Abstract
Three per cent hydrogen peroxide (H2O2) is widely used to irrigate acute and chronic wounds in the surgical setting and clinical experience tells us that it is more effective at removing dried-on blood than normal saline alone. We hypothesise that this is due to the effect of H2O2 on fibrin clot architecture via fibrinolysis. We investigate the mechanisms and discuss the clinical implications using an in vitro model. Coagulation assays with normal saline (NaCl), 1% and 3% concentrations of H2O2 were performed to determine the effect on fibrin clot formation. These effects were confirmed by spectrophotometry. The effects of 1%, 3% and 10% H2O2 on the macroscopic and microscopic features of fibrin clots were assessed at set time intervals and compared to a NaCl control. Quantitative analysis of fibrin networks was undertaken to determine the fibre length, diameter, branch point density and pore size. Fibrin clots immersed in 1%, 3% and 10% H2O2 demonstrated volume losses of 0.09-0.25mm3/min, whereas those immersed in the normal saline gained in volume by 0.02±0.13 mm3/min. Quantitative analysis showed that H2O2 affects the structure of the fibrin clot in a concentration-dependent manner, with the increase in fibre length, diameter and consequently pore sizes. Our results support our hypothesis that the efficacy of H2O2 in cleaning blood from wounds is enhanced by its effects on fibrin clot architecture in a concentration- and time-dependent manner. The observed changes in fibre size and branch point density suggest that H2O2 is acting on the quaternary structure of the fibrin clot, most likely via its effect on cross-linking of the fibrin monomers and may therefore be of benefit for the removal of other fibrin-dependent structures such as wound slough.
Highlights
Hydrogen peroxide (H2O2), at 3% final concentration in a 50:50 mixture with normal saline (NaCl), is commonly used for irrigating traumatic wounds in a range of plastic and reconstructive surgical procedures (Figure 1)
We investigate the effects of different concentrations of H2O2 on the macroscopic and microscopic features of fibrin clots in comparison to an NaCl control and perform quantitative analysis of the fibrin networks to determine fibre length, diameter, branch point density and pore size, which are recognised factors in the susceptibility to fibrinolysis.[22]
Fibrin clots immersed in 1%, 3% and 10% H2O2 demonstrated a 0.09mm3/min (±0.14SD), 0.25mm3/min (±0.13SD) and 0.14mm3/min (±0.04SD) rate of volume loss respectively, whereas those immersed in the NaCl increased in volume by 0.02mm3/min (±0.13SD)
Summary
Hydrogen peroxide (H2O2), at 3% final concentration in a 50:50 mixture with normal saline (NaCl), is commonly used for irrigating traumatic wounds in a range of plastic and reconstructive surgical procedures (e.g., hand surgery, breast reduction, abdominoplasty, lymph node dissections, acute and chronic wound debridement) (Figure 1). We have noted that it is very effective for cleaning off clotted and dried-on blood from skin surfaces at the end of a procedure, compared with NaCl irrigation alone. This is often attributed to the effervescence, which can aid in mechanical wound debridement. It can be helpful with haemostasis by helping to show bleeding points more clearly. There are reports in the literature of the use of H2O2 to clear blood clots to visualise the base of ulcers during endoscopy.[1,2,3] as with much of surgical practice, the mechanism of action underpinning these clinical observations has never been investigated
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