Tranexamic acid in paediatric surgery and trauma

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Objectives

To standardise the administration of intravenous tranexamic acid within RHC Glasgow

Scope

This guideline applies to all patients within RHC. The authors would like to highlight there is limited evidence applicable to neonates. Tranexamic acid is available as an oral medicine, this guideline does not apply to oral use.

Audience

Healthcare staff within RHC Glasgow

Summary

  • Tranexamic acid (TXA) is a synthetic lysine analogue that inhibits fibrinolysis and reduces bleeding.
  • TXA has been shown to reduce blood loss and transfusion requirements in both cardiac and non-cardiac surgery.
  • There is currently a wide variety of dosage regimes being used in clinical practice with high cumulative doses (>80mg/kg) correlated with increased risks of post operative seizure without evidence of better haemostasis.
  • Doses used should meet the threshold for clinical efficacy whilst avoiding unnecessarily high concentrations. The doses given below will be <80mg/kg even if continued for 24 hours.

Recommendation

Based on current literature, modelling studies and guidance from the RCPCH, separate dosing regimes are recommended for cardiac surgery involving cardiopulmonary bypass (CPB) and all other indications associated with potential significant blood loss.

Tranexamic acid in cardiac surgery with CPB or any extracorporeal circulation

At induction

10mg/kg tranexamic acid over 10 minutes

and commence

2mg/kg/hr infusion

until closure

CPB

10mg/kg tranexamic acid
into prime volume

After protamine

10mg/kg tranexamic acid over 10 minutes

If ECMO/VAD consider

2mg/kg/hr infusion

 


If patient in PICU going onto ECMO/VAD

Tranexamic acid up to 20mg/kg over 10 minutes
then 2mg/kg/hr infusion

 

Intravenous tranexamic acid in non-cardiac surgery  / major trauma / other use

At induction / presentation

15mg/kg tranexamic acid (max 1g) over 10 minutes

and commence

2mg/kg/hr infusion

until closure or reduction of risk of haemorrhage

References

Basta MN, Stricker PA, Taylor JA. A systematic review of the use of antifibrinolytic agents in pediatric surgery and implications for craniofacial use. Pediatr Surg Int, 2012; 28(11): 1059-69

Faraoni D, Willems A, Melot C, De Hert S, Van der Linden P. Efficacy of tranexamic acid in paediatric cardiac surgery: a systematic review and meta-analysis. Eur J Cardiothorac Surg, 2012; 42(5): 781-6

Lecker I, Wang DS, Whissell PD, Avramescu S, Mazer CD, Orser BA. Tranexamic Acid–Associated Seizures: Causes and Treatment. Ann Neurol., 2016; 79(1): 18-26

The Royal College of Paediatrics and Child Health. Evidence Statement: Major trauma and the use of tranexamic acid in children. November 2012.

Editorial Information

Last reviewed: 22 January 2018

Next review: 18 January 2021

Author(s): Dr Graham Bell, Paediatric Anaesthetist

Version: 1

Co-Author(s): Dr Tony Whyte, Foundation Dr; Ms Heather Read, Orthopaedic Surgeon; Dr Liz Chalmers, Paediatric Haematologist; Dr Judith McEwen, Paediatric Cardiac Anaesthetist; Dr Jonathan Coutts, Neonatologist / ECMO Team; Dr Mark Davidson, Paediatric Intensivist

Reviewer Name(s): Lesley McKee; Claire Murnaghan; Stephen Bowhay