Nebulised Tranexamic Acid for Post-Tonsillectomy Haemorrhage
Date First Published:
February 2, 2025
Last Updated:
February 6, 2025
Report by:
Aimee Vafaie MD, Consultant Paediatrician (Bristol Royal Children's Hospital)
Search checked by:
Aimee Vafaie, Bristol Royal Children's Hospital
Three-Part Question:
In [patients with post-tonsillectomy haemorrhage] does [nebulised tranexamic acid] [decrease the need for procedural intervention]?
Clinical Scenario:
A 5 year old child presents to ED 5 days after tonsillectomy with bleeding from the tonsilar bed. You wonder if nebulised TXA plays an evidence based role in his management to minimise his bleeding and particularly his need for other intervention.
Search Strategy:
Medline using Ovid interface, 1946 to 31-1-2025
Search Details:
("post-tonsillectomy" OR "post tonsillectomy") AND ("hemorrhage" OR "haemorrhage" or "bleeding") AND ("tranexamic acid" OR "TXA")
Outcome:
19 papers, of which 9 are relevant to using nebulized TXA to treat at the time of presentation with post-tonsillectomy bleed. Of the 9, one (1) is a meta-analysis and four (4) are retrospective cohort studies which are included in the meta-analysis. The remaining 4 are case reports or case series, which are all also included in the meta-analysis. I will discuss the meta-analysis and the 4 retrospective cohort studies.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Nebulized tranexamic acid for treatment of post-tonsillectomy bleeding: a systematic review and meta-analysis Alghamdi AS, et al 2024 Oct 02 Saudi Arabia | Meta-analysis of 9 studies (3 retrospective comparative studies, 4 case series, and 2 case reports) totalling 448 patients. | Meta-analysis | Need for re-operation | Risk Ratio of need for re-operation 0.55 (95% CI 0.39-0.77) | small n, retrospective data without randomization, heterogeneous patient characteristics and adjunct therapies, lack of objective criteria for need for reoperation |
| Treatment of Post-Tonsillectomy Hemorrhage With Nebulized Tranexamic Acid: Initial Investigation of a Novel Therapeutic Modality Maksimoski, M, et al. 2024 Aug USA | 21 patients age 18-50 presenting with post-tonsillectomy bleeding between 5-15 days post-op, some of whom were treated with 500mg nebulized TXA | Retrospective Cohort | Need for re-operation | 6 patient received nebulized TXA, none requiring re-operation. 15 patients did not received nebulized TXA, of whom 8 required re-operation. Absolute risk reduction 47.1% (95% CI 23%-71%). NNT 1.4-4.3. | small n, retrospective, non-standardized treatment, non-randomization, no objective criteria for requiring re-operation |
| Treatment of post-tonsillectomy hemorrhage with nebulized tranexamic acid: a retrospective study Shin, TJ, et al. 2023 Aug USA | 1100 adult and pediatric patients, mean age 20.1 +/- 11.8yr of whom 83 (7.5%) received nebulized TXA (typically 500mg) | Retrospective Cohort | Need for re-operation | TXA Cohort 36.1% rate of OR intervention. Control group 60.2% rate of OR intervention. Odds ratio 0.37 (95% CI 0.22-0.63) | small n in TXA group, retrospective, non-standardized treatment, non-randomization, no objective criteria for requiring re-operation |
| Post-tonsillectomy hemorrhage control with nebulized tranexamic acid: a retrospective cohort study Erwin DZ, et al 2021 June USA | 58 pediatric patients with post-tonsillectomy hemorrhage, 44 patients presenting in one time frame did not receive TXA, whilst 14 patients presenting in a later time frame received TXA in addition to other treatments. | Retrospective Cohort | Need for re-operation | Control group: 32 of 44 required operative intervention (73%, 95% CI 59-86%). TXA group: 4 of 14 patients required operative intervention (29%, 95% CI 1.5-56%). | small n, retrospective, non-standardized treatment, non-randomization (time based cohorts), no objective criteria for requiring re-operation |
| Efficacy of tranexamic acid (TXA) for post-tonsillectomy hemorrhage Spencer, R, et al. 2022 Sep-Oct USA | 82 adult and pediatric patients presenting with post-tonsillectomy hemorrhage at single facility. Of these, 55 were categorized as "non-active" and did not receive TXA and did not require intervention. 27 were regarded as active bleeds, some of which received either nebulized, intravenous, or topical TXA. | Retrospective Cohort | Need for re-operation | 17 patients received nebulized TXA with a need for re-operation rate of 23.5%. 27 patients who received TXA by any route had need for re-operation rate of 22.2%. Control (no TXA) group had rate of 53.6%. p-value for any TXA vs no TXA 0.026. | small n, retrospective, non-standardized treatment, non-randomization, no objective criteria for requiring re-operation, multiple routes of administration |
Author Commentary:
Whilst there are no randomized studies, and the retrospective studies are small and have various confounders including variable adjunct treatments and doses and unclear objective criteria of success, there are promising indications that nebulized TXA, commonly at a dose of 500mg, may decrease need for re-operation in post-tonsillectomy hemorrhage.
Bottom Line:
Given its general evidence of safety, there is reasonable evidence of benefit to support the use of nebulized TXA for post-tonsillectomy hemorrhage.
References:
- Alghamdi AS, et al. Nebulized tranexamic acid for treatment of post-tonsillectomy bleeding: a systematic review and meta-analysis
- Maksimoski, M, et al.. Treatment of Post-Tonsillectomy Hemorrhage With Nebulized Tranexamic Acid: Initial Investigation of a Novel Therapeutic Modality
- Shin, TJ, et al.. Treatment of post-tonsillectomy hemorrhage with nebulized tranexamic acid: a retrospective study
- Erwin DZ, et al. Post-tonsillectomy hemorrhage control with nebulized tranexamic acid: a retrospective cohort study
- Spencer, R, et al. . Efficacy of tranexamic acid (TXA) for post-tonsillectomy hemorrhage