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Use of tranexamic acid to reduce bleeding in burns surgery
Journal of Plastic, Reconstructive & Aesthetic Surgery (2012) 65, 684e686
CASE REPORT
Use of tranexamic acid to reduce bleeding in burns surgery* Y.M.J. Tang*, T.W.L. Chapman, P. Brooks Burns & Plastic Surgery Department, Nottingham University Hospitals, City Hospital Campus, Hucknall Road, NG5 1PB Nottingham, United Kingdom Received 20 July 2011; accepted 19 September 2011
KEYWORDS Tranexamic acid; Topical; Burns Debridement; Bleeding
Summary We describe, for the first time, the use of topical tranexamic acid as an adjunct to traditional methods in the control of bleeding in burns surgery. We illustrate our use with a case example and continue to discuss the reasons we believe it is a useful, effective and safe means of achieving haemostasis. ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Introduction
Methods
Bloods loss associated with surgical burns intervention is a challenging problem. It may be particularly pronounced in certain scenarios such as delayed burns debridement and in the head and neck area. There have been several methods described for haemostasis during burns surgery. These include non-chemical methods such as elevation and tourniquet, and chemical methods such as epinephrine tumescence, topical thrombin, fibrin sealant and systemic therapy.1 Here we describe the use of topical tranexamic acid as a further adjunct to control bleeding in burns surgery.
For three years our unit has used topical tranexamic solution as a haemostatic agent following selective cases of burns debridement and grafting in areas where epinephrine tumescence is not appropriate or unsuccessful. Dressing gauze is soaked in 500 mg/mL of tranexamic acid diluted in 100 mL of 0.9% Saline, and applied to the bleeding area after debridement for 5e10 min. We have used this method in over 30 cases to date, and found the agent very effective in the control of bleeding and without complications (including thromboembolic phenomenon).
Case example *
This case has never been presented at any meeting prior to or at the time of submission of this paper and no funding was required. * Corresponding author. Tel.: 44(0) 115 969 1169. E-mail address: [email protected] (Y.M.J. Tang).
A 58-year-old man with 11% TBSA flame burns predominantly to the head and neck area underwent delayed tangential debridement and grafting to his face and the
1748-6815/$ - see front matter ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2011.09.028
Use of tranexamic acid to reduce bleeding in burns surgery
685
right side of his scalp 4 weeks after injury (having spent 26 days in ITU with a significant inhalational injury) under tumescent therapy with 1:500,000 epinepherine in 0.9% Saline. Soaked gauzes containing 1:100,000 epinephrine in 0.9% Saline applied to the wound for 10 min failed to achieve haemostasis. Dressing gauze was then soaked in 500 mg/mL of tranexamic acid diluted in 100 mL of 0.9% Saline, and applied, which subsequently, successfully controlled bleeding (Figure 1). Unmeshed split skin grafts (8:1000 inch) were then applied after topical application of a fibrin sealant, Tiseel (Baxter Healthcare Corp., Deerfield, IL). Postoperative wound check revealed excellent graft take (Figure 2).
Discussion Tranexamic acid is an antifibrinolytic that competitively inhibits the activation of plasminogen, thereby reducing the conversion of plasminogen to plasmin, a molecule responsible for the degradation of fibrin clots, and other plasma proteins, including the procoagulant factors V and VIII. The normal and licensed route of delivery is systemically through intravenous injection. Topical use is unlicensed by the manufacturer, but has been widely popularised in other forms of surgery. There is published
Figure 2
Postoperative results.
literature on the efficacy of topical tranexamic acid in dental,2 cardiac,3 elective orthopaedic surgery4 and gynaecology5 but to date, none have been reported about its use in burns surgery. There is no consensus as to what the ideal concentration of tranexamic acid should be and different concentrations are used in the various surgical specialties.2e5 We found that using a 0.1% (5 mg/1 ml) solution is sufficient during burns surgery but up to 5% (50 mg/ml) concentrations have been described in literature for use in dental surgery for patients with bleeding disorders.6,7 No adverse affects or interactions have been reported in topical use to date. In our experience, the effectiveness of this treatment in not reliant on using fibrin sealant to as a graft fixator although it was used in the case discussed.
Conclusions
Figure 1 applied.
Haemostasis achieved and unmeshed skin graft
The use of topical tranexamic acid is a method worth considering where bleeding is a problem after burns debridement especially where conventional methods fail. We believe that this is particularly useful in situations where epinephrine has limited effect (e.g. where the subeschar viable tissue is fibrotic and vasoconstrictors have limited activity). Although use is off-licence, it appears effective and safe.
686
Y.M.J. Tang et al.
Conflict of interest None.
4.
Funding 5.
None.
References
6.
1. Sterling JP, Heimbach DM. Hemostasis in burn surgery e a review. Burns 2011 Jun;37(4):559e65. 2. Patatanian E, Fugate SE. Hemostatic mouthwashes in anticoagulated patients undergoing dental extraction. Ann Pharmacother 2006 Dec;40(12):2205e10. 3. Abrishami A, Chung F, Wong J. Topical application of antifibrinolytic drugs for on-pump cardiac surgery: A systematic
7.
review and meta-analysis. Can J Anaesth 2009 Mar;56(3): 202e12. Wong J, Abrishami A, El Beheiry H, et al. Topical application of tranexamic acid reduces postoperative blood loss in total knee arthroplasty: a randomized, controlled trial. J Bone Joint Surg Am. 2010 Nov 3;92(15):2503e13. Sarris I, Arafa A, Konaris L, Kadir RA. Topical use of tranexamic acid to control perioperative local bleeding in gynaecology patients with clotting disorders: two cases. Haemophilia 2007; 13(1):115e6. Ramstrom G, Sindet-Pedersen S, Hall G, Blomback M, Alander U. Prevention of postsurgical bleeding in oral surgery using tranexamic acid without dose modification of oral anticoagulants. J Oral Maxillofac Surg 1993 Nov;51(11): 1211e6. Hewson I, Makhmalbaf P, Street A, McCarthy P, Walsh M. Dental surgery with minimal factor support in the inherited bleeding disorder population at the Alfred Hospital. Haemophilia 2011 Jan;17(1):e185e8.
CASE REPORT
Use of tranexamic acid to reduce bleeding in burns surgery* Y.M.J. Tang*, T.W.L. Chapman, P. Brooks Burns & Plastic Surgery Department, Nottingham University Hospitals, City Hospital Campus, Hucknall Road, NG5 1PB Nottingham, United Kingdom Received 20 July 2011; accepted 19 September 2011
KEYWORDS Tranexamic acid; Topical; Burns Debridement; Bleeding
Summary We describe, for the first time, the use of topical tranexamic acid as an adjunct to traditional methods in the control of bleeding in burns surgery. We illustrate our use with a case example and continue to discuss the reasons we believe it is a useful, effective and safe means of achieving haemostasis. ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Introduction
Methods
Bloods loss associated with surgical burns intervention is a challenging problem. It may be particularly pronounced in certain scenarios such as delayed burns debridement and in the head and neck area. There have been several methods described for haemostasis during burns surgery. These include non-chemical methods such as elevation and tourniquet, and chemical methods such as epinephrine tumescence, topical thrombin, fibrin sealant and systemic therapy.1 Here we describe the use of topical tranexamic acid as a further adjunct to control bleeding in burns surgery.
For three years our unit has used topical tranexamic solution as a haemostatic agent following selective cases of burns debridement and grafting in areas where epinephrine tumescence is not appropriate or unsuccessful. Dressing gauze is soaked in 500 mg/mL of tranexamic acid diluted in 100 mL of 0.9% Saline, and applied to the bleeding area after debridement for 5e10 min. We have used this method in over 30 cases to date, and found the agent very effective in the control of bleeding and without complications (including thromboembolic phenomenon).
Case example *
This case has never been presented at any meeting prior to or at the time of submission of this paper and no funding was required. * Corresponding author. Tel.: 44(0) 115 969 1169. E-mail address: [email protected] (Y.M.J. Tang).
A 58-year-old man with 11% TBSA flame burns predominantly to the head and neck area underwent delayed tangential debridement and grafting to his face and the
1748-6815/$ - see front matter ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2011.09.028
Use of tranexamic acid to reduce bleeding in burns surgery
685
right side of his scalp 4 weeks after injury (having spent 26 days in ITU with a significant inhalational injury) under tumescent therapy with 1:500,000 epinepherine in 0.9% Saline. Soaked gauzes containing 1:100,000 epinephrine in 0.9% Saline applied to the wound for 10 min failed to achieve haemostasis. Dressing gauze was then soaked in 500 mg/mL of tranexamic acid diluted in 100 mL of 0.9% Saline, and applied, which subsequently, successfully controlled bleeding (Figure 1). Unmeshed split skin grafts (8:1000 inch) were then applied after topical application of a fibrin sealant, Tiseel (Baxter Healthcare Corp., Deerfield, IL). Postoperative wound check revealed excellent graft take (Figure 2).
Discussion Tranexamic acid is an antifibrinolytic that competitively inhibits the activation of plasminogen, thereby reducing the conversion of plasminogen to plasmin, a molecule responsible for the degradation of fibrin clots, and other plasma proteins, including the procoagulant factors V and VIII. The normal and licensed route of delivery is systemically through intravenous injection. Topical use is unlicensed by the manufacturer, but has been widely popularised in other forms of surgery. There is published
Figure 2
Postoperative results.
literature on the efficacy of topical tranexamic acid in dental,2 cardiac,3 elective orthopaedic surgery4 and gynaecology5 but to date, none have been reported about its use in burns surgery. There is no consensus as to what the ideal concentration of tranexamic acid should be and different concentrations are used in the various surgical specialties.2e5 We found that using a 0.1% (5 mg/1 ml) solution is sufficient during burns surgery but up to 5% (50 mg/ml) concentrations have been described in literature for use in dental surgery for patients with bleeding disorders.6,7 No adverse affects or interactions have been reported in topical use to date. In our experience, the effectiveness of this treatment in not reliant on using fibrin sealant to as a graft fixator although it was used in the case discussed.
Conclusions
Figure 1 applied.
Haemostasis achieved and unmeshed skin graft
The use of topical tranexamic acid is a method worth considering where bleeding is a problem after burns debridement especially where conventional methods fail. We believe that this is particularly useful in situations where epinephrine has limited effect (e.g. where the subeschar viable tissue is fibrotic and vasoconstrictors have limited activity). Although use is off-licence, it appears effective and safe.
686
Y.M.J. Tang et al.
Conflict of interest None.
4.
Funding 5.
None.
References
6.
1. Sterling JP, Heimbach DM. Hemostasis in burn surgery e a review. Burns 2011 Jun;37(4):559e65. 2. Patatanian E, Fugate SE. Hemostatic mouthwashes in anticoagulated patients undergoing dental extraction. Ann Pharmacother 2006 Dec;40(12):2205e10. 3. Abrishami A, Chung F, Wong J. Topical application of antifibrinolytic drugs for on-pump cardiac surgery: A systematic
7.
review and meta-analysis. Can J Anaesth 2009 Mar;56(3): 202e12. Wong J, Abrishami A, El Beheiry H, et al. Topical application of tranexamic acid reduces postoperative blood loss in total knee arthroplasty: a randomized, controlled trial. J Bone Joint Surg Am. 2010 Nov 3;92(15):2503e13. Sarris I, Arafa A, Konaris L, Kadir RA. Topical use of tranexamic acid to control perioperative local bleeding in gynaecology patients with clotting disorders: two cases. Haemophilia 2007; 13(1):115e6. Ramstrom G, Sindet-Pedersen S, Hall G, Blomback M, Alander U. Prevention of postsurgical bleeding in oral surgery using tranexamic acid without dose modification of oral anticoagulants. J Oral Maxillofac Surg 1993 Nov;51(11): 1211e6. Hewson I, Makhmalbaf P, Street A, McCarthy P, Walsh M. Dental surgery with minimal factor support in the inherited bleeding disorder population at the Alfred Hospital. Haemophilia 2011 Jan;17(1):e185e8.