From the Guidelines
Management of post-operative hemorrhage following oral surgery in the emergency department requires prompt assessment and intervention, with the administration of tranexamic acid being a crucial step, as recommended by the most recent guidelines 1. The first step in managing post-operative hemorrhage is to apply direct pressure to the bleeding site using gauze pads for 15-20 minutes.
- For persistent bleeding, local measures include applying hemostatic agents such as oxidized cellulose (Surgicel), gelatin sponge (Gelfoam), or tranexamic acid-soaked gauze, as suggested by the American College of Chest Physicians clinical practice guideline 1.
- Inject local anesthetic with epinephrine (1:100,000) around the surgical site to promote vasoconstriction.
- If suturing is needed, use 3-0 or 4-0 resorbable sutures to close the wound. Systemic approaches include administering tranexamic acid (1g IV over 10 minutes, followed by 1g over 8 hours) to inhibit fibrinolysis, which has been shown to be effective in reducing bleeding complications 1.
- For patients on anticoagulants, consider reversal agents if appropriate - protamine for heparin, vitamin K (10mg IV) and prothrombin complex concentrate for warfarin, or specific reversal agents for DOACs, as recommended by the French Working Group on Perioperative Haemostasis (GIHP) 1.
- Address underlying coagulopathies with appropriate blood products. Patients should be advised to avoid hot foods/drinks, alcohol, smoking, strenuous activity, and rinsing/spitting for 24 hours.
- They should maintain a soft diet, apply ice packs externally, and elevate their head when lying down. These interventions work by promoting clot formation, reducing blood flow to the area, and preventing clot disruption, which are essential for achieving hemostasis in the highly vascular oral cavity.
From the Research
Management of Post-Operative Hemorrhage
- The management of post-operative hemorrhage following oral surgery in the emergency department (ED) involves various approaches, including the use of tranexamic acid (TXA) [ 2 ], which has been shown to be effective in preventing postoperative bleeding in oral surgery patients on oral anticoagulant medication [ 3 ].
- A "tie-over" hemostatic approach, involving the intraoral use of Xeroform® gauze and oral rinsing with a liquid mixture of hemostatic agents, has been described as an alternative option for recurrent episodes of postoperative intraoral hemorrhage [ 4 ].
- The quality of bleeding has a strong influence on oral surgeons' decisions to apply further surgical means, with sutures and native collagen fleeces being the favored methods to stop moderate and severe bleeding [ 2 ].
- Hemostatic approaches should begin with the least invasive procedure, and topical application of TXA can be a useful supportive tool to stop mild bleeding events [ 2 ].
- The management of post-operative hemorrhage also involves rapid assessment of patients using the ABCDE (airway, breathing, circulation, disability, exposure) approach and outlines the management interventions used to halt the bleeding and restore intravascular volume [ 5 ].
Hemostatic Agents and Techniques
- Tranexamic acid (TXA) is widely used in the prevention of postsurgical oral bleeding and can be applied topically or used as a mouthwash [ 2, 3 ].
- The "tie-over" approach involves the intraoral use of Xeroform® gauze and oral rinsing with a liquid mixture of hemostatic agents [ 4 ].
- Sutures and native collagen fleeces are favored methods to stop moderate and severe bleeding [ 2 ].
Patient Evaluation and Management
- Proper preoperative patient evaluation is essential in preventing perioperative hemorrhage [ 6 ].
- Knowledge of the various bleeding disorders and characterization of the correct methods of management are crucial in ensuring adequate hemostasis [ 6 ].
- Considerations of treatment for patients with bleeding disorders should be discussed regarding the best management options for adequate hemostasis [ 6 ].