Evaluating the Effectiveness of Transexamic Acid in Managing Acute Pediatric Post-tonsillectomy Hemorrhage

Introduction: Tranexamic acid (TXA) has been used in the acute management of post-tonsillectomy hemorrhage (PTH) to mitigate the need for operative intervention. We examined a large pediatric cohort in the context of PTH to compare the success of hemostasis, rate of re-operation, and post-treatment outcomes of those who did versus did not receive TXA.

Methods: A retrospective chart review of emergency department encounters for pediatric PTH was conducted within a single tertiary healthcare system. Patients were included if aged 0 to 18, had previously undergone tonsillectomy, and were reported either at home or within the hospital to have bled after surgery between days (0 to 24). Patient demographics, medical history, operative technique, TXA use, and PTH outcomes were analyzed.

Results: 130 patients (mean age 8.9 years; 50% female; 40.7% Hispanic) were analyzed, of which 91 received TXA (60.7%). Tonsillectomies were commonly for obstructive sleep apnea or chronic tonsillitis, extracapsular (78.2%), and involved coblator use (78.8%). Demographics, surgical indication, history, and ENT examination findings did not significantly differ between TXA and non-TXA groups (p>0.05). The majority of patients received nebulized TXA (65.9%). Dosing was not associated with age or BMI (p>0.05). For patients without active bleeding (n=113), hemostasis and the decision to pursue surgery did not differ significantly between TXA (n=67) and non-TXA (n=46) groups, including when stratified by TXA route (p>0.05). Among those with active bleeding (n=17), nearly all patients required surgery regardless of TXA use. Active bleeding on exam was a significant predictor of surgical intervention (p=0.003). Among the remaining variables, surgical technique was also significant: extracapsular tonsillectomies were 11 times more likely to return to the operating room compared to intracapsular, regardless of TXA use (p=0.03).

Conclusions: TXA may not significantly impact hemostasis or prevent surgical intervention. The only significant factors in determining operative intervention for PTH were surgical technique and active bleeding on exam.