Transexamic acid and blood loss

Key Points

• Tranexamic acid can help to overcome the problem of readmission in day surgery patients.

• By avoiding keeping patients in hospital it helps to reduce cost.

• It can be of use in all dentoalveolar procedures including periodontal surgery under local or general anaesthesia.

Abstract

Objective

To evaluate the effect of pre-operative administration of tranexamic acid in preventing prolonged post-operative bleeding in day-case patients. Day-case admission is highly appropriate for dentoalveolar surgery but one of the problems is prolonged post-operative haemorrhage which at times may delay discharge or necessitate readmission to hospital. Tranexamic acid has traditionally been used to treat post-operative bleeding.

Design

A prospective double-blind randomised study

Setting

Eastman Dental Hospital, London.

Subjects and methods

Fifty-six patients were consecutively selected from healthy adult volunteers who were having third molar extraction in the day case unit of the Eastman Dental Hospital over a period of 22 weeks. Tranexamic acid (25 mg/kg) or normal saline was administered intravenously at induction by the anaesthetist and blood loss was measured intra- and post-operatively.

Results

A significant reduction (P = 0.023) in the post-operative blood loss was found in the tranexamic acid group. However, there was no significant difference in the intra-operative (P = 0.4) and the overall total blood loss (P = 0.21). No patient receiving tranexamic acid required readmission to control prolonged bleeding, or suffered any side effects from the drug.

Conclusion

This study has shown that one intravenous pre-operative dose of tranexamic acid is effective in preventing excessive post-operative bleeding in patients undergoing third molar extraction under a day case general anaesthetic and therefore facilitates safe discharge from hospital.

Main

The effect of tranexamic acid (cyclokapron) on blood loss after third molar extraction under a day case general anaesthetic Senghore N. and Harris M. Br Dent J 1999; 186: 634–636

Comment

Post-extraction bleeding following 3rd molar extractions is not a common problem and accounts for 0.25–2.5% as reported by some authors. Despite its rarity, prevention of this complication has been of interest to many researchers.

Bleeding elimination allows the early discharge of patients and reduces the possibility of their returning for re-hospitalization, hence making the treatment more efficient and less costly. The use of tranexamic acid administered either as a mouthwash or systematically for hemorrhage reduction in patients with coagulation disorders has been discussed previously in the literature with encouraging results.^1,2,3 The uniqueness of this paper lies in its study group, which consisted of healthy individuals only, without any known coagulopathies.

The main point of the article is the effect of intravenous administration of tranexamic acid on post-operative bleeding following third molar surgery. Although there was no statistically significant difference between the two groups regarding the intraoperative bleeding, it is clear that postoperative bleeding was indeed reduced using this method. Nevertheless, the clinical relevance of this study is questionable in patients who are not prone to excessive bleeding.

Furthermore, meticulous suturing and application of local homeostatic methods (including the local application of tranexamic acid as a mouthwash) may be no less effective. The efficiency of local anti-fibrinolytic activity has shown that the conversion of tranexamic acid mouthwash in saliva remains significantly high to avoid fibrinolysis for several hours after use.⁴

On the other hand, due to the basic mechanism of tranexemic acid, which acts as a potent inhibitor of fibrinolysis, it may elevate the tendency for thromboembolies.

In conclusion, this article is a good double blind prospective study, and adds further information to the investigation of tranexamic acid as an aid for the prevention of postoperative bleeding following the removal of third molars. Nevertheless, the use of intravenous acid routinely in healthy patients is questionable.