Topical Hemostatic-Anesthetic Solution to Reduce Bleeding During Mohs Micrographic Surgery: A Case Control Study

July 2016 | Volume 15 | Issue 7 | Original Article | 851 | Copyright © July 2016


Isaac Zilinsky MD,a Tamar Brutman Barazani PhD,b Boris Shenkman PhD,b Oren Weisman MD,c Nimrod Farber MD,c and Uriel Martinowitz MDb

aMohs Unit, The Chaim Sheba Medical Center, Ramat Gan, Israel
bNational Hemophilia Centre, The Chaim Sheba Medical Center, Ramat Gan, Israel
cPlastic and Reconstructive Surgery, The Chaim Sheba Medical Center, Ramat Gan, Israel

Abstract
BACKGROUND: Between stages of Mohs micrographic surgery, the wound is dressed and the patient waits for the histopathological results.
OBJECTIVE: To investigate the efficacy of a hemostatic-anesthetic solution-impregnated gauze in decreasing bleeding between Mohs stages.
MATERIALS AND METHODS: Twenty patients were treated with a hemostatic-anesthetic solution composed of tranexamic acid, adrenaline, and lidocaine (TAL), and 20 others were treated with a saline solution for control. At the second Mohs stage, size measurements of the blood stain on a Telfa pad and the defect were recorded. The Rotation Thromboelastometry Method (ROTEM) was used to investigate a possible effect of lidocaine and adrenaline on the clot stability induced by tranexamic acid.
RESULTS: The ratio of blood stain size to Mohs defect size in the hemostatic anesthetic solution group was 1:1.47, whereas the ratio in the control saline group was 1:3.37 (P<.001). Results of the ROTEM test showed that lidocaine and adrenaline did not interfere with the effect of tranexamic acid on clot formation and stability.
CONCLUSION: The application of gauze impregnated with tranexamic acid, adrenaline, and lidocaine on a surgical wound may be effective in reducing bleeding between Mohs stages.

J Drugs Dermatol. 2016;15(7):851-855.

INTRODUCTION

Mohs micrographic surgery (MMS) is the preferred treatment for skin tumors on cosmetically and functionally important areas of the body. The surgical technique entails microscopic controlled tumor resection in one or more stages until margins are cleared histologically, followed by reconstruction of the surgical defect. The surgical defects, which are areas of raw surface, are temporarily dressed and the patient awaits the result of the histopathological workup in a designated resting area.
Bleeding during the surgery obscures the surgical field and mandates meticulous hemostasis. This contributes to tissue damage by electrocautery, lengthens the procedure, and intensifies patient’s discomfort. In addition, bleeding may result in delayed wound healing, a higher tendency for infection, and a less than optimal scar.
Antifibrinolytic drugs promote blood clotting by preventing blood clots from breaking down. Thus, the use of antifibrinolytic agents such as tranexamic acid (TXA) (Hexakapron®) successfully reduces bleeding during and after surgery. A recently published systematic review that included 20,451 patients concluded that TXA safely reduces mortality in trauma patients with bleeding, without increasing the risk of adverse reactions such as vascular occlusive events (myocardial infarction, stroke, deep vein thrombosis, and pulmonary embolism).1 This treatment is used topically in tooth extraction, orthopedic procedures, cardiac surgery, and other surgical procedures. TXA is also injected intravenously in various cases such as postpartum hemorrhage, heart surgery, and for children following tonsillectomy.2- 11 Dosing varies widely, according to the literature and in clinical practice.
Adrenaline is used routinely in combination with lidocaine or bupivacaine to constrict the blood vessels at the area of surgery, thus reducing bleeding and delaying fast absorption, as well as clearance of the local anesthetic agent. The optimal dose for both agents in surgery is unknown.
We investigated the efficacy of a topical hemostatic-anesthetic solution composed of tranexamic acid, adrenaline, and lidocaine (TAL) in reducing local bleeding between MMS stages while maintaining local anesthesia.

MATERIALS AND METHODS

Patients scheduled for MMS of the head and neck were considered for participation in the study. Inclusion criteria were aged 18 years or older and agreement to participate and to sign informed consent. Exclusion criteria were treatment with anticoagulants, systolic blood pressure greater than 200 mm Hg, and defects larger than 3 cm.
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