Reducing Surgery for Pediatric Post- Tonsillectomy Hemorrhage Using Tranexamic Acid: A Quality Improvement Initiative

CLINICAL QUESTION

Can standardized administration of tranexamic acid (TXA) reduce the need for operative intervention in children presenting with post-tonsillectomy hemorrhage (PTH)?

BOTTOM LINE

Implementing a TXA protocol significantly lowered the rate of return to the operating room for PTH, avoided an estimated 21 surgeries in one year, and saved nearly $175,000, with no observed drug-related complications.

BACKGROUND: Post-tonsillectomy hemorrhage is a common complication of adenotonsillectomy, one of the most frequent pediatric surgeries in the U.S. Current management often requires repeat operative intervention, which carries risk, cost, and stress for families. TXA, an antifibrinolytic agent with a favorable safety profile, has shown promise in reducing bleeding across multiple surgical fields, but its role in pediatric PTH has been underexplored.

STUDY DESIGN: Retrospective before-and-after analysis of a prospectively implemented quality-improvement protocol at a tertiary children’s hospital. Patients under 18 presenting to the emergency department with PTH were included. Outcomes compared pre-protocol (April 2022–March 2023) versus post-protocol (April 2023–March 2024). SETTING: Single tertiary-care children’s hospital.

SYNOPSIS: The study found that in the year before protocol implementation, 1,800 adenotonsillectomies were performed, and 40 children (2.2 per 100 cases) required surgical control of bleeding. In the following year, 2,356 adenotonsillectomies were performed and only 30 children (1.3 per 100 cases) required a return to the operating room, representing a 41% relative reduction (RR 0.59, 95% CI 0.36–0.92, p=.020). No adverse events were attributed to TXA. Patient dispositions were also found to shift significantly after the protocol. A larger proportion were admitted for observation (58% post-protocol versus 36% pre-protocol), while fewer required operative intervention (31% versus 45%). Among 57 children admitted for observation and treated with intravenous TXA, 86% were discharged without surgery. Hospital length of stay remained unchanged between groups. Furthermore, 30-day emergency department revisit rates were also comparable between the groups (9% pre-protocol versus 6% post-protocol), with no significant differences in the proportion requiring additional surgical management. The study also suggested that 21 surgeries were avoided, and 26 extra admissions occurred post-protocol, resulting in a net savings of nearly $175,000 despite increased observation. Certain limitations existed in this study, however, including the single-center design and the absence of a placebo group. Nonetheless, these findings support TXA as a safe, cost-effective strategy for standardizing PTH management.

CITATION: Petrauskas LA, et al. Reducing surgery for pediatric post-tonsillectomy hemorrhage using tranexamic acid: a quality improvement initiative. Otolaryngol Head Neck Surg. 2025;173:745-753. doi: 10.1002/ohn.1300.

COMMENT: This study showed that the utilization of the IV tranexamic acid (TXA) protocol significantly decreased takebacks to the operative room for post-operative tonsillar bleeds. Though the number of children that require re-cauterization for tonsil bleeds can be low, the use of TXA in this protocol reduced this number to a relative risk of 0.59 with no adverse events. It also equates to significant cost savings, avoiding the OR for re-bleeds of the tonsillar fossa.—Ryan Belcher, MD, MPH