Topical application of tranexamic acid for haemostasis in nail surgery

PROBLEM

As the nail apparatus is highly vascularised, bleeding after tourniquet removal is a common challenge in nail surgery. A variety of haemostatic products and techniques have been described such as direct pressure with gauze, aluminium chloride, kaolin-impregnated gauze, microporous polysaccharide haemospheres and brimonidine gel.^[1] However, a haemostatic agent that is widely accessible, affordable, safe and effective is desirable.

SOLUTION

Following the removal of the tourniquet, a simple method for managing bleeding after nail surgery is presented. Following the application of a Tranexamic acid (TXA)-impregnated gauze (10 mL vial of 100 mg/mL), the nail unit is pressure-wrapped with a multi-layered gauze for a duration of 10 min [Figures 1 and 2]. A standard dressing is applied once haemostasis has been achieved.

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Figure 1: (a-c) Bleeding after nail surgery and tourniquet removal.

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Figure 2: (a-c) Haemostasis is achieved in 10 min by covering the nail unit with a multilayer pressure dressing, made of an innermost gauze impregnated with tranexamic acid (10 mL vial of 100 mg/mL).

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Topical tranexamic acid (TXA) is a promising option for securing haemostasis. It has the potential to inhibit local fibrinolysis at the site of bleeding through topical application which avoids systemic side effects, such as thromboembolic events. The intravenous use of TXA in the management of bleeding is well established. A plasma concentration of at least 10 µg/mL of TXA is required to significantly inhibit fibrinolysis.^[2] Therefore, even a 1 mg/mL solution exposes the wound surface to a concentration 100-fold stronger than what is considered the lowest inhibitory concentration in plasma. Topical application of TXA provides a high drug concentration at the site of the wound and a low systemic concentration. However, the lowest effective concentration of local use of TXA remains unknown. It is also unclear whether the topical effect is determined by drug concentration, total drug dose, contact time or a combination of these factors.^[3] Reliable evidence has shown Article in Press that the topical application of TXA can reduce bleeding in a variety of surgical procedures, including dermato-surgical procedures, such as deroofing in patients with hidradenitis suppurativa.^[4,5] In orthopaedic surgery, a 20–25% reduction in post-operative blood loss has been seen following a 5-min application of 1.5–3 g of topical TXA directly into the surgical wound before closure at the end of total knee arthroplasty.^[6]

The rationale for the use of topical TXA in nail surgery is based on the evidence of its effectiveness in the management of epistaxis. Indeed, the anterior region of the nasal septum, similar to the nail unit, is characterised by a rich vascular network known as Kiesselbach’s plexus and accounts for approximately 90% of anterior nosebleeds.^[7] In a randomised controlled trial involving 216 patients, topical TXA (500 mg in 5 mL), applied using cotton pledgets, was compared with conventional anterior nasal packing. Haemostasis within 10 min was achieved in 70% of patients in the TXA group, compared with 30% in the nasal packing group.^[8] Another randomised controlled study evaluated the efficacy of gauze soaked with TXA at doses of 500 mg and 1000 mg versus gauze soaked with saline in 152 patients with anterior epistaxis. The gauze soaked with TXA or saline was applied for 10 min and then removed. Bleeding cessation at 10 min was observed in 82% of patients receiving 1000 mg TXA, 72% of those receiving 500 mg TXA and 55% of those in the saline group.^[9]

In our experience, the use of topical TXA in nail surgery clearly reduces post-operative bleeding, is easy to perform and is cost-effective. We believe that it could become a routine part of nail surgery practice.