Safety and efficacy of nebulized tranexamic acid in the treatment of pediatric post-tonsillectomy hemorrhage: a systematic review
Poster #: 031
Session/Time: B
Author:
Meghan Lee, BS, MS
Mentor:
Erin Hamersley, BS, DO
Research Type: Review Article
Abstract
INTRODUCTION:
Post-tonsillectomy hemorrhage (PTH) is a potentially serious complication occurring in approximately 3-5% of pediatric patients. PTH can result in significant clinical consequences including pain, patient and caregiver distress, prolonged recovery, need for blood transfusions, and, in severe cases, return to the operating room (ROR) for hemostasis. Standard emergency management relies on supportive care and topical agents, but their effectiveness is inconsistent. Nebulized tranexamic acid (nTXA), a non-invasive antifibrinolytic medication, has emerged as a promising alternative treatment. While its use is becoming increasingly common, no systematic evaluation of its safety and efficacy in the treatment of pediatric post-tonsillectomy hemorrhage has been conducted.
MAIN BODY:
A comprehensive literature search was conducted using six databases: PubMed, CINAHL, MEDLINE, Cochrane Library, ScienceDirect, and Web of Science. Search terms included combinations of "post-tonsillectomy hemorrhage," "nebulized tranexamic acid," and related phrases. Eligible studies included case reports, case series, cohort studies, and clinical trials involving patients aged ≤18 years treated with nebulized TXA for PTH. Primary outcomes were safety (e.g., adverse events) and efficacy (e.g. ROR rate). A total of 93 studies were imported into Rayyan for screening. Two independent reviewers screened titles and abstracts, with conflicts resolved by a third reviewer. The systematic review has been registered into PROSPERO. Eight studies met inclusion criteria, comprising case reports, case series, retrospective cohort studies, and one randomized controlled trial (RCT), with a combined total of 177 pediatric patients. Across these studies, the pooled incidence of return to the operating room (ROR) among patients receiving nebulized tranexamic acid (nTXA) was 24.3%. Seven of the eight studies reported no adverse events attributable to nTXA. The single RCT, which compared nTXA (n=37) with intravenous TXA (n=38), identified mild adverse events in a subset of nTXA recipients including nausea (n=10), vomiting (n=4), and abdominal discomfort (n=3); no serious adverse events were reported. To evaluate efficacy, a pooled analysis was performed using data from three retrospective cohort studies that included non-TXA control groups (Erwin 2021, Spencer 2022, and Ojeaga 2025). Across these studies, nebulized TXA was associated with a 45% relative reduction in ROR risk compared with control (pooled relative risk [RR], 0.55; 95% CI, 0.40-0.75). This equated to a pooled absolute risk reduction of 22.7%, corresponding to a number needed to treat (NNT) of approximately five patients to prevent one return to the operating room.
CONCLUSION:
Across eight studies involving 177 children, nebulized tranexamic acid (nTXA) was well tolerated, with seven studies reporting no adverse events and only mild, self-limited symptoms (nausea, vomiting, abdominal discomfort) in the single randomized trial. No serious complications were observed, supporting nTXA as a safe adjunctive therapy. Although findings suggest nTXA is both safe and effective for post-tonsillectomy hemorrhage, the evidence is limited, relying largely on observational studies with only one randomized trial. Variability in dosing, timing, and concurrent interventions may limit generalizability. Larger, multicenter randomized studies with standardized protocols are needed to confirm these results and define optimal use.
Post-tonsillectomy hemorrhage (PTH) is a potentially serious complication occurring in approximately 3-5% of pediatric patients. PTH can result in significant clinical consequences including pain, patient and caregiver distress, prolonged recovery, need for blood transfusions, and, in severe cases, return to the operating room (ROR) for hemostasis. Standard emergency management relies on supportive care and topical agents, but their effectiveness is inconsistent. Nebulized tranexamic acid (nTXA), a non-invasive antifibrinolytic medication, has emerged as a promising alternative treatment. While its use is becoming increasingly common, no systematic evaluation of its safety and efficacy in the treatment of pediatric post-tonsillectomy hemorrhage has been conducted.
MAIN BODY:
A comprehensive literature search was conducted using six databases: PubMed, CINAHL, MEDLINE, Cochrane Library, ScienceDirect, and Web of Science. Search terms included combinations of "post-tonsillectomy hemorrhage," "nebulized tranexamic acid," and related phrases. Eligible studies included case reports, case series, cohort studies, and clinical trials involving patients aged ≤18 years treated with nebulized TXA for PTH. Primary outcomes were safety (e.g., adverse events) and efficacy (e.g. ROR rate). A total of 93 studies were imported into Rayyan for screening. Two independent reviewers screened titles and abstracts, with conflicts resolved by a third reviewer. The systematic review has been registered into PROSPERO. Eight studies met inclusion criteria, comprising case reports, case series, retrospective cohort studies, and one randomized controlled trial (RCT), with a combined total of 177 pediatric patients. Across these studies, the pooled incidence of return to the operating room (ROR) among patients receiving nebulized tranexamic acid (nTXA) was 24.3%. Seven of the eight studies reported no adverse events attributable to nTXA. The single RCT, which compared nTXA (n=37) with intravenous TXA (n=38), identified mild adverse events in a subset of nTXA recipients including nausea (n=10), vomiting (n=4), and abdominal discomfort (n=3); no serious adverse events were reported. To evaluate efficacy, a pooled analysis was performed using data from three retrospective cohort studies that included non-TXA control groups (Erwin 2021, Spencer 2022, and Ojeaga 2025). Across these studies, nebulized TXA was associated with a 45% relative reduction in ROR risk compared with control (pooled relative risk [RR], 0.55; 95% CI, 0.40-0.75). This equated to a pooled absolute risk reduction of 22.7%, corresponding to a number needed to treat (NNT) of approximately five patients to prevent one return to the operating room.
CONCLUSION:
Across eight studies involving 177 children, nebulized tranexamic acid (nTXA) was well tolerated, with seven studies reporting no adverse events and only mild, self-limited symptoms (nausea, vomiting, abdominal discomfort) in the single randomized trial. No serious complications were observed, supporting nTXA as a safe adjunctive therapy. Although findings suggest nTXA is both safe and effective for post-tonsillectomy hemorrhage, the evidence is limited, relying largely on observational studies with only one randomized trial. Variability in dosing, timing, and concurrent interventions may limit generalizability. Larger, multicenter randomized studies with standardized protocols are needed to confirm these results and define optimal use.