Tranexamic Acid Dosing During Surgery
For surgical bleeding management, tranexamic acid (TXA) should be administered as a 1g IV loading dose over 10 minutes, followed by a 1g infusion over 8 hours. 1, 2
Dosing Regimen Details
- Initial dose: 1g IV over 10 minutes
- Maintenance dose: 1g IV infusion over 8 hours
- Alternative dosing by weight: 15 mg/kg IV loading dose, followed by 2 mg/kg/hour infusion 1
Timing Considerations
- TXA should be administered as early as possible in the surgical course when bleeding is identified or anticipated
- Maximum benefit is achieved when administered within 3 hours of injury/bleeding onset 1, 2
- Early administration (≤1 hour) shows the greatest mortality benefit 1, 2
- Administration between 1-3 hours still provides mortality reduction but with diminishing returns 2
- TXA should NOT be administered after 3 hours from injury/bleeding onset as it may increase mortality risk 1, 2
Clinical Settings and Dosing
| Clinical Setting | Recommended Dose |
|---|---|
| Trauma | 1g IV over 10 minutes, followed by 1g over 8 hours |
| Cardiac/Major Non-Cardiac Surgery | 1g IV over 10 minutes, followed by 1g over 8 hours |
| Postpartum Hemorrhage | 1g IV over 10 minutes, with second 1g dose if bleeding continues after 30 minutes |
Dosage Adjustments
Adjust dosage based on renal function:
| Serum Creatinine | TXA IV Dosage |
|---|---|
| 1.36-2.83 mg/dL | 10 mg/kg twice daily |
| 2.83-5.66 mg/dL | 10 mg/kg daily |
| >5.66 mg/dL | 10 mg/kg every 48 hours or 5 mg/kg every 24 hours |
Evidence and Efficacy
- TXA reduces blood loss in surgical patients by approximately 34% 3
- Higher doses (beyond 1g) have not demonstrated additional benefit in reducing blood loss 3
- The CRASH-2 trial demonstrated mortality reduction with the 1g + 1g over 8 hours regimen 4
- TXA is highly cost-effective across different income countries 1
Monitoring and Precautions
- Monitor for fibrinolysis if possible using thromboelastometric monitoring
- Consider stopping antifibrinolytic therapy once bleeding has been adequately controlled 1
- Contraindicated in patients with:
- Subarachnoid hemorrhage
- Active intravascular clotting
- Hypersensitivity to TXA or its ingredients 1
Common Side Effects
- Nausea, vomiting, diarrhea
- Allergic dermatitis
- Giddiness and hypotension
- Monitor for potential seizures and thrombotic events in high-risk patients 1
The evidence consistently supports this dosing regimen across multiple clinical guidelines, with the most recent and highest quality evidence confirming the 1g loading dose followed by 1g over 8 hours as the standard approach for surgical bleeding management.