12 for 5,000 units/viral load (vL) and $339.65 for 20,000 units/vL; Flowables (eg, FloSeal®, Surgiflo®) combine a mechanical hemostat and an active hemostat into a single application format.15 The products are a mix of human plasma thrombin with either bovine collagen gelatin or porcine collagen gelatin. Human plasma thrombin, which is typically reconstituted as a liquid and can thus run off the bleeding surface, has a solid or pasty consistency when combined with a gelatin.15 Therefore, flowable hemostatic agents remain in place more effectively than beta-catenin inhibitor does the liquid thrombin alone.15 Clinical trials have demonstrated that flowables are highly effective at achieving hemostasis.26 and 27 In a multicenter

trial, 93 cardiac surgery patients were randomly assigned to receive either FloSeal or Gelfoam plus thrombin.26 Researchers found that 94% of patients who received FloSeal exhibited complete cessation of bleeding within 10 minutes compared INK-128 with 60% of patients who received Gelfoam® plus thrombin (P < .001). 26 For bleeding sites categorized as “heavy,” 77% of patients

who received FloSeal achieved hemostasis at three minutes compared with 0% of patients who received Gelfoam® plus thrombin (P < .001). 26 A multicenter, prospective, single-arm study evaluated the hemostatic effectiveness of Surgiflo in 30 patients undergoing revision endoscopic sinus surgery for chronic sinusitis 27; the researchers found that 96.7% of patients achieved hemostasis within 10 minutes of product application, with a median total time to hemostasis, including manual compression, of 61 seconds. 27 Fibrin sealants (eg, Tisseel®, Crosseal®, Hemaseel®, Evicel®) are effective in patients with coagulopathy who do not have sufficient fibrinogen to form a clot.15 and 28 Fibrin sealants work by combining Niclosamide human thrombin with

its target fibrinogen in a single product to create fibrin.15 and 28 Active bleeding is not necessary for fibrin sealants to be effective.15 and 28 Fibrin sealants are multicomponent products that contain fibrinogen, factor XIII, thrombin, fibronectin, and ionized calcium.28 Tisseel also contains aprotinin, a bovine-derived antifibrinolytic, to counteract fibrinolysis by plasmin. Unlike Tisseel, Crosseal and Hemaseel are made from human products, including concentrated human plasma and purified human thrombin, and thus do not carry the risk of anaphylactic reaction that Tisseel does, although they do carry the risk of infectious disease transmission.28 Fibrin sealants are commonly used in open surgeries and are becoming more popular in controlling hemostasis in laparoscopic surgeries.28 Typically, fibrin sealants are used as adjunctive therapy when thermal or chemical hemostatic methods fail or are insufficient to achieve hemostasis.28 Fibrin sealants, however, have been used in laparoscopic surgery as a primary hemostatic strategy.