Tranexamic acid and post-tonsillectomy hemorrhage: propensity score and instrumental variable analyses

Hemorrhage risk after coblation tonsillectomy in Chinese pediatric: a multicenter, prospective, observational cohort study

OBJECTIVES

The study aimed to assess the incidence of post-coblation tonsillectomy hemorrhage (PCTH) and identify associated risk factors in a pediatric Chinese population.

METHODS

This prospective, multicenter cohort study, conducted over 17 months, included 8854 pediatric patients who underwent coblation tonsillectomy across 15 research centers in China. Patient data were collected through an Electronic Data Capture (EDC) system. The primary outcome was the incidence of PCTH within 21 days post-surgery. Secondary outcomes involved analyzing risk factors for PCTH using multivariable logistic regression.

RESULTS

The incidence of PCTH was 1.99%, with 176 patients experiencing hemorrhage. Significant risk factors included abnormal coagulation indicators (OR 10.56), longer surgery duration (OR 1.02), simultaneous adenoidectomy (OR 0.35), semi-liquid diet (OR 0.13), postoperative cough (OR 1.76), and the use of hemostatic agents (OR 1.58), intravenous antibiotics (OR 2.34), and painkillers (OR 2.33). Regional variations showed lower hemorrhage rates in East, Southwest, Central, and South China compared to North China.

CONCLUSIONS

The study found that the hemorrhage rate after coblation tonsillectomy is comparable to traditional tonsillectomy. Risk factors include coagulation status, surgical duration, and postoperative care. Regional differences in hemorrhage rates suggest the need for tailored approaches based on location. Coblation tonsillectomy is a safe and effective procedure for pediatric patients. TRIAL REGISTRATION NUMBER AND DATE OF REGISTRATION FOR PROSPECTIVELY REGISTERED TRIALS: This study was registered on Clinical trials.gov (NCT05206799), and approved by the Ethics Committee of Shanghai Children's Hospital, Shanghai Jiaotong University (2021R096-E01).

Treatment of post-tonsillectomy hemorrhage with nebulized tranexamic acid: A retrospective study

OBJECTIVE

To evaluate the association of treatment with nebulized tranexamic acid (TXA) with rates of operative intervention in post-tonsillectomy hemorrhage (PTH).

METHODS

Single tertiary-referral center and satellite hospitals, retrospective cohort of adult and pediatric patients who were diagnosed with PTH in 2015-2022 and treated with nebulized TXA and standard care, compared with an age- and gender-matched control cohort treated with standard care. Patients were typically treated in the emergency department with a single dose of 500mg/5 mL TXA delivered via nebulizer.

RESULTS

1110 total cases of PTH were observed, and 83 were treated with nebulized TXA. Compared to 249 age- and gender-matched PTH controls, TXA-treated patients had a rate of operating room (OR) intervention of 36.1% versus 60.2% (p < 0.0001) and a rate of repeat bleeding of 4.9% versus 14.2% (p < 0.02). The odds ratio for OR intervention with TXA treatment was 0.37 (95% CI 0.22, 0.63). There were no adverse effects identified with an average follow-up time of 586 days.

CONCLUSION

Treatment of PTH with nebulized TXA is associated with lower rates of operative intervention and lower rates of repeat bleeding events. Prospective studies are needed to further characterize efficacy and optimal treatment protocols.

LEVEL OF EVIDENCE: 3

Strategies to Address Current Challenges in Real-World Evidence Generation in Japan

The generation of real-world evidence (RWE), which describes patient characteristics or treatment patterns using real-world data (RWD), is rapidly growing more popular as a tool for decision-making in Japan. The aim of this review was to summarize challenges to RWE generation in Japan related to pharmacoepidemiology, and to propose strategies to address some of these challenges. We first focused on data-related issues, including the lack of transparency of RWD sources, linkage across different care settings, definitions of clinical outcomes, and the overall assessment framework of RWD when used for research purposes. Next the study reviewed methodology-related challenges. As lack of design transparency impairs study reproducibility, transparent reporting of study design is critical for stakeholders. For this review, we considered different sources of biases and time-varying confounding, along with potential study design and methodological solutions. Additionally, the implementation of robust assessment of definition uncertainty, misclassification, and unmeasured confounders would enhance RWE credibility in light of RWD source-related limitations, and is being strongly considered by task forces in Japan. Overall, the development of guidance for best practices on data source selection, design transparency, and analytical methods to address different sources of biases and robustness in the process of RWE generation will enhance credibility for stakeholders and local decision-makers.

Treatments and outcomes of adult parapharyngeal and retropharyngeal abscess: 1882 cases from a Japanese nationwide database

PURPOSE

Although parapharyngeal and retropharyngeal abscesses are potentially fatal deep neck abscesses, there is limited evidence for the treatment courses for adult patients with these abscesses. We aimed to describe the practice patterns and clinical outcomes of adult patients undergoing an emergency surgery for parapharyngeal or retropharyngeal abscesses using a nationwide database.

MATERIALS AND METHODS

We identified patients aged ≥18 years who underwent emergency surgery for parapharyngeal (para group, n = 1148) or retropharyngeal (retro group, n = 734) abscesses from July 2010 to March 2020, using a nationwide inpatient database. We performed between-group comparisons of the baseline characteristics, treatment course, and outcomes.

RESULTS

Compared with the retro group, the para group was more likely to be older (median, 66 vs. 60 years; P < 0.001) and have several comorbidities, such as diabetes (21 % vs 16 %; P = 0.010) and epiglottitis (33 % vs. 26 %; P = 0.002), except for peritonsillar abscess (14 % vs. 22 %; P < 0.001) and tonsillitis (2.1 % vs. 13 %; P < 0.001). Regarding intravenous drugs administered within 2 days of admission, approximately half of the patients received steroids, non-antipseudomonal penicillins, and lincomycins. The para group received more comprehensive treatments, such as tracheostomy, intensive care unit admissions, and swallowing rehabilitation, within total hospitalization than the retro group. Moreover, it demonstrated higher in-hospital mortality (2.7 % vs. 1.1 %; P = 0.017) and morbidity (16 % vs. 9.7 %; P < 0.001), and longer length of hospitalization than the retro group.

CONCLUSION

The current nationwide study provided an overview of the characteristics, treatments, and outcomes for patients who underwent an emergency surgery for parapharyngeal or retropharyngeal abscess.

Pediatric Anesthesia Management for Post-Tonsillectomy Bleed: Current Status and Future Directions

After medical stabilization, several techniques are considered for anesthesia in the surgical intervention of post-tonsillectomy bleeding in children. Hypoxia during induction of general anesthesia occurs more frequently than aspiration for this population. While classical (apneic) rapid sequence induction and intubation with cricoid pressure still has a role, controlled rapid sequence induction and intubation that incorporates mask ventilation at low pressure (<12 cm H₂O) before direct laryngoscopy under a deep plane of anesthesia is a viable alternative for cases of slow venous bleeding. Supplemental oxygen delivery during laryngoscopy to permit apneic oxygenation is a future trend in management. While the routine administration of tranexamic acid during tonsillectomy has not been shown to be of benefit, it may have a role in post-tonsillectomy hemorrhage with further study.

Effectiveness and Adverse Effects of Tranexamic Acid in Bleeding during Adenotonsillectomy: A Randomized, Controlled, Double-blind Clinical Trial

Introduction  Intra and postoperative bleeding are the most frequent and feared complications in adenotonsillectomy (AT). Tranexamic acid (TXA), which is known for its antifibrinolytic effects, has a proven benefit in reducing bleeding in hemorrhagic trauma and cardiac surgery; however, the effectiveness and timing of its application in AT have not yet been established.

Objectives  We aimed to evaluate the efficacy of TXA in controlling bleeding during and after AT and assess its possible adverse effects in children.

Methods  The present randomized, controlled, double-blind clinical trial included 63 children aged 2 to 12 years. They were randomly assigned to receive either intravenous TXA (10 mg/kg) or placebo 10 minutes before surgery. The volume of intraoperative bleeding, presence of postoperative bleeding, and adverse effects during and 8 hours after the surgery were assessed.

Results  No difference in bleeding volume was noted between the 2 groups (mean, 122.7 ml in the TXA group versus 115.5 ml in the placebo group, p  = 0.36). No intraoperative or postoperative adverse effects were noted because of TXA use. Furthermore, no primary or secondary postoperative bleeding was observed in any of the participants.

Conclusion  In our pediatric sample, TXA (10 mg/kg) administration before AT was safely used, without any adverse effects. It did not reduce the bleeding volume in children during this type of surgery. Future studies should assess the use of higher doses of TXA and its administration at other time points before or during surgery.

Tranexamic acid in otorhinolaryngology - A contemporary review

Tranexamic acid (TXA) is an anti-fibrinolytic agent which has been proven beneficial in multiple surgical specialties where significant bleeding can occur. Whilst it has been widely available for over 40 years its use within Otorhinolaryngology is still limited. Operations in Otorhinolaryngology are particularly varied with some such as tonsillectomy having the potential for significant life threatening bleeding. Other operations are performed within small confined surgical fields and even small amounts of bleeding can significantly detriment surgical field and increase technical difficulty and operative time. This review evaluated the current literature on the benefits of tranexamic acid within the field of Otorhinolaryngology and Head and Neck Surgery. Overall TXA was demonstrated to be a safe drug with no major adverse effects including thromboembolic events reported in any study. It has been shown to be of particular benefit in rhinology by improving surgical field, reducing operative time and reducing postoperative swelling and ecchymosis. The benefit in tonsillectomy is less clear and further studies are required to evaluate its potential use in the reduction of post tonsillectomy haemorrhage rates.

The efficacy of Tranexamic Acid Administration in Patients Undergoing Tonsillectomy: An Updated Meta-Analysis

OBJECTIVE

There is controversy regarding the efficacy and safety of tranexamic acid (TXA) in reducing tonsillectomy-related hemorrhage. We conducted a systematic review and meta-analysis to evaluate the prophylactic role of TXA in tonsillectomy.

METHODS

We searched 6 databases to identify studies that directly compare the effect of TXA versus controls in tonsillectomy patients. Standardized mean difference was applied to summate the findings across the studies. Dichotomous data were expressed as relative risk.

RESULTS

Ten studies representing a total of 111 898 patients were included. The pooled results showed a significant reduction of intraoperative blood loss by 39.02 ml (SMD = -1.05, 95% CI: -1.91 to -0.20, P = .016) and the rate of post-tonsillectomy hemorrhage (RR = 0.42, 95% CI: 0.28 to 0.65, P < .0001), with no significant difference in reduction of further intervention risk (RR = 0.78, 95% CI: 0.45 to 1.35, P = .373).

CONCLUSIONS

Overall, this study indicates that TXA may reduce blood loss and frequency of post-operative hemorrhage associated with tonsillectomy. Further large, high-quality clinical trials are still needed to explore TXA's effect on post-tonsillectomy hemorrhage and the safety of its use.

Nebulized Tranexamic Acid for Pediatric Post-tonsillectomy Hemorrhage: A Report of Two Cases

INTRODUCTION

Tranexamic acid (TXA) use in pediatrics to control hemorrhage has gained interest in recent years, but there is limited literature on nebulized TXA especially regarding dosing and adverse effects. Tranexamic acid has anti-fibrinolytic properties via competitive inhibition of plasminogen activation making it a logical approach to promote hemostasis in cases of post-tonsillectomy hemorrhage.

CASE REPORT

We describe two cases of post-tonsillectomy hemorrhage managed with nebulized TXA. In both cases, bleeding was stopped after TXA administration.

CONCLUSION

To our knowledge, this is the first case report to describe the use of nebulized TXA without an adjunct pharmacotherapy. Our two cases add additional reportable data on the safety of nebulized TXA and possible effectiveness on post-tonsillectomy hemorrhage.

Nebulized Tranexamic Acid in Secondary Post-Tonsillectomy Hemorrhage: Case Series and Review of the Literature

INTRODUCTION

Post-tonsillectomy hemorrhage is a serious postoperative complication, and its acute management can present a challenge for the emergency provider. Although various strategies have been proposed, guidance on the best approach for management of this condition in the emergency department (ED) setting remains limited. Anecdotal reports of the use of nebulized tranexamic acid (TXA) for management of tonsillar bleeding have emerged over the past two years. Two recently published case reports describe the successful use of nebulized TXA for stabilization of post-tonsillectomy hemorrhage in an adult and a pediatric patient.

CASE SERIES

Eight patients who presented to our ED with secondary post-tonsillectomy hemorrhage received nebulized TXA for hemostatic management. The most common TXA dose used was 500 milligrams, and all but one patient received a single dose of the medication in the ED. Hemostatic benefit was observed in six patients, with complete bleeding cessation observed in five cases. Interventions prior to nebulized TXA administration were attempted in three of the six patients and included ice water gargle, direct pressure with TXA-soaked gauze, and nebulized racemic epinephrine. All but one of the patients were taken to the operating room for definitive management after initial stabilization in the ED.

CONCLUSION

Nebulized TXA may offer a hemostatic benefit and aid in stabilization of tonsillectomy hemorrhage in the acute care setting, prior to definitive surgical intervention. Consideration of general principles of nebulization and aerosol particle size may be an important factor for drug delivery to the target tissue site.

Post-tonsillectomy hemorrhage control with nebulized tranexamic acid: A retrospective cohort study

OBJECTIVE

Evaluate nebulized tranexamic acid (TXA) as a treatment to reduce the need for an operation to control a post-tonsillectomy hemorrhage (PTH).

METHODS

Based on a successful case report of a child treated with nebulized TXA for PTH in 2018, our institution began to treat PTH patients with three doses of nebulized TXA. To evaluate the outcomes of this non-invasive management, we conducted a three-year retrospective cohort study of children presenting with PTH from 2016 to 2019. Demographics, insurance, and laboratory information were collected from all pediatric tonsillectomies with and without adenoidectomy performed during the study period. Tonsillar fossae observations of bleeding and clot were documented before and after receiving TXA.

RESULTS

The incidence of pediatric PTH at our institution during the study period was 5.4%. Fourteen out of 58 PTH patients received nebulized TXA. Receiving nebulized TXA had no adverse events and over 60% showed resolution of bleeding on exam. Receiving nebulized TXA compared to routine care decreased the need for an operation to restore hemostasis by 44%, p < 0.005. There was no significant difference in age, gender, body mass index, hemoglobin, platelet count, trainee presence, or Medicaid status between the children that received TXA and those that did not.

CONCLUSION

Treatment of PTH with nebulized TXA may be a safe first-line therapy to decrease the need for operative control of bleeding. This data suggests that a large clinical trial is needed to determine the efficacy of nebulized TXA to mitigate this common and potentially fatal post-operative complication.

LEVEL OF EVIDENCE

4.

Association Between Tonsillectomy and Outcomes in Patients With Immunoglobulin A Nephropathy

IMPORTANCE

Immunoglobulin A nephropathy is a major cause of end-stage renal disease worldwide; previous methods of medical management, including use of renin-angiotensin system inhibitors and corticosteroids, remain unproven in clinical trials.

OBJECTIVE

To investigate the possible association between tonsillectomy and outcomes in patients with IgA nephropathy.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included 1065 patients with IgA nephropathy enrolled between 2002 and 2004 and divided into 2 groups, those who underwent tonsillectomy and those who did not. Initial treatments (renin-angiotensin system inhibitors or corticosteroids) within 1 year after renal biopsy were also evaluated. A 1:1 propensity score matching was performed to account for between-group differences and 153 matched pairs were obtained. Follow-up concluded January 31, 2014. Analysis was conducted between September 11, 2017, and July 31, 2018.

EXPOSURE

Tonsillectomy.

MAIN OUTCOMES AND MEASURES

The primary outcome was the first occurrence of a 1.5-fold increase in serum creatinine level from baseline or dialysis initiation. Secondary outcomes included additional therapy with renin-angiotensin system inhibitors or corticosteroids initiated 1 year after renal biopsy and adverse events.

RESULTS

In 1065 patients (49.8% women; median [interquartile range] age, 35 [25-52] years), the mean (SD) estimated glomerular filtration rate was 76.6 (28.9) mL/min/1.73 m2 and the median (interquartile range) proteinuria was 0.68 (0.29-1.30) g per day. In all, 252 patients (23.7%) underwent tonsillectomy within 1 year after renal biopsy and 813 patients (76.3%) did not undergo tonsillectomy. The primary outcome was reached by 129 patients (12.1%) during a median (interquartile range) follow-up of 5.8 (1.9-8.5) years. In matching analysis, tonsillectomy was associated with primary outcome reduction (hazard ratio, 0.34; 95% CI, 0.13-0.77; P = .009). In subgroup analyses, benefit associated with tonsillectomy was not modified by baseline characteristic differences. Those undergoing tonsillectomy required fewer additional therapies 1 year following renal biopsy (adjusted hazard ratio, 0.37; 95% CI, 0.20-0.63; P < .001) without increased risks for adverse events, except transient tonsillectomy-related complications.

CONCLUSIONS AND RELEVANCE

This study found that tonsillectomy was associated with a lower risk of renal outcomes in patients with IgA nephropathy. The potential role of tonsillectomy should be considered for preventing end-stage renal disease in patients with IgA nephropathy.