Clinical Question: What is the dose of Nebulized Tranexamic Acid for Pediatric Post-tonsillectomy Hemorrhage? How do we administer it?
Background:
Tranexamic acid (TXA) is a fibrinolytic that displaces plasminogen from fibrin by forming a reversible complex resulting in fibrinolysis inhibition. This process promotes hemostasis and decreases bleeding.
Post-tonsillectomy hemorrhage is an uncommon complication of tonsillectomies but may be life-threatening. Primary hemorrhage is defined as bleeding within 24 hours of surgery and secondary hemorrhage is defined as any bleeding >24 hours after surgery, typically happening 5-10 days later.
Current treatment for hemorrhage includes observation as they may resolve spontaneously, IV fluid resuscitation, airway management, blood transfusions, or return to operating room, as warranted by patient status.
Limited evidence has currently shown that nebulized tranexamic acid may decrease the need for operative intervention in post-tonsillectomy hemorrhage in pediatric patients with minimal adverse effects.
Answer:
Current literature suggests nebulized TXA can be given at a dose of 250 mg for children ≤ 25 kg and a dose of 500 mg for children >25 kg, doses can be given every 20 minutes up to 3 total doses.
Some administered as masked nebulization at a flow rate of 8 liters over 4 minutes.
Nebulized TXA is generally well tolerated with possible side effects being nausea, vomiting, headache, dizziness.
Conclusion:
Nebulized tranexamic acid may be a suitable option for children presenting for post-tonsillectomy hemorrhage that are refractory to standard treatment with minimal adverse effects.
Further studies are warranted to determine the best dosing practices and line in therapy of nebulized tranexamic acid for post-tonsillectomy hemorrhage in pediatrics.
References:
Angela Cao, Joshua Silverman, Gerald Zahtz, Lee P. Smith. Use of nebulized tranexamic acid in adult and pediatric post-tonsillectomy hemorrhage, Otolaryngology Case Reports, Volume 23, 2022, 100409, ISSN 2468-5488. doi: 10.1016/j.xocr.2022.100409.
Arms, Kearney, Kuldanek, Lawson, Tibesar. Children's Minnesota ED Guideline 2024.
Monteilh C, Rabon L, Mayer-Hirshfeld I, McGreevy J. Nebulized Tranexamic Acid for Pediatric Post-tonsillectomy Hemorrhage: A Report of Two Cases. Clin Pract Cases Emerg Med. 2021;5(2):148-151. doi:10.5811/cpcem.2021.2.50799
Maksimoski M, McCauley M, Osoba M, Pirotte M, Liddy W. Treatment of Post-Tonsillectomy Hemorrhage With Nebulized Tranexamic Acid: Initial Investigation of a Novel Therapeutic Modality. Ann Otol Rhinol Laryngol. 2024;133(8):729-734. doi:10.1177/00034894241254697
Adrian Williamson, etc. The Use Of Tranexamic Acid for Control of Post-Tonsillectomy Hemorrhage in the Pediatric Population. Children's Mercy Kansas. Published 2024.
Authored by Mariam Isa, PharmD and Joanne Routsolias, PharmD