Assessment of the effect of tranexamic acid on perioperative bleeding in pediatric patients undergoing tonsillectomy

The Utility and Safety of Prophylactic Tranexamic Acid in Tonsillectomy: A Systematic Review and Meta-analysis

OBJECTIVE

We conducted a systematic review of randomized controlled trials (RCTs) to evaluate the efficacy of tranexamic acid (TXA) in reducing posttonsillectomy hemorrhage (PTH).

DATA SOURCES

We searched MEDLINE, EMBASE, and CENTRAL for RCT comparing prophylactic TXA to control in patients undergoing tonsillectomy.

REVIEW METHODS

Per Preferred Reporting Items for Systematic Review and Meta-analysis guidelines, the databases were searched from date of inception through October 2023. RCTs of patients undergoing tonsillectomy or adenotonsillectomy and receiving prophylactic TXA versus control were included. Two reviewers screened citations, extracted data, assessed the risk of bias, and classification of Grading of Recommendations, Assessment, Development, and Evaluation independently. Standardized mean difference with 95% confidence interval (CI) was applied for continuous variables. Dichotomous data were expressed as relative risk with 95% CI.

RESULTS

A total of 10 RCT were included in our quantitative analysis. Eight studies reported on PTH rate. Prophylactic TXA showed non-significant decrease in PTH (relative risk or risk ratio [RR]: 0.62 [0.35, 1.10]). Sensitivity analysis showed significant decrease in PTH after exclusion of High-risk bias studies (RR: 0.48 [0.30, 0.77]). Intraoperative blood loss volume was significantly lower in the TXA group (35.59 mL [-48.19, -22.99]).

CONCLUSION

Overall, this study showed a tendency toward lesser PTH rate with prophylactic TXA. However, this tendency only reaches statistical significance when studies with high risk of bias are excluded. Well-designed trials are still needed to support our observations.

The use of tranexamic acid in paediatric adenotonsillectomy - A systematic review and meta-analysis

BACKGROUND

Tonsillectomy and adenoidectomy (AT) are two of the most commonly performed ENT procedures in children, with over 500,000 cases performed annually in the United States. Whilst generally considered a safe and well-tolerated operation, it is not without its risks and complications including pain, nausea, anorexia and most importantly bleeding and post-tonsillectomy haemorrhage (PTH). Whilst tranexamic acid (TXA) has a proven benefit in reducing bleeding and transfusion requirements in patients undergoing trauma, spinal and cardiac surgery; the effectiveness, timing and safety of its application in paediatric tonsillectomy has not yet been established.

AIMS, OBJECTIVES & SIGNIFICANCE

To date, there has been no published systematic review of the literature specifically looking at paediatric patients undergoing AT, despite a massive surge in popularity of the use of TXA perioperatively. The aim of this study is therefore to systematically review the current literature and collate evidence regarding the efficacy and safety of using TXA to reduce bleeding in children undergoing tonsillectomy and/or adenoidectomy.

METHODS

A structured search of bibliographic databases (MEDLINE, EMBASE, PubMed, CINAHL, Cochrane CENTRAL) was undertaken to retrieve randomised controlled trials, non-randomised case-control studies and ongoing clinical trials that describe the use of TXA in paediatric patients undergoing AT. The following search terms (and their variations) were used as both medical subject headings (MeSH terms) and text words: tranexamic acid, bleeding, tonsillectomy, adenoidectomy, paediatrics. To ensure that all relevant data was captured, the search did not contain any restrictions on language or publication time. Data extraction and risk of bias assessment was performed independently and in duplicate.

RESULTS

This review identified and included a total of eight studies (n = 1315). Five studies reported on the intravenous use of TXA (n = 531) whilst three studies reported on the topical use of TXA (n = 784), and these were analysed separately. The intravenous use of TXA did not reduce intraoperative blood loss significantly (95 % CI: -0.1 to 0.33 p = 0.28) and there was not enough information to analyse the effect on PTH in these studies. Topical TXA led to a significant reduction in both intraoperative blood loss (95 % CI 0.11 to 5.31, p = 0.04) and post operative bleeding rates (RR 0.04, 95 % CI 0.01 to 0.08, P = 0.02).

CONCLUSION

The results of this systematic review and meta-analysis suggest that TXA administered via the intravenous route does not reduce perioperative bleeding associated with AT in paediatric patients. However, when topical TXA is used intraoperatively at the surgical site in paediatric patients undergoing adenoidectomy alone, there was a significant reduction in both intraoperative blood loss and post operative bleeding. TXA appears to be a safe and well-tolerated drug in the paediatric population with no adverse effects reported in this review. Nevertheless, further large and well-designed randomised controlled trials are needed to investigate the risks and benefits of TXA in paediatric AT with a particular focus on its use topically and in association with newly developed surgical equipment.

The Effect of Tranexamic Acid Local Injection on Bleeding during and after Tonsillectomy: A Double-Blind Randomized Placebo-Controlled Trial

Background

Tonsillectomy-related bleeding is one of the most prevalent and potentially fatal complications of this common surgical procedure. We aimed to assess the effect of tranexamic acid (TXA) local injection on bleeding during and after tonsillectomy.

Methods

This double-blind, randomized placebo-controlled trial included 20 candidates for tonsillectomy referred to Al-Zahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran, in 2022. The subjects were randomized into two groups. Ten patients received TXA on their left side and the other ten on their right side 10 min before surgery. Placebo was administered to the contralateral side. The primary outcome was the volume of blood loss during tonsillectomy and up to 24 hours post-tonsillectomy. The secondary outcomes were surgeon satisfaction (rated 0-10), hemodynamic complications (patients' heart rate (HR) and mean arterial pressure (MAP) were recorded every 10 min), and rebleeding. The duration of surgery was also noted.

Results

The mean age of the patients was 21.35 ± 3.16 years, of whom 8 (30%) were male and 12 (60%) were female. there was no significant difference between groups in terms of HR and MAP at any time point. The median of surgery duration did not differ significantly between the two groups; however, the surgeon satisfaction with the procedure was significantly higher with TXA compared to placebo. None of the patients developed hemodynamic complications, and rebleeding did not occur in any of the subjects.

Conclusions

TXA local injection was not superior to placebo in terms of bleeding control during and after tonsillectomy, hemodynamic complications, rebleeding, and surgery duration.

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.

Efficacy and Safety of Antifibrinolytic Drugs in Pediatric Surgery: A Systematic Review

Antifibrinolytic drugs are used to reduce blood loss and subsequent transfusions during surgery and following trauma, but the optimal dosing regimen in the pediatric population is still unresolved. The aim of this systematic review was to evaluate efficacy and safety of antifibrinolytic drugs in pediatric surgery and trauma to determine the optimal dosing regimen. A literature search was performed in PubMed, Embase, Cochrane, and Web of Science on May 3, 2020. We included randomized controlled studies investigating the effect of tranexamic acid (TXA), aprotinin, and epsilon-aminocaproic acid, in terms of reducing blood loss, blood transfusions, reoperations, and rebleeds in pediatric patients aged 0 to 18 years undergoing cardiac surgery, noncardiac surgery, or trauma. Fifty randomized controlled trials (RCTs) were included; 28 RCTs investigated cardiac surgery and 22 investigated noncardiac surgery. No RCTs regarding trauma met the inclusion criteria. All antifibrinolytic drugs reduced postoperative blood loss and transfusions when used in pediatric surgery. The dosing regimen varied between studies, but similar effect sizes were found in terms of reduced blood loss regardless of the cumulative dose used. Few studies found adverse events, and no difference in incidence or type of adverse events was seen between the antifibrinolytic and the placebo group. In conclusion, use of antifibrinolytics is efficient and safe in children undergoing surgery. We propose TXA as the drug of choice based on its level of evidence and safety profile; we recommend a dosing regimen composed of a loading dose of 10 to 15 mg/kg prior to surgery followed by 1 to 5 mg/kg/h as continuous infusion throughout surgery.

Exclusion criteria and adverse events in perioperative trials of tranexamic acid: a systematic review and meta-analysis

BACKGROUND

Tranexamic acid (TXA) is an inexpensive therapy effective at minimizing perioperative blood loss and transfusion. However, it remains underutilized due to safety concerns. To date, no evidence-based guidelines exist identifying which patients should not receive TXA therapy. This study determined patient groups for whom safety information regarding TXA is lacking due to common exclusion from perioperative TXA trials.

STUDY DESIGN AND METHODS

A systematic review searching the databases Medline, EMBASE, CENTRAL, and Clinicaltrials.gov was performed. Randomized controlled trials (RCTs) administering systemic TXA perioperatively to elective or emergent surgery patients were eligible. Our primary outcome was to describe exclusion criteria of RCTs, and the secondary outcome was TXA safety. A descriptive synthesis of exclusion criteria was performed, and TXA safety was assessed by meta-analysis.

RESULTS

A total of 268 eligible RCTs were included. Meta-analysis showed that systemic TXA did not increase risk of adverse events compared to placebo or no intervention (relative risk, 1.05; 95% confidence interval, 0.99-1.12). Patient groups commonly excluded from perioperative TXA trials, and thus potentially lacking TXA safety data, were those with major comorbidities, a history of thromboembolism, medication use affecting coagulation, TXA allergy, and coagulopathy. Exclusion of patients with major comorbidities may not be necessary; we showed that the risk of adverse events was similar in studies that excluded patients with major comorbidities and those that did not.

CONCLUSION

Sufficient evidence exists to develop perioperative guidelines for TXA use in many populations. Further studies evaluating perioperative TXA use in patients with a history of thromboembolism are warranted.