title: Use of thrombin-based haemostatic matrix in head and neck reconstructions: a potential risk factor for pulmonary embolism.
abstract: BACKGROUND
  Haemostatic agents including thrombin-based haemostatic matrix are widely used in patients undergoing cardiac, vascular and spinal surgery. These agents promote local haemostasis through activation of the clotting cascade. To our knowledge, this case series is the first report of pulmonary embolization associated with FloSeal following head and neck oncology resection and free flap reconstruction.
  
  
  METHODS
  We present five patients who were diagnosed with symptomatic pulmonary embolism after oncologic head and neck free flap reconstructions in 2014 and 2015.
  
  
  RESULTS
  There were five patients consisting of three males and two females. The mean age was 67 years, ranging from 60 to 74 years. Pulmonary embolism occurred between 3 and 30 days with a mean of 12 days. Four out of the five reported cases showed involvement of more than one lobe, and two cases had bilateral pulmonary involvement. All but one patient underwent infratemporal fossa dissections as part of the cancer resection. Ten millilitres of FloSeal was applied to the pterygoid plexi in the four patients to achieve haemostasis. All patients received heparin infusion followed by warfarin therapy for at least 6 months with no mortality or complications relating to pulmonary embolism to date.
  
  
  CONCLUSIONS
  Although inconclusive due to study design and small numbers, this series raises the possibility that there may be an association between the use of haemostatic matrix in head and neck oncologic reconstructions and pulmonary embolism. Haemostatic matrix must be used in caution when there is a direct contact with venous endolumens such as the pterygoid plexus and soleus.
authors.affiliation: Plastic and Reconstructive Surgery, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.
authors.forename: Brian Y T
authors.initials: BYT
authors.lastname: Yue
authors.affiliation: Plastic and Reconstructive Surgery, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.
authors.forename: Richard
authors.initials: R
authors.lastname: Zinn
authors.affiliation: Plastic and Reconstructive Surgery, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.
authors.forename: Rachael
authors.initials: R
authors.lastname: Roberts
authors.affiliation: Plastic and Reconstructive Surgery, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.
authors.forename: Jeremy
authors.initials: J
authors.lastname: Wilson
mesh_terms: D000368:Aged; D000925:Anticoagulants / Q000627:therapeutic use; D005260:Female; D058752:Free Tissue Flaps / Q000637:transplantation; D006258:Head and Neck Neoplasms / Q000150:complications* / Q000188:drug therapy / Q000401:mortality / Q000601:surgery*; D006490:Hemostatics / Q000009:adverse effects*; D006493:Heparin / Q000008:administration & dosage / Q000627:therapeutic use*; D006801:Humans; D007262:Infusions, Intravenous; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000401:mortality; D011655:Pulmonary Embolism / Q000139:chemically induced* / Q000453:epidemiology; D019651:Plastic Surgery Procedures / Q000009:adverse effects* / Q000379:methods; D012189:Retrospective Studies; D012307:Risk Factors; D013917:Thrombin / Q000009:adverse effects*; D014859:Warfarin / Q000008:administration & dosage / Q000627:therapeutic use
chemical_list: D000925:Anticoagulants; D006490:Hemostatics; D014859:Warfarin; D006493:Heparin; D013917:Thrombin
keywords: free tissue flaps; haemostatic matrix; head and neck reconstructions; postoperative complications; pulmonary embolism