What is the recommended intravenous dose and infusion rate of tranexamic acid (TXA) for adults (including trauma or massive hemorrhage) and for children?

Tranexamic Acid IV Dosing

Standard Adult Dosing Protocol

For adults with trauma, massive hemorrhage, or postpartum bleeding, administer tranexamic acid 1 gram IV over 10 minutes as a loading dose, followed by 1 gram IV infused over 8 hours as maintenance therapy. 1, 2, 3, 4

Loading Dose

• 1 gram IV administered over 10 minutes 1, 2, 3, 4
• This fixed dose applies regardless of patient weight, including smaller patients (e.g., 50 kg) 2
• Administer as soon as bleeding is identified or suspected 2, 3, 4

Maintenance Infusion

• 1 gram IV infused over 8 hours for procedures or bleeding expected to exceed 2-3 hours 2, 3, 4
• This continuous infusion maintains therapeutic plasma levels of 10 μg/mL necessary to inhibit systemic fibrinolysis 2

Alternative Single-Bolus Regimen

• 1 gram IV bolus only (without maintenance infusion) is an acceptable alternative, particularly when prolonged infusion is not feasible 5
• A 2024 comparative analysis found equivalent 28-day mortality (21%) across 1g bolus-only, 1g + 1g infusion, and 2g bolus strategies 5
• Single bolus administration may be preferable to bolus-plus-infusion in some trauma settings 5

Second Dose for Postpartum Hemorrhage

• Administer a second 1 gram IV dose if bleeding continues after 30 minutes or restarts within 24 hours of the first dose 1
• This applies specifically to postpartum hemorrhage scenarios 1

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Pediatric Dosing

For children undergoing surgery or experiencing trauma-related bleeding, administer 10-30 mg/kg IV loading dose followed by 5-10 mg/kg/hour maintenance infusion. 6

Loading Dose

• 10-30 mg/kg IV administered over 10 minutes 6
• The higher end of this range (20-30 mg/kg) may be considered for major hemorrhage 6

Maintenance Infusion

• 5-10 mg/kg/hour IV continuous infusion 6
• Duration should match the expected bleeding period, typically throughout surgery and immediate postoperative period 6

Volume-Based Dosing Alternative

• 10 mL/kg of blood products may be used as a reference for pediatric resuscitation protocols 4

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Critical Timing Considerations

Tranexamic acid MUST be administered within 3 hours of injury or bleeding onset for maximum benefit; administration after 3 hours may cause harm. 1, 2, 3, 4

Time-Dependent Efficacy

• Efficacy decreases by 10% for every 15-minute delay in administration 1, 2, 3, 4
• Early administration (≤1 hour from injury) reduces bleeding death by 32% (relative risk 0.68) 2
• Treatment between 1-3 hours still provides 21% reduction in bleeding death (relative risk 0.79) 2
• No benefit observed after 3 hours, with potential paradoxical increase in bleeding death risk (relative risk 1.44) 1, 2, 3, 4

Pre-Hospital Administration

• Consider pre-hospital administration to ensure treatment within the critical 3-hour window 2, 4, 7
• The loading dose of 1 gram IV over 10 minutes can be safely administered in the field 7

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Dose Adjustments for Renal Impairment

Patients with renal dysfunction require dose reduction, as tranexamic acid is 90% renally excreted and accumulates in renal failure. 2, 3

Assessment and Adjustment

• Calculate creatinine clearance before administration whenever possible 2
• Reduce dose proportionally for any degree of renal impairment 2
• Specific dose reduction protocols vary, but general principle is to decrease both loading and maintenance doses based on creatinine clearance 2, 3

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Safety Considerations and Maximum Dosing

Seizure Risk

• Do NOT exceed 100 mg/kg total dose to minimize seizure risk, particularly in patients over 50 years 3, 4
• Higher doses (≥4g/24h) are associated with increased seizure risk, especially in cardiac surgery 2, 3, 4

Thrombotic Risk

• No increased risk of thrombotic events (MI, stroke, DVT, PE) has been demonstrated in trauma or surgical patients receiving standard doses 2, 8
• Meta-analysis of 125,550 participants found no evidence of increased thromboembolic complications (risk difference = 0.001; 95% CI, -0.001 to 0.002) 2

High-Risk Populations Requiring Caution

• Patients on oral contraceptive pills: use with caution due to theoretical thrombosis risk 2
• Patients with massive hematuria: risk of ureteric obstruction from clot formation 2
• Post-stroke patients: use with extreme caution 2

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Absolute Contraindications

Do NOT administer tranexamic acid in the following scenarios:

• Active intravascular clotting or disseminated intravascular coagulation (DIC) 2
• Subarachnoid hemorrhage (risk of cerebral edema and infarction) 3
• Severe hypersensitivity to tranexamic acid 2
• High-dose TXA (≥4g/24h) in critically ill patients with gastrointestinal bleeding (increases DVT, PE, and seizure risk without mortality benefit) 2
• Concomitant use with activated prothrombin complex concentrate (aPCC) in acquired hemophilia 2

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Route of Administration

Intravenous administration is the only evidence-based and FDA-approved route for acute hemorrhage. 3

• Intramuscular dosing is not recommended and lacks specific guideline support 4
• Topical application may be used as an adjunct for localized bleeding but should not replace systemic IV therapy when systemic hemostatic support is needed 2

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Common Clinical Pitfalls to Avoid

• Do NOT delay administration waiting for laboratory results or viscoelastic assessment; early treatment is critical 2
• Do NOT administer after 3 hours from injury or bleeding onset, as this may increase mortality 1, 2, 3, 4
• Do NOT use topical agents as a substitute for IV tranexamic acid when systemic bleeding control is required 2
• Do NOT withhold due to thrombotic concerns in appropriate bleeding scenarios, as mortality benefit far outweighs theoretical thrombotic risk 2
• Do NOT forget to assess renal function and adjust dose accordingly to prevent drug accumulation and toxicity 2, 3