What is the recommended intravenous tranexamic acid dose for a child, including loading dose, repeat dosing, maximum daily dose, infusion rate, and adjustments for renal impairment?

Intravenous Tranexamic Acid Dosing in Children

For pediatric trauma and surgery, administer a loading dose of 15 mg/kg IV over 10 minutes, followed by a continuous infusion of 2 mg/kg/hour. 1, 2, 3

Loading Dose

• 15 mg/kg IV administered over 10 minutes (maximum 1 g) 1, 2, 3
• The FDA-approved dosing for dental extraction procedures is 10 mg/kg actual body weight infused at no more than 1 mL/minute to avoid hypotension 4
• For cardiac surgery specifically, higher loading doses of 100 mg/kg have been used in pharmacokinetic studies, though this exceeds typical trauma dosing 5

Maintenance Infusion

• 2 mg/kg/hour as a continuous infusion 1, 2, 3
• Duration of 8 hours is standard for trauma, following the CRASH-2 protocol adapted for pediatrics 6
• Alternative dosing schemes for cardiac surgery use 1 mg/kg/hour throughout the operation 7

Maximum Daily Dose

• 100 mg/kg total dose in 24 hours to avoid seizure risk, particularly important in cardiac surgery patients 6
• For non-surgical indications (menorrhagia, hereditary angioedema prophylaxis): 3-4 g per day maximum divided into 2-3 doses 1, 2
• The maximum single loading dose should be capped at 1 gram even if weight-based calculation exceeds this 1

Infusion Rate

• Administer loading dose over 10 minutes 1, 2
• For FDA-approved dental extraction indication, infuse at no more than 1 mL/minute to prevent hypotension 4
• Maintenance infusion runs continuously at the calculated hourly rate 3

Renal Impairment Adjustments

• Reduce dosage in patients with elevated creatinine using FDA renal dosing guidelines 6, 4
• Tranexamic acid has a plasma half-life of 120 minutes in normal renal function but is dramatically prolonged in renal impairment 6
• Monitor renal function closely in adolescents with known renal impairment 2

Critical Timing Considerations

• Administer within 3 hours of injury for trauma patients to achieve mortality benefit 6
• Benefit decreases by approximately 10% for every 15 minutes of delay 1
• Administration beyond 3 hours may be harmful rather than beneficial 1

Context-Specific Dosing Variations

Cardiac Surgery with Cardiopulmonary Bypass

• Loading: 100 mg/kg followed by 1 mg/kg/hour infusion throughout surgery 7, 5
• Additional 100 mg/kg added to cardiopulmonary bypass prime 5
• Age affects both distribution and elimination more significantly than weight in this population 5

Dental Extraction (FDA-Approved)

• 10 mg/kg IV before extraction with replacement therapy 4
• 10 mg/kg IV 3-4 times daily for 2-8 days post-extraction 4

Hereditary Angioedema Prophylaxis

• 15-25 mg/kg two to three times daily (maximum 3 g/day) 2

Important Safety Caveats

• Contraindications: Recent thrombosis, atrial fibrillation, known thrombophilia are relative contraindications 2
• Seizure risk: Doses exceeding 100 mg/kg total are associated with significantly increased seizure risk, particularly in cardiac surgery patients over 50 years 6
• Hypotension risk: Rapid IV administration can cause hypotension; maintain appropriate infusion rates 4
• Avoid fixed adult dosing: Using fixed adult doses (1 g) in small children leads to overdosing and increased adverse event risk 1

Common Pitfall to Avoid

The most common error is using the adult fixed-dose regimen (1 g loading, 1 g over 8 hours) in children without weight-based calculation, which can result in either underdosing in larger adolescents or dangerous overdosing in younger/smaller children 1. Always calculate weight-based doses for pediatric patients, with appropriate maximum dose caps.