What is the recommended dosage of Tranexa (tranexamic acid) IV for pediatric patients?

Tranexamic Acid IV Dosing for Pediatric Patients

For pediatric trauma, administer tranexamic acid as a loading dose of 15 mg/kg IV followed by an infusion of 2 mg/kg/hour, based on the most widely adopted dosing regimen in U.S. pediatric trauma centers and international trauma guidelines. 1

Context-Specific Dosing Regimens

Trauma Setting

• Loading dose: 15 mg/kg IV administered over several minutes 1, 2
• Maintenance infusion: 2 mg/kg/hour for 8 hours 1, 2
• This regimen is used by 68% of U.S. pediatric trauma centers that administer TXA, with 87% following the loading dose with a maintenance infusion 2
• Critical timing: Must be administered within 3 hours of injury for maximum mortality benefit, with efficacy decreasing after this window 3

Cardiac Surgery (Infants <1 Year)

• Initial bolus: 10 mg/kg IV at induction of anesthesia 4
• Maintenance infusion: 10 mg/kg/hour during surgery 4
• CPB prime: 4 mg/kg added to cardiopulmonary bypass circuit 4
• Post-CPB infusion: Reduce to 4 mg/kg/hour after CPB initiation 4
• This "10-10-4-4 rule" maintains therapeutic plasma concentrations above 20 μg/mL while avoiding neurotoxic peak levels 4

Major Surgery (General Pediatric)

• Loading dose: 10-30 mg/kg IV 5
• Maintenance infusion: 5-10 mg/kg/hour 5
• This range is recommended for major surgeries with anticipated significant blood loss, including scoliosis surgery and craniosynostosis repair 1, 5

Adolescents >12 Years

• Use adult dosing: 1 gram IV loading dose followed by 1 gram over 8 hours for trauma 1
• This applies when the patient weighs >40 kg and is physiologically mature 1

Administration Guidelines

Route and Rate

• Intravenous only - never administer intrathecally, as this has caused seizures and cardiac arrhythmias 6
• Infusion rate: Maximum 1 mL/minute (100 mg/minute) to prevent hypotension 6
• Dilution: May be mixed with electrolyte solutions, carbohydrate solutions, or amino acid solutions 6
• Stability: Diluted mixture stable for 4 hours at room temperature 6

Critical Contraindications

• Active intravascular clotting - TXA is prothrombotic and contraindicated in disseminated intravascular coagulation 6
• Subarachnoid hemorrhage - risk of cerebral edema and infarction 6
• Known hypersensitivity to tranexamic acid 6

Renal Dosing Adjustments

Dose reduction is mandatory in renal impairment for all indications 6:

• Serum creatinine 1.36-2.83 mg/dL: 10 mg/kg twice daily 6
• Serum creatinine 2.83-5.66 mg/dL: 10 mg/kg once daily 6
• Serum creatinine >5.66 mg/dL: 10 mg/kg every 48 hours OR 5 mg/kg every 24 hours 6

Blood Product Dosing Context

When TXA is used as part of massive transfusion protocols, pediatric blood product dosing should follow these volumes 1:

• Red blood cells: 10 mL/kg (increases Hb by ~20 g/L) 1
• Fresh frozen plasma: 10-15 mL/kg 1
• Platelets: 10-20 mL/kg 1
• Cryoprecipitate: 5-10 mL/kg 1
• Fibrinogen concentrate: 70 mg/kg (maximum 2 g), increased to 100 mg/kg in severe bleeding 1

Key Clinical Pitfalls

Avoid Excessive Dosing in Cardiac Surgery

• Doses exceeding 100 mg/kg total in cardiac surgery patients >50 years are associated with neurotoxicity 3
• While this primarily applies to adults, the principle of avoiding excessive cumulative doses applies to older adolescents undergoing cardiac procedures 3

Timing is Critical in Trauma

• Administer within 3 hours of injury - mortality benefit is lost if given after 3 hours 3
• Early administration (within 1 hour) provides maximum benefit 3

Drug Interactions

• Avoid concomitant prothrombotic agents: Factor IX concentrates, anti-inhibitor coagulant concentrates, and hormonal contraceptives increase thrombosis risk 6
• Do not mix with penicillin solutions - TXA is a synthetic amino acid incompatible with penicillin 6

Evidence Quality Considerations

The 15 mg/kg loading dose followed by 2 mg/kg/hour infusion for trauma represents the most widely adopted regimen based on extrapolation from the adult CRASH-2 trial and current U.S. practice patterns 1, 2. However, the optimal pediatric dosing remains an area of active investigation, as pharmacokinetic studies in infants suggest higher weight-adjusted clearance may require different dosing strategies 4. The trauma dosing recommendation prioritizes established safety data and widespread clinical adoption over theoretical pharmacokinetic optimization 2, 5.