Minimizing intraoperative and postoperative blood loss is critical to ensuring patient wellness. Techniques have much progressed since the use of barley, wax, grease, and animal skin across Ancient Egypt, Greece, and Native America 1, and a range of options exist in modern medicine. Though in many situations, anticoagulant medications are used, there is also a role for coagulant drugs in the surgical setting.
In some contexts, such as to treat hemorrhagic syndrome, systemic hemostatic drugs are required. For example, desmopressin, an analog of vasopressin, may help prevent or reduce surgical bleeding in patients with von Willebrand’s disease or mild hemophilia 2. Similarly, activated factor VII may be used in hemophilia patients undergoing a variety of major or minor surgical procedures 3.
However, in many clinical contexts and surgical settings, it is dangerous to use coagulant drugs with a systemic impact given the risk of bleeding in an anticoagulated patient and risk of thrombosis if anticoagulation is ceased all together. In such cases, such as for a patient who is on an anticoagulant drug due to a high risk of thrombosis, the patient may simply need to be taken off the drug 4. Management thus often first involves the temporary pre- and post-operative interruption of the anticoagulant.
Thereafter, a local agent that either boosts clot formation or inhibits clot degradation would be critical—allowing for the reversal of anticoagulation at a specific site while maintaining anticoagulation systemically.
Such local coagulant options include but are not limited to tranexamic acid, topical thrombin and fibrin, and hemostats.
An anti-fibrinolytic, tranexamic acid binds to plasmin, preventing the degradation of fibrin. Topical tranexamic acid, effective across a range of clinical and surgical settings, is thus used to control bleeding following oral surgery, as well as nose bleeding resulting from anticoagulation and coagulation disorders 5.
Topical thrombin and fibrin sealants can also be used to achieve hemostasis, particularly across dermatologic surgical settings 6. While they are expensive and may trigger an immunologic response, their benefits are that they act very swiftly 7.
Finally, a wide range of hemostats—dressings, sponges, meshes, or powders applied to a bleeding area to promote coagulation—can be used as well, the composition of which is determined based on surgical need in light of their advantages and disadvantages 8. Physical and absorbable hemostats, such as bone wax, collagen and cellulose, are effective at controlling low-pressure bleeding but may embolize and interfere with healing. In contrast, and arguably the safest option, polysaccharide hemostats appear to be very useful 9.
The selection of the ideal local coagulant agent depends on factors such as ease of use and delivery, effectiveness, lack of antigenic properties, and cost. It is important to note, for example, that agents that rely on an intact coagulation pathway, such as those containing cellulose, collagen, or gelatin, are less effective in patients in whom these pathways are disrupted.
The main challenge to the advancement of local coagulant drugs remains drug delivery in the surgical setting. Meanwhile, while no single local agent developed to date has emerged as the best, the development of local coagulation agents continues to progress. In the end, skillful surgery combined with careful management of blood coagulation will help minimize hemorrhage and reduce unnecessary blood loss and the risks associated with blood transfusions.
References
1. Achneck, H. E. et al. A comprehensive review of topical hemostatic agents: Efficacy and recommendations for use. Annals of Surgery (2010). doi:10.1097/SLA.0b013e3181c3bcca
2. Özgönenel, B., Rajpurkar, M. & Lusher, J. M. How do you treat bleeding disorders with desmopressin? Postgraduate Medical Journal (2007). doi:10.1136/pgmj.2006.052118
3. Castaman, G. The role of recombinant activated factor VII in the haematological management of elective orthopaedic surgery in haemophilia A patients with inhibitors. Blood Transfusion (2017). doi:10.2450/2017.0369-16
4. Oliver, J. D. et al. Local pro-and anti-coagulation therapy in the plastic surgical patient: A literature review of the evidence and clinical applications. Med. (2019). doi:10.3390/medicina55050208
5. Zirk, M. et al. Supportive topical tranexamic acid application for hemostasis in oral bleeding events – Retrospective cohort study of 542 patients. J. Cranio-Maxillofacial Surg. (2018). doi:10.1016/j.jcms.2018.03.009
6. Howe, N. & Cherpelis, B. Obtaining rapid and effective hemostasis: Part I. Update and review of topical hemostatic agents. Journal of the American Academy of Dermatology (2013). doi:10.1016/j.jaad.2013.07.014
7. Pannucci, C. J. et al. The impact of once-versus twice-daily enoxaparin prophylaxis on risk for venous thromboembolism and clinically relevant bleeding. Plast. Reconstr. Surg. (2018). doi:10.1097/PRS.0000000000004517
8. Seyednejad, H., Imani, M., Jamieson, T. & Seifalian, A. M. Topical haemostatic agents. British Journal of Surgery (2008). doi:10.1002/bjs.6357
9. Biranje, S. S. et al. Polysaccharide-based hemostats: recent developments, challenges, and future perspectives. Cellulose (2021). doi:10.1007/s10570-021-04132-x