Supportive topical tranexamic acid application for hemostasis in oral bleeding events – Retrospective cohort study of 542 patients

Abstract

Purpose

Tranexamic acid (TXA) is widely used in the prevention of postsurgical oral bleeding. Tranexamic acid in addition to further surgical measures is widely utilized in prevention of post-surgical oral bleeding. The aim of the present study was to investigate: Can oral hemostasis be achieved by merely compression and topical application of tranexamic acid in different anticoagulant regimes among patients attending a general emergency department? Where are the limits to this procedure? Which has the greater impact on surgeons' choice for an invasive hemostatic approach—bleeding quality or oral anticoagulant therapy?

Materials and methods

A retrospective cohort study of 542 patients who consecutively received treatment for oral bleeding was performed. We surveyed the values of the diverse hemostatic approaches. Special attention was granted to patient anticoagulant regimen and quality of the oral bleeding event.

Results

A total of 199 of 542 (36.7%) oral bleeding events were stopped by compression with a gauze or gauze soaked with TXA (4.8%). Stopping an oral bleeding event with wound compression can be improved by factor 1.6 if the gauze is soaked with tranexamic acid (4.8%), p ≤ 0.05. LMWH presented significantly more moderate bleeding than bloody oozing of the wound, p < 0.05. The quality of bleeding had a strong influence on oral surgeons' decisions to apply further surgical means. Sutures and native collagen fleeces were the favored methods to stop moderate and severe bleeding (p < 0.05).

Conclusion

Topical application of TXA aids as a useful supportive tool to stop mild bleeding events such as the bloody oozing of an oral wound. The quality of an oral bleeding episode should be considered in the choice of hemostatic measure. Hemostatic approaches should begin with the least invasive procedure. TXA is a helpful tool.

Introduction

Postsurgical bleeding is a frequently observed complication in patients receiving an antiplatelet therapy or anticoagulant (Pototski and Amenabar, 2007). In the treatment of cardiovascular diseases, anticoagulant agents are commonly prescribed (Wahl, 1998). Likewise, antiplatelet therapy is prescribed for patients with coronary heart syndrome or elevated risk for a cerebral stroke (Arora and Rai, 2009, Su et al., 2016). Recently, well-established anticoagulant and antiplatelet drugs such as heparins, hirudins, coumarins, and acetylsalicylic acid have been complemented with a list of modern drugs (Hofmeier, 2015). The development of anti-Xa agents for oral use presents further options in anticoagulant therapy (Fareed et al., 2008a). At the same time, newer drugs with greater antithrombotic efficacy for antiplatelet therapy (e.g., clopidogrel, ticlopidine, dipyridamole, prasugrel, and cilostazol) than acetylsalicylic acid have emerged in the market for the secondary prevention of cardiac or cerebrovascular diseases (Wahl, 2014, Zirk et al., 2016). These newer drugs are attractive for several reasons, including cost-effectiveness and targeted treatments; however, they are not expected to completely replace conventional drugs in polytherapeutic approaches in the near future (Fareed et al., 2008b, Hoppensteadt et al., 2008).

In general, patients receiving anticoagulant therapy are of advanced age and have several comorbidities (Baillargeon et al., 2012). In addition, elderly patients have an increased risk for bleeding due to their high demand for oral surgery (de Vasconcellos et al., 2016). Diverse protocols exist in the challenging surgical treatment of anticoagulated patients, ranging from no interference in anticoagulant therapy or bridging regimens with low-molecular-weight heparin (LMWH) to complete interruption of antithromboembolic therapy (Ward and Smith, 2007, Zirk et al., 2016). In the management of minor oral surgery, the literature presents evidence in favor of an uninterrupted approach in anticoagulant therapy (Kammerer et al., 2015). It is argued that the potential of fatal thromboembolism outweighs the risk of a postoperative bleeding episode (Kammerer et al., 2015). With regard to antiplatelet therapy, severe bleeding complications are rare, and most oral bleedings are stopped by local hemostatic measures (Wahl, 2014).

The hemostatic measures used to stop bleeding are diverse (Costa et al., 2013). Oral surgeons use gauze, oxidized cellulose, gelatin sponges, and collagen fleeces with or without sutures to prevent or stop oral bleeding (Bajkin et al., 2009, Hong et al., 2010, Morimoto et al., 2011, Morimoto et al., 2015, Zirk et al., 2016). Furthermore, electrocautery, compression by an acrylic splint, or adjuvants such as fibrin or histoacryl glue are included in hemostatic therapy (Bodner et al., 1998, Halfpenny et al., 2001, Al-Belasy and Amer, 2003, Carter et al., 2003, Eichhorn et al., 2012). In some reports, additional antifibrinolytic solutions such as tranexamic acid mouthwashes are applied (Ramstrom et al., 1993, Souto et al., 1996, Carter and Goss, 2003). In the oral cavity, hemostasis depends on the dynamic balance of fibrin and plasmin formation (Costa et al., 2013). Tranexamic acid inhibits fibrinolysis by preventing the proteolytic degeneration of fibrin; therefore, it is a viable tool in achieving hemostasis (Carter and Goss, 2003).

The aim of this study was to investigate the role and influence of the topical application of tranexamic acid among other local hemostatic approaches in oral bleeding, and its feasibility for patients with different anticoagulant regimens presenting to the general emergency department. Can oral hemostasis be achieved by compression and topical application of tranexamic acid alone in patients on an anticoagulant regimen? What are the limits to this procedure? Which has the greater impact on surgeons' choice for an invasive hemostatic approach—bleeding quality or oral anticoagulant therapy?