Topical Silver Nitrate for the Management of Hemostasis: A Review of Clinical Effectiveness, Cost-Effectiveness, and Guidelines (original) (raw)

Context and Policy Issues

Effective and rapid hemostasis by accelerating the clotting process is critical in the management of wound bleeding. Topical hemostatic agents have been used in the treatment for superficial wound bleeding and include chemical cauterizing agents (e.g, silver nitrate), adhesives (e.g., fibrin sealant), absorbable agents (e.g, QuikClot), biologics (e.g, Thrombostat), and combination products (e.g, TAC: tetracaine, adrenaline and cocaine).1–3 Silver nitrate is an inorganic chemical with antimicrobial properties and available as a solution or an applicator stick. It has been used as a cauterizing agent by delivering free silver ions which bind to tissue, forming an eschar and obstructing vessels.1,4,5 Despite its proven antiseptic ability to manage and prevent wound infection,6–8 the role of topical silver nitrate in hemostasis as compared to other hemostatic agents is somewhat unclear.

This Rapid Response report aims to review the comparative clinical and cost-effectiveness of topical silver nitrate for the management of hemostasis. Evidence-based guidelines on the use of topical agents for the management of hemostasis will also be reviewed.

Research Question

1. What is the clinical effectiveness of topical application of silver nitrate for the management of hemostasis?
2. What is the cost effectiveness of topical silver nitrate for the management of hemostasis?
3. What are the guidelines regarding the application of topical agents for the management of hemostasis?

Key Findings

There were no studies that met the pre-specified criteria regarding the comparative clinical effectiveness and cost-effectiveness of topical silver nitrate for the management of hemostasis. No evidence-based guidelines on the use of topical agents for the management of hemostasis were found.

Methods

A limited literature search was conducted on key resources including PubMed, the Cochrane Library, University of York Centre for Reviews and Dissemination (CRD) databases, Canadian and major international health technology agencies, as well as a focused Internet search. Methodological filters were applied to limit the retrieval to health technology assessments, systematic reviews, and meta-analyses, randomized controlled trials, economic evaluations, non-randomized studies, and guidelines. Where possible, retrieval was limited to the human population. The search was also limited to English language documents published between January 1, 2008 and October 1, 2018.

Rapid Response reports are organized so that the evidence for each research question is presented separately.

Selection Criteria and Methods

One reviewer screened citations and selected studies. In the first level of screening, titles and abstracts were reviewed and potentially relevant articles were retrieved and assessed for inclusion. The final selection of full-text articles was based on the inclusion criteria presented in Table 1.

Exclusion Criteria

Articles were excluded if they did not meet the selection criteria outlined in Table 1, they were duplicate publications, or were published prior to 2008.

Critical Appraisal of Individual Studies

Critical appraisal was not performed as no eligible studies were identified.

Summary of Evidence

Quantity of Research Available

A total of 785 citations were identified in the literature search. Following screening of titles and abstracts, 774 citations were excluded and 11 potentially relevant reports from the electronic search were retrieved for full-text review. No potentially relevant publication was retrieved from the grey literature search. Of these potentially relevant articles, 11 publications were excluded for various reasons, and no publications met the inclusion criteria and were included in this report. Appendix 1 presents the PRISMA flowchart of the study selection.

Summary of Findings

No relevant HTAs, SRs, MAs, RCTs, non-RCTs, cost-effectiveness studies, or evidence-based guidelines on the clinical effectiveness or cost-effectiveness of topical silver nitrate for the management of hemostasis were identified.

Conclusions and Implications for Decision or Policy Making

There were no studies that met the pre-specified criteria on the comparative clinical effectiveness or the cost-effectiveness of topical silver nitrate for the management of hemostasis. No evidence-based guidelines on the use of topical agents for the management of hemostasis were identified.

A review on the management of epistaxis in patients with ventricular assist device found that cauterization with silver nitrate alone was associated with a higher likelihood of bleeding recurrence than with the use of other hemostatic materials.9 A randomized controlled trial evaluated different concentrations of silver nitrate cauterization in children with epistaxis found 75% solution was more efficacious than 95% solution in epistaxis resolution while causing less pain.10

Clinical and economic studies comparing topical silver nitrate to other cauterizing agents and hemostats are needed to evaluate the efficacy and cost-effectiveness of topical silver nitrate, and to guide its use in the management of hemostasis.

References

Howe N, Cherpelis B. Obtaining rapid and effective hemostasis: Part I. Update and review of topical hemostatic agents. J Am Acad Dermatol. 2013;69(5):659.e651–659.e617. [PubMed: 24124834]

Peralta E. Overview of topical hemostatic agents and tissue adhesives. In: Post TW, ed. UpToDate. Waltham (MA): UpToDate; 2018: www​.uptodate.com. Accessed 2018 Oct 12.

De Zotti C. Wound care advice – using silver nitrate sticks. Nurses for Nurses Network 2017; www​.nursesfornurses.com.au. Accessed Oct 12, 2018

British Columbia Provincial Nursing Skin and Wound Committee. Silver nitrate (AgNO3) sticks for wound care. Vancouver: BC Patient Safety & Quality Council; 2013: https://www​.clwk.ca/buddydrive​/file/silver-nitrate. Accessed 2018 Oct 12.

Hassiba AJ, El Zowalaty ME, Webster TJ, et al. Synthesis, characterization, and antimicrobial properties of novel double layer nanocomposite electrospun fibers for wound dressing applications. Int J Nanomedicine. 2017;12:2205–2213. [PMC free article: PMC5367563] [PubMed: 28356737]

Liang D, Lu Z, Yang H, Gao J, Chen R. Novel asymmetric wettable AgNPs/chitosan wound dressing: in vitro and in vivo evaluation. ACS Appl Mat Interfaces. 2016;8(6):3958–3968. [PubMed: 26800283]

Guidelines for using silver-impregnated dressings and topical agents. Plymouth Meeting (PA): ECRI. www​.ecri.org. Accessed 2018 Oct 12.

Brown CS, Abi-Hachem R, Jang DW. Management of epistaxis in patients with ventricular assist device: a retrospective review. J Otolaryngol Head Neck Surg. 2018;47(1):48. [PMC free article: PMC6090909] [PubMed: 30068378]

Glynn F, Amin M, Sheahan P, McShane D. Prospective double blind randomized clinical trial comparing 75% versus 95% silver nitrate cauterization in the management of idiopathic childhood epistaxis. Int J Ped Otorhinolaryngol. 2011;75(1). [PubMed: 21093066]

Appendix 1. Selection of Included Studies

About the Series

CADTH Rapid Response Report: Summary with Critical Appraisal

Version: 1.0

Funding: CADTH receives funding from Canada’s federal, provincial, and territorial governments, with the exception of Quebec.

Suggested citation:

Topical silver nitrate for the management of hemostasis: a review of clinical effectiveness, cost-effectiveness, and guidelines. Ottawa: CADTH; 2018 Oct. (CADTH rapid response report: summary with critical appraisal).

Disclaimer: The information in this document is intended to help Canadian health care decision-makers, health care professionals, health systems leaders, and policy-makers make well-informed decisions and thereby improve the quality of health care services. While patients and others may access this document, the document is made available for informational purposes only and no representations or warranties are made with respect to its fitness for any particular purpose. The information in this document should not be used as a substitute for professional medical advice or as a substitute for the application of clinical judgment in respect of the care of a particular patient or other professional judgment in any decision-making process. The Canadian Agency for Drugs and Technologies in Health (CADTH) does not endorse any information, drugs, therapies, treatments, products, processes, or services.

While care has been taken to ensure that the information prepared by CADTH in this document is accurate, complete, and up-to-date as at the applicable date the material was first published by CADTH, CADTH does not make any guarantees to that effect. CADTH does not guarantee and is not responsible for the quality, currency, propriety, accuracy, or reasonableness of any statements, information, or conclusions contained in any third-party materials used in preparing this document. The views and opinions of third parties published in this document do not necessarily state or reflect those of CADTH.

CADTH is not responsible for any errors, omissions, injury, loss, or damage arising from or relating to the use (or misuse) of any information, statements, or conclusions contained in or implied by the contents of this document or any of the source materials.

This document may contain links to third-party websites. CADTH does not have control over the content of such sites. Use of third-party sites is governed by the third-party website owners’ own terms and conditions set out for such sites. CADTH does not make any guarantee with respect to any information contained on such third-party sites and CADTH is not responsible for any injury, loss, or damage suffered as a result of using such third-party sites. CADTH has no responsibility for the collection, use, and disclosure of personal information by third-party sites.

Subject to the aforementioned limitations, the views expressed herein are those of CADTH and do not necessarily represent the views of Canada’s federal, provincial, or territorial governmentsor any third party supplier of information.

This document is prepared and intended for use in the context of the Canadian health care system. The use of this document outside of Canada is done so at the user’s own risk.

This disclaimer and any questions or matters of any nature arising from or relating to the content or use (or misuse) of this document will be governed by and interpreted in accordance with the laws of the Province of Ontario and the laws of Canada applicable therein, and all proceedings shall be subject to the exclusive jurisdiction of the courts of the Province of Ontario, Canada.