Topical use of prohemostatic agents may be an important adjunctive intervention to achieve optimal surgical hemostasis. Tranexamic acid is an antifibrinolytic drug that has proven to be effective in reducing perioperative blood loss in a myriad of clinical circumstances. In most trials tranexamic acid was administered systemically, but topical use of the drug may also be considered. Dell’amore et al. studied 89 patients scheduled for pulmonary resection in a randomized double blind trial. Patients were randomized to receive 5 grams of tranexamic acid in 100 mL saline in the pleural cavity whereas controls were treated with saline alone. Perioperative blood loss was significantly lower at 12 hours after the operation in the topical tranexamic acid group (298 ± 73 vs. 458 ± 89 mL; P < 0.02). At 24 hours the difference was only 44 mL in favor of topical tranexamic acid and statistical significance was lost. In topical tranexamic acid-treated patients the amount of red cell transfusion was lower than in the control group (1.5 U of red blood cell unit versus 1.9 U; P < 0.04). There was no statistical difference between the two groups in terms of time of chest tube removal and hospital stay or any other clinically relevant outcome. This study supports the concept that topical application of tranexamic acid may cause a reduction of perioperative blood losses. Since the absolute reduction of blood loss and the effect on blood transfusion rates is quite modest (it is unclear whether tranexamic acid prevented transfusion at all), it is not likely that these results will change practice. However, as topical administration of tranexamic acid seems simple, relatively safe and cheap, this mode of intervention requires further exploration. – Marcel Levi