CHAPTER 40 Topical Hemostatic Agents
In medical training there is a cynical phrase quoted to novice medical students on a surgery rotation: “All bleeding stops eventually.” Although this is true, the lesson to learn is that usually the best amount of bleeding is the least amount of bleeding. Effective, rapid hemostasis is the goal of physicians performing cutaneous surgery. This chapter covers the most useful methods of achieving topical hemostasis (Table 40-1).
The various methods range from physical techniques, such as simple pressure with an index finger and gauze pad, to chemical, electrical, and even laser techniques. The method used depends on the specifics of the surgery being performed, the experience of the office surgeon, and the availability of the agents or equipment.
Each method has its own benefits and drawbacks, and the astute clinician will match the method that best fits the needs of the particular patient. The older chemical agents (the so-called vasoconstrictive, vaso-occlusive, or denaturing agents) produce an eschar and actually cause some tissue damage. Newer, so-called physiologic agents facilitate the clotting mechanism but can be exorbitantly expensive (e.g., $30 or more for a single pack of Gelfoam). It is therefore important for the physician or health care provider to be familiar and accomplished with multiple methods to ensure the most positive outcome.
Contraindications
Relative
note: Cautery technically refers to a hot wire (most often, a battery-powered unit). This method is generally safe for patients with a pacemaker. On the other hand, electrocautery (e.g., Bovie, Hyfrecator, Ellman Surgitron) produces a low-amperage current (causing electrofulguration, electrodesiccation, or electrocoagulation) that may pose a risk to pacemaker users. Most new pacemakers are shielded. Use of these electrosurgical units should not be a problem, but other safe alternatives exist. See Chapter 30, Radiofrequency Surgery (Modern Electrosurgery), for details of electrosurgical principles.
Equipment and Supplies
Hemostatic Agents
See Figure 40-1 for a depiction of several common hemostatic agents.

Figure 40-1 Common hemostatic agents.
From top to bottom: silver nitrate stick, aluminum hydroxide with applicator, and absorbable Gelfoam.
Preprocedure Patient Education
Discuss the procedure, including the rare but possible risks of further bleeding, infection, nerve damage, and scarring. Determine if the patient is known to be allergic to any of the agents. If using silver nitrate or Monsel’s solution, inform the patient of the possibility of pigmentary change (“tattooing”), which is usually temporary but still requires discretion when being used in exposed areas such as the face.
Procedure
Please see the corresponding chapter for the initial procedure being performed. Topical hemostatic agents are not a substitute for meticulous surgical technique, and many cannot be used inside a wound to be sutured. When topical hemostatic agents are required, ensure the patient is positioned on the examination or procedure table to provide adequate access to the wound.
Vaso-occlusive Denaturing Agents
These agents are applied topically and are not used if a wound is to be closed surgically. To maximize the coagulation effect, these agents should be applied as close to the source of bleeding as possible, and the wound should be sponged free of excess blood just before their application.
Ferric Subsulfate Solution (20%; Monsel’s Solution)
First described by Leon Monsel in 1856, this liquid is perhaps the most commonly used topical hemostatic agent (Fig. 40-2). The solution is dark brown, almost black. If the bottle is left open, evaporation results in a pasty solution that, because it is more concentrated, is more effective. Do not let it become too thick, however. If it crystallizes, it can be reconstituted with water. Keep the container covered once the desired consistency is obtained. Hemostasis is effective with only rare staining, which can last up to 3 months. Application of Monsel’s solution to a relatively dry wound bed (achieved by stretching and blotting the skin) controls oozing effectively.


Figure 40-2 Topical astringent. A, Monsel’s solution in open bottle, which allows it to thicken. B, Inner bottle. C, Cotton-tipped applicator used to apply thickened solution. Do not reinsert into bottle/container. D, Applying Monsel’s with cotton-tipped applicator.
Monsel’s solution is applied with a cotton-tipped swab after drying and stretching the skin with the other hand. The swab is applied with light pressure. The low pH and the subsulfate group denature protein and occlude blood vessels. The practitioner cannot use too much. Once in contact with blood, the black, coagulated mixture can be wiped away. Monsel’s works particularly well after cervical biopsies, loop electrosurgical excision procedures, and anorectal biopsies. It is also commonly used after shave excision and punch biopsies except in very fair-skinned individuals.
Monsel’s solution is inexpensive, easily applied, easily stored, and readily available. However, there is a rare risk of “tattooing,” so some physicians do not recommend it for the face, especially on light skin (Fig. 40-3). In clinical practice there is often a compromise in which Monsel’s, given its superior hemostatic properties, is still used for the face and on patients with a very light complexion. (Aluminum chloride is nonstaining and should be tried first in these cases.) The tattooing can last several months. Monsel’s may also cause temporary artifactual changes in skin and cervical biopsies, confounding the histologic evaluation of reexcisions for a few weeks thereafter. It also stains clothing. Stains on laboratory coats can be removed with dilute hydrochloric acid, such as that often found in toilet bowl cleaners, or by using Iron-Out. Monsel’s stains need to be treated before washing in hot water or drying with heat because each seems to set the stain permanently.

Figure 40-3 Monsel’s staining. A, Three weeks after initial use. B, Spontaneous resolution after 6 to 8 weeks.

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