What is the recommended use of tranexamic acid (TXA) in the perioperative period to reduce blood loss during high-risk surgeries?

Tranexamic Acid in Perioperative High-Risk Surgery

Tranexamic acid should be routinely administered in major surgeries with anticipated significant blood loss, including cardiac surgery, major orthopedic procedures (scoliosis, total hip arthroplasty), craniosynostosis surgery, and major trauma, as it reduces bleeding by 25-54% without increasing thrombotic complications. 1, 2, 3

Evidence-Based Indications

Cardiac Surgery

• The Enhanced Recovery After Surgery (ERAS) Society provides a Class I, Level A recommendation (highest evidence level) for tranexamic acid during on-pump cardiac procedures 2
• Reduces total blood product transfusions and major hemorrhage requiring reoperation by 29-54% compared to placebo 2, 4
• Meta-analysis of 216 trials with 125,550 participants found no evidence of increased thromboembolic complications, including no increased risk of graft thrombosis 2

Major Orthopedic Surgery

• Recommended for major scoliosis surgery and total hip arthroplasty as part of multi-component patient blood management 1
• Reduces perioperative blood loss significantly, with surgical approach influencing effectiveness (posterolateral approach shows least intraoperative blood loss) 5

Pediatric High-Risk Surgery

• Use in children undergoing cardiac surgery, major scoliosis surgery, and craniosynostosis surgery 1
• Children >12 years should receive adult dosing 1
• Can be incorporated into massive hemorrhage protocols for major traumatic hemorrhage 1

Trauma and Emergency Surgery

• In trauma patients (20,211 participants), tranexamic acid actually showed lower rates of thrombosis, especially myocardial infarction, compared to placebo 2

Dosing Protocols

Standard Adult Dosing

• Loading dose: 10 mg/kg IV followed by infusion of 1-5 mg/kg/hour 6, 4
• Alternative acceptable dosing schedules exist and are in current use 1

Pediatric Dosing

• Dosing remains uncertain with multiple acceptable schedules 1
• Higher infusion rates are also acceptable and currently used 1
• Children >12 years: use adult dose 1

Critical Safety Threshold

• Maximum total dose must not exceed 100 mg/kg due to seizure risk at higher doses 2

Absolute Contraindications

Screen for these before administration:

• Active disseminated intravascular coagulation (DIC) 6, 2
• Active thromboembolic disease or history of recent thrombosis 2
• Massive hematuria (risk of ureteral obstruction) 6

Mandatory Dose Adjustments

Renal Impairment

• Dose reduction is mandatory in renal dysfunction as tranexamic acid is renally excreted 2
• Higher risk of neurotoxicity and ocular toxicity in renal impairment 6, 2
• Assess renal function before initiating therapy 6

Safety Profile: Addressing Thrombotic Concerns

Robust Evidence Against Thrombotic Risk

• 2025 meta-analysis of 216 trials involving 125,550 participants across all clinical settings found no evidence of increased thromboembolic complications 2
• Meta-analysis of 191 randomized controlled trials with 40,621 participants in non-cardiac surgery confirms no increased risk of cardiovascular thromboembolic complications, convulsions, or 30-day mortality 6
• No randomized studies have raised concerns over safety regarding vein graft patency 7

Special Populations Requiring Caution

• Avoid in patients with spontaneous coronary artery dissection (SCAD) due to association with myocardial infarction and thrombosis 8
• Use with caution in patients with cardiovascular disease 8
• Patients with mechanical mitral valves (high thrombotic risk) can still benefit with appropriate monitoring 6

Clinical Algorithm for Perioperative Use

1. Screen for absolute contraindications (active DIC, active thrombosis, history of thromboembolism) 6, 2
2. Assess renal function and adjust dose if impaired 6, 2
3. Calculate maximum allowable dose (not to exceed 100 mg/kg total) 2
4. Administer loading dose of 10 mg/kg IV 6, 4
5. Follow with infusion of 1-5 mg/kg/hour 6, 4
6. Monitor for adverse effects (seizures at high doses, nausea, diarrhea) 9, 4

Integration with Anticoagulation Management

Perioperative Anticoagulation Bridging

• For low bleeding-risk procedures: vitamin K antagonists can continue until day before surgery 6
• P2Y12 inhibitors (clopidogrel): discontinue 5-7 days before procedure 6
• Patients with coronary stents: maintain dual antiplatelet therapy for minimum 4 weeks (bare metal) or 12 months (drug-eluting) 6
• Tranexamic acid serves as an effective strategy to reduce perioperative bleeding in anticoagulated patients 6

Common Pitfalls to Avoid

• Do not exceed 100 mg/kg total dose to prevent seizures 2
• Do not use standard doses in renal impairment without adjustment 6, 2
• Do not withhold due to unfounded thrombotic concerns in appropriate candidates—evidence shows safety 2, 3
• Nausea and diarrhea are most common adverse events but are generally mild to moderate 9, 4

Cost-Effectiveness Considerations

• Reduces need for blood transfusions, which decreases transfusion-related complications (stroke, MI, acute kidney injury, infections, longer hospital stays) 1
• Potential cost advantages over aprotinin 4
• Improves surgical safety and saves healthcare funds 3