the gelatin matrices, which can be used wet or dried, the efficacy of Surgicel® is superior if it is applied dry to the area of bleeding, so it may not be appropriate for use with topical thrombin. As Surgicel® undergoes reaction with the tissue, it produces an acidic environment, which has been demonstrated to have in vivo bactericidal properties. The acidic environment that it produces may impair wound healing, perhaps making it a less optimal choice for controlling bleeding in large areas of tissue avulsion. Complications of its use have primarily reported to be localized tissue reactions.
Arista® AH is a powder hemostatic agent derived from plant polysaccharides. The mechanism of action of Arista® is poorly understood, but is thought to produce a mechanical scaffolding for clot formation rather than have a direct effect on the clotting cascade [17]. Its powdered form has limited use in an emergency department environment.
Avitene® is a microfibrillar collagen hemostat available as a sponge, sheet, and powder. The collagen matrix of Avitene® is thought to promote platelet activation, inducing clot formation [18]. Avitene® has been on the market for more than 40 years and has widespread applications in surgical hemostasis and epistaxis treatment.
Chitosan is a naturally occurring polycationic polysaccharide derived from multiple sources including shrimp, crabs, and certain fungi. The hemostatic mechanism of chitosan is incompletely understood, but is thought to include gelatinous aggregation of red blood cells, platelet activation, and contact system activation [19].
In a case series of 35 patients on antiplatelet agents or anticoagulants who failed initial management with cautery and nasal packing, 32 patients were successfully treated with application of a foam anterior pack wrapped in a chitosan sheet [20]. A small study of 40 patients on oral anticoagulation undergoing multiple tooth extractions compared a site treated with a chitosan pledget with a site treated with gauze and pressure and found decreased bleeding times and decreased postoperative pain in the chitosan treated site [21]. Another small study of 20 patients on oral anticoagulants undergoing dental extraction of multiple teeth found that the extraction sites treated with chitosan had shorter bleeding times than control extraction sites treated with a collagen matrix plug [22].
Thrombin is a protein which is part of the clotting cascade and has the effect of activating fibrinogen to fibrin, which is essential for clot formation, as well as activating platelets. Several formulations exist on the market, and thrombin can be of bovine or human origin. Topical thrombin can be applied to mucosal bleeding sites such as dental sites and epistaxis or can be applied topically. Additionally, topical thrombin can be used in conjunction with gelatin matrix sponges. No clinical trials comparing efficacy to other techniques have been published. Because these products are derived from other species or individuals, the primary complications include sensitivity reactions or rarely antibody formation against factor V, resulting in life-threatening bleeding complications [23].
Tranexamic acid is a synthetic derivative of the amino acid lysine that inhibits fibrinolysis by reversibly blocking the interaction of plasminogen with the lysine fragments on fibrin. The intravenous formulation of TXA is typically 100 mg/ml, which is equivalent to a 10% solution. Intravenous TXA formulations can be used topically as adjuvant treatment for patients with epistaxis, oral bleeding, or bleeding from topical sites.
A randomized controlled trial of 216 patients who were randomized to receive an anterior nasal packing soaked in 5 ml of 10% solution versus lidocaine plus epinephrine found that those treated with TXA had more rapid resolution of bleeding and earlier emergency department discharge [24]. A study of 124 patients taking antiplatelet agents who were randomized to TXA versus anterior packing also found more rapid resolution of bleeding as well as decreased visits for rebleeding [25]. A retrospective analysis of oral bleeding in 542 patients demonstrated improvement in bleeding in patients treated with TXA-soaked gauze and compression over use of gauze alone [26]. A systematic review of 5 studies including 252 patients taking oral anticoagulants undergoing dental procedures found that TXA was significantly protective against bleeding with a RR of 0.13 (95% CI 0.05–0.36; p < 0.0001) [27]. In addition to using the intravenous formulation of TXA topically, a paste of TXA can be made by crushing several 650 mg TXA tablets and adding small aliquots of saline to form the paste.
Kaolin is an inorganic mineral that has been demonstrated to promote activation of Factor XII, which is the first step in the activation of the intrinsic pathway of the clotting cascade. Kaolin-impregnated gauze is primary developed for controlling hemorrhage from external wounds in non-compressible sites in the setting of military and civilian trauma.
Little data exists evaluating the effectiveness of kaolin gauze in humans. In swine models of uncontrolled hemorrhage, QuickClot® outperformed comparative hemostatic agents in terms of survival [28].
Although the manufacturer states that there are no complications with the use of QuickClot® because it is not biologically derived, there is a case report of thermal burn with its use [29].
When it comes to primary wound closure, skin adhesives have several advantages over traditional suture repair. They bond quickly, resulting in saved time on the part of the physician performing the repair, and they are less painful than standard suture repair [30, 31]. They do not require a second visit for suture removal, saving the patient time and reducing the burden to the health-care system [30]. The closure is strong, similar in strength to healed tissue at 7 days post-repair [30]. In addition, the closure with tissue adhesives is cosmetically similar to that achieved with standard suture closure [31]. Tissue adhesives are more expensive than suture materials, but that cost is offset by the inherent costs associated with physician time to suture, bandaging, and repeat visit for suture removal [32]. In a busy and unpredictable emergency department, this time saving is essential.
Unlike topical hemostatic agents, which are often natural polymers, tissue adhesives used for wound closure in the emergency department are primarily synthetic polymers [33]. This is largely due to their high tensile strength, flexibility, and ability to form mechanical bonds [33]. The three primary classes of tissue adhesives used for wound closure are polyurethane-based tissue adhesives, polyethylene glycol-based tissue adhesives, and cyanoacrylate synthetic glues [33].
Polyurethane-based tissue adhesives are not commonly used in emergency practice, although they do have applications in surgical practice. The isocyanate pre-polymers in the adhesive bond to the amines in tissue proteins, forming a urea bond [3]. Historically, there have been issues with polyurethane-based tissue adhesive toxicity (including thrombosis and hemolysis) and long setup time [3], but they are undergoing development currently using various concentrations of castor oil and other additives to optimize their surgical adhesive properties [34, 35]. Although there is currently some application of these adhesives in the operating theater in renal, plastics, and orthopedic surgery, they are not currently used for traumatic injuries typically seen in the emergency department. As they have shown promise in reducing seroma formation in surgical wounds, they may have applications for larger traumatic wounds in the future.
Polyethylene-based adhesives are not currently typically used in emergency practice. Like polyurethane-based adhesives, they are primarily used inside the body, with current uses most commonly related to sealing lung surgical sites and preventing dural leaks after neurosurgery [36]. These adhesives have a very fast setup time and are strong and biodegradable [36]. They have potential for emergency department application in the future.
Cyanoacrylate synthetic glues are by far the most common tissue adhesives used for wound repair in emergency departments (Table 2). These glues were initially developed during attempts to make a clear plastic. Initially, they were too brittle and caused significant inflammation to tissue but subsequently underwent tremendous redesign over the course of decades prior to their final approval by the FDA in the form of 2-octyl cyanoacrylate in the late 1990s [3, 30]. Cyanoacrylate glues are monomers that react upon contact with water on tissue in an exothermic reaction, causing them to polymerize across the wound edges, allowing healing to take place below. These agents are also antimicrobial, which is an additional advantage [3, 30, 32].
Product | Manufacturer | |
---|---|---|
Cyanoacrylate synthetic glues | Dermabond® | Ethicon Inc., Somerville, NJ, USA |
Histoacryl® | BBraun, Melsungen, Germany | |
SurgiSeal® | Adhezion Biomedical LLC., Reading, PA, USA | |
Periacryl® | GluStitch, Delta, BC, Canada | |
Glu-Stitch® | GluStitch, Delta, BC, Canada | |
Indermil® | Surgical Specialties, Frenchs Forest, NSW, Australia |
Tissue adhesives.
Cyanoacrylate glues have the tensile strength of 5-0 suture, and they reach their maximal bonding strength 2.5 min after application [30]. Given these properties, it stands to reason that wounds most appropriate for glue repair are wounds that would require a suture strength of 5-0 or 6-0. Therefore, cyanoacrylate synthetic glues are not recommended for wounds under tension such as those crossing joint lines, highly gaping wounds, or wounds in very moist areas of the body [30, 32]. It is acceptable to use tissue adhesive glue on wounds that require deep sutures to reduce tension and gaping on the wound, so long as after those sutures are placed, the wound would be appropriate for closure with 5-0 or 6-0 suture. Cosmetically, cyanoacrylate has similar outcomes to standard sutures in appropriately chosen lacerations but a slightly higher risk of dehiscence [30, 31].
Tissue adhesive should be applied to an appropriately cleaned and dry wound. The wound edges should be approximated, and the adhesive should be applied over the approximated edges three to four times [30]. The hydroxyl ions in the wound edges activate the adhesive and seal the wound. The adhesive should never be introduced into the wound. In addition to causing an exothermic reaction because of the amount of moisture, it creates a foreign body reaction, with tissue inflammation and poor healing [30, 32]. Tissue adhesives should therefore not be used on heavily contaminated wounds, bites, macerated wounds, or wounds that are complex and difficult to approximate [30, 31, 32].
Cyanoacrylate glues are used in oral surgery practice, but their use for dental injuries in the emergency department is currently off-label. Nevertheless, tissue adhesives have found a niche in emergency department management of dental injuries. In the setting of an acutely fractured tooth involving exposed dentin (which is extremely painful), standard of care is to cover the exposed fracture site with calcium hydroxide paste. If this is unavailable, some providers advocate for using cyanoacrylate glue to cover the exposed dentin, as it controls pain and can be removed without difficulty using a solvent in the dentist’s office [37, 38]. One study also evaluated the use of cyanoacrylate for pain control in carious teeth, which found it effective for pain control [38]. Cyanoacrylate has antimicrobial properties, which provides theoretical benefits in these settings. However, cyanoacrylate has not been studied for safety in these scenarios, nor has it been assessed for adverse events, only for pain control. Therefore, the physician needs to be aware that any use of cyanoacrylate in treatment of dental fractures in the emergency department setting is not evidence-based.
In patients with avulsed and replanted teeth or in those with subluxed teeth, cyanoacrylate can be useful in splinting the injured tooth.
Topical hemostatic agents, tissue adhesives, and sealants may have adverse effects usually related to the composition of the agent, location of placement of the agent, and the absorption times of the agent. Slowly degrading products can serve as a nidus for infection especially if excessive amounts are used. In many cases, these agents are used in confined places and can then lead to compression of surrounding structures. Many of the complications associated with these agents are related to surgical uses rather than emergency department applications [39].
Air embolism is a rare complication that has been reported with the use of injectable agents such as spray thrombin or fibrin sealant. Care must be taken when spraying these objects so as not to exceed recommended pressures and to spray at an appropriate distance from the affected tissue. There are no reported cases of air embolism secondary to use of an atomizer, as may be used with TXA [40, 41, 42].
Wound infection may be associated with the use of topical hemostatic agents. It is difficult to analyze the risk of infection due solely to hemostatic agents versus due to confounding factors. Adverse factors, such as type and location of wound, foreign body material in the wound, and etiology of the wound, all play a role in development of wound infection. If a patient has other systemic symptoms that need to be addressed and needs urgent or emergent wound closure, that too can play a role in development of wound infection. The risk of infection, as it relates to hemostatic agents, can be minimized by cleaning the wound thoroughly and removing excess topical agent after hemostasis is achieved.
Impaired wound healing may be due to failure to effectively close the wound, dehiscence of the wound repair, and excessive amounts of hemostatic agent being used. When excessive amount of agent is used, as in cyanoacrylate closure, increased metabolites can form and cause an inflammatory response in the surrounding tissue which leads to poor wound healing [43].
Hypotension has been reported in some individuals receiving injections of bovine-derived products, such as thrombin. The hypotension is believed to occur with higher than normal concentrations of bovine thrombin but has been noted to be mostly transient lasting less than a minute. The hypotension does respond to epinephrine, if needed, and can be avoided by reducing the amount of bovine thrombin used and compression of injection sites [44, 45, 46].
Anaphylaxis and allergic reactions are also mostly related to bovine-derived products. These products must be avoided in individuals with a history of prior anaphylactic reactions to plasma products or IgA deficiency [47].
Infectious disease transmission is a potential complication when any products using blood components are used, and transmission may be more likely when hemostatic agents are used in an aerosolized form. Though there is a theoretical risk of viral transmission, including HIV and hepatitis, with topical hemostatic agents, there have been no reported cases in the last 20 years [48].
Vascular thrombosis is also a theoretical risk; however, there is no increased rate of vascular or graft thrombosis with the use of topical hemostatic agents. Great care must be taken not to inject these agents into a blood vessel or opened vessel [49, 50].
An immune-mediated bleeding diathesis can occur with the use of bovine thrombin preparations. The diathesis occurs due to development of a factor V deficiency secondary to an antibovine factor V antibody that cross-reacts with endogenous factor V. The risk of this complication can be reduced by using human thrombin. If patients have prior exposure to a bovine thrombin, antibodies may persist for years, and if known bovine thrombin should be avoided [51, 52].
Much of the literature found on uses of topical hemostatic agents for bleeding involves surgical and perioperative indications. However, different bleeding scenarios may present to the emergency department where topical adhesives and hemostatic agents may be of benefit. We will discuss some of these indications, including cutaneous bleeding, varicosity bleeding, AV fistula bleeding, post-tooth extraction bleeding, and epistaxis.
Approximately 6 million minor wounds are treated in emergency departments in the United States every year. Most cutaneous bleeding occurs due to lacerations of the skin. These lacerations can be caused by blunt or penetrating trauma to the epidermal and dermal layers. Management of these minor wounds has three goals: control of bleeding, avoidance of infection, and cosmetically acceptable, functional scars. Many factors contribute to management of these wounds. The wound must be assessed, and factors such as age of injury, mechanism of injury, extent of wound, neurovascular injury, and location of wound all play a role in determining the type of closure employed. Hemostasis of these wounds must be accomplished, and most times simple pressure for 10–15 min can achieve this. Persistent bleeding may require lidocaine with epinephrine injected or applied to the wound. In those cases where bleeding is difficult to stop, the direct application of surgical absorbable gelatin foam (Gelfoam®) to the wound is an alternative method of achieving hemostasis. Gelfoam®, however, should not be used in infected wounds or at the skin closure site because it may delay healing. After achieving hemostasis, wounds may require debridement, irrigation, and foreign body removal. Once the wound has been adequately assessed and prepared, primary closure with suture, staples, skin tape, or topical adhesive may be utilized. The most common topical adhesives used in the emergency department are cyanoacrylate synthetic glues. These offer tensile strength equivalent to 5-0 sutures. They have similar cosmetic outcomes to sutures but do have a slightly higher risk of dehiscence [53, 54, 55].
Varicose veins are dilated, elongated, tortuous, subcutaneous veins 3 mm or greater in diameter. They may involve the saphenous veins, saphenous tributaries, or superficial leg veins. Complications of varicose veins most commonly include superficial vein thrombosis and bleeding and, though uncommon, may require immediate attention. Varicose veins located near bony prominences are more prone to hemorrhage, and bleeding is usually due to minor trauma. Hemorrhage, in most cases, can be controlled with direct pressure and elevation of the leg. When these measures fail to sufficiently control bleeding, injections with lidocaine with epinephrine, suturing, and topical hemostatic agents may be helpful. Though no formal studies have specifically looked at topical agents to help with varicose bleeding, anecdotally, the use of topical thrombin, TXA, and absorbable gelatin foam may stop bleeding or control it until more definitive surgical interventions can be performed [56, 57].
Arteriovenous (AV) fistula is the vascular access preferred for long-term hemodialysis in patients with end-stage renal disease. Hemodialysis accesses are subject to complications such as clotting, stenosis, infection, and hemorrhage. Access complications are common among hemodialysis patients, but they are usually not life-threatening. Fatal vascular access hemorrhage is very rare with an incidence of only 0.4%, but when these patients present to the emergency department, various measures can be employed in order to control the bleeding until definitive measures can be taken, usually by a vascular surgeon. Most of the literature regarding fistula bleeding is related to intraoperative bleeding which can be controlled with suturing, topical thrombin, and cellulose gelatin foam. Extrapolating this data, one could conclude that emergency department management of AV fistula bleeding should involve direct pressure to the site of bleeding with the aid of topical thrombin products and gelatin foam products. Definitive treatment usually will involve suture repair done by a vascular surgeon either in the emergency department or operating room [58].
Post-extraction bleeding is a recognized, frequently encountered complication in dental practices. It is defined as bleeding that continues beyond 8–12 hours after dental extraction. The incidence of post-extraction bleeding varies from 0 to 26%. If post-extraction bleeding is not managed, complications can range from soft tissue hematomas to severe blood loss. Local causes of bleeding include soft tissue and bone bleeding. Systemic causes include platelet problems, coagulation disorders, or excessive fibrinolysis. There is a wide array of techniques suggested for the treatment of post-extraction bleeding, which include interventions aimed at both local and systemic causes. Many of these patients will present to the emergency department with their bleeding complications. In addition to treating systemic causes, many techniques can be employed to control the local etiologies of the bleeding. Surgical interventions mainly involve suturing of the site. In addition, nonsurgical hemostatic measures can be employed as well as combination therapy with surgical and nonsurgical techniques. Nonsurgical measures commonly include hemostatic agents such as oxidized cellulose, gel foam, thrombin, collagen fleeces, cyanoacrylate glue, acrylic or surgical splints, and local antifibrinolytic solutions, such as tranexamic acid mouthwash [59].
Epistaxis is a common problem encountered in the emergency department. It occurs in up to 60% of the general population; however, 10% or fewer seek medical attention. Epistaxis can be classified as anterior with the common source of bleeding being Kiesselbach’s plexus or posterior with the source being the sphenopalatine artery. Initial treatment at home or in the emergency department include conservative measures such as blowing the nose to remove clots, using vasoconstrictive sprays such as oxymetazoline, applying steady pressure for 10 minutes, placing cold compresses on the bridge of the nose, placing a cotton pledget in the nostril, and having the patient bend forward so as not to accumulate blood in the oropharynx. When these measures fail, more invasive measures can be used such as cautery, nasal packing with tampons, gauze, or balloon catheters. There has recently been more literature regarding the use of thrombogenic foams and gels as well as the use of TXA as an adjunct to these measures. Fibrin glue is a safe and effective addition and has been shown to be as effective as cautery and packing [60]. Thrombin gel, such as Floseal, was associated with an absolute 26% lower rebleeding rate compared with nasal packing and was easier to insert and judged more satisfactory by both providers and patients in a randomized trial of 70 patients with acute anterior nosebleeds [14]. In another prospective study, FloSeal® effectively controlled posterior bleeds in 8 of 10 patients whose initial packing failed [61]. Surgicel® and Gelfoam® are common conformable hemostatic materials and have been described in reviews or small case series as useful in nasal bleeding refractory to cautery [62]. These materials can be trimmed to an appropriate size and then applied directly to the bleeding source. Tranexamic acid has been studied for epistaxis and has shown some benefit in both short-term cessation of bleeding and decreasing rates of rebleeding. There was also a trend towards improved control of bleeding when directly compared to nasal packing alone. The delivery of TXA can be done by using an atomizer and/or saturating nasal tampons with topical application of 500 mg of the IV formulation (TXA 100 mg/ml). Care must be taken in patients with higher risk of systemic thrombosis as systemic absorption may be variable when TXA is applied to the nasal mucosa [63].
A number of products are available to assist in topical hemostasis. The choice of which product to use is based partly on availability as well as the particular application. Similarly, there are multiple tissue adhesives available on the market, but the provider will likely be limited to one or two different products.
The authors declare no conflicts of interest to disclose.
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