Recommended Dosage of Tranexamic Acid (TXA) for Surgery
For surgical procedures, tranexamic acid should be administered at a loading dose of 10 mg/kg followed by an infusion of 1 mg/kg/h to effectively reduce bleeding and minimize transfusion requirements. 1
General Surgical Dosing Recommendations
Standard Dosing
- Loading dose: 10 mg/kg intravenously (administered slowly, no more than 1 mL/minute to avoid hypotension)
- Maintenance infusion: 1 mg/kg/h
- Administration timing: Begin immediately before surgical incision and continue throughout the procedure
Alternative Dosing Regimens
- For cardiac surgery: Loading dose of 10 mg/kg followed by infusion of 1 mg/kg/h has been shown to maintain adequate plasma concentrations throughout cardiopulmonary bypass 1
- Higher loading doses (up to 30 mg/kg) and maintenance infusions (up to 10 mg/kg/h) have been studied in pediatric populations 2
Dosing Adjustments for Special Populations
Renal Impairment
Dose adjustment is required for patients with renal dysfunction 3, 4:
- Moderate impairment (serum creatinine 1.36-2.83 mg/dL): 10 mg/kg twice daily
- Severe impairment (serum creatinine 2.83-5.66 mg/dL): 10 mg/kg once daily
- End-stage renal disease (serum creatinine >5.66 mg/dL): 10 mg/kg every 48 hours or 5 mg/kg every 24 hours
Specific Surgical Contexts
Trauma Surgery
For trauma patients with significant bleeding:
- Loading dose: 1 g infused over 10 minutes
- Maintenance infusion: 1 g over 8 hours
- Critical timing: Must be administered within 3 hours of injury for mortality benefit 1, 5
Cardiac Surgery
- The tranexamic acid dosing regimen of 10 mg/kg initial dose followed by an infusion of 1 mg/kg/h results in adequate plasma concentrations to prevent fibrinolysis 1
- Alternative regimens used in cardiac surgery range from loading doses of 2.5 to 100 mg/kg with maintenance infusions of 0.25 to 4.0 mg/kg/h 1
Tooth Extraction in Hemophilia Patients
According to FDA labeling 3:
- Initial dose: 10 mg/kg immediately before extraction
- Post-extraction: 10 mg/kg 3-4 times daily for 2-8 days
Important Considerations and Precautions
Contraindications
- Active intravascular clotting
- Subarachnoid hemorrhage
- Hypersensitivity to tranexamic acid
Monitoring
- Monitor for thromboembolic events, especially in patients with risk factors
- Ensure proper intravenous administration (never intrathecal)
- For prolonged surgeries, consider monitoring fibrinolysis if available 1
Important Caveats
- TXA is not recommended for gastrointestinal bleeding due to lack of mortality benefit and increased risk of thromboembolic events 6
- Higher doses (≥4g/24h) have been associated with increased risk of deep vein thrombosis, pulmonary embolism, and seizures 6
- TXA should be administered slowly (maximum 1 mL/minute) to avoid hypotension 3
The evidence strongly supports that appropriate dosing of tranexamic acid effectively reduces perioperative blood loss, decreases transfusion requirements, and may improve patient outcomes when used in the right clinical context with proper attention to timing and dosage adjustments for special populations.