Systematic review of the use of tranexamic acid in pediatric post tonsillectomy hemorrhage

Introduction: Post tonsillectomy hemorrhage is a major complication that can lead to significant morbidity and mortality. Tranexamic acid (TXA) is an antifibrinolytic agent that has been used off-label to control primary and secondary bleeding events in a variety of pathologies. The role of TXA in control of post-operative tonsillectomy hemorrhage (PTH) has not been systematically reviewed in pediatric patients and the American Academy of Otolaryngology-Head and Neck Surgery guidelines do not report the best way to control PTH in pediatric patients. This systematic review aims to evaluate the effectiveness of TXA in managing bleeding and preventing return to the operating room for control of PTH. Secondarily, to identify the adverse effect associated with TXA use.

Methods: 3 databases (PubMed, Web of Science, and Embase) were reviewed to identify studies that examined the use of TXA in Pediatric PTH. Study selection, data extraction, and quality assessment were conducted independently by two reviewers.

Results: 1 Retrospective study, 1 Case Series, and 3 Case Reports for a total of 67 pediatric patients with PTH were identified. The most common route of TXA administration was via nebulized TXA in a saline solution at a dose of 250mg for patients < 25kg and 500mg for patients >25 kg. In pooled analysis, nebulized TXA stopped PTH in 70% of patients compared to only 27.3% in the control group (p = 0.0013). Further, nebulized TXA prevented return to the OR in 56.5% of patients when nebulized TXA was administered, compared to 27.3% in the control group (p = 0.0477). No adverse events were reported with any route of TXA administration.

Conclusions: The studies reviewed reported the effectiveness of TXA in managing post-operative bleeding and preventing return to the operating room in pediatric PTH patients. However, due to the limitations of all studies, including the retrospective nature and lack of standardized indications for TXA use, a large randomized clinical trial is needed before recommending TXA as part of a management plan for pediatric PTH.