Topical thrombins: benefits and risks.

Whether from surgical misadventure, inherent patient factors, or iatrogenic causes, postoperative bleeding can be a consequence of any surgical procedure. There are many methods and products available to assist in managing or preventing bleeding. For each method, there may be specific benefits and indications, but they may also carry some degree of risk. Topical thrombin is used extensively in many surgical specialties, especially in the cardiovascular and neurosurgical arenas where other hemostatic modalities may not be appropriate choices. As a class, topical thrombins are generally a safe and effective method for achieving intraoperative hemostasis; however, some members of the class carry associated risks with their use. For example, the United States Food and Drug Administration required the addition of a black-box warning to the prescribing information of bovine-derived thrombin, the oldest member of the class, due to concerns of immune-mediated coagulopathies developing after use. In addition, human thrombin derived from pooled plasma has its own, if theoretical, risk of transmitting infections due to viral or prion agents. We address the topical thrombin class and review each product in the context of the current literature.