For Doctors in a Hurry
- Clinicians lack consensus on using tranexamic acid to manage pediatric posttonsillectomy hemorrhage, prompting an investigation into current practice patterns.
- The researchers analyzed 19,572 pediatric emergency department encounters between 2016 and 2024 using a large national hospital database.
- Tranexamic acid administration was associated with lower adjusted odds of reoperation (aOR 0.66; 95% CI 0.56 to 0.77).
- The authors concluded that while usage rates increased significantly, tranexamic acid did not correlate with reduced hospital admission rates.
- Physicians should note that tranexamic acid may reduce surgical reintervention, though hospital-level practice variation remains substantial across the country.
Managing the Risks of Posttonsillectomy Hemorrhage
Tonsillectomy remains a cornerstone of pediatric surgical practice, with approximately 289,000 procedures performed annually in the United States for children under 15 years of age [1]. While the surgery is routine, secondary posttonsillectomy hemorrhage, defined as bleeding occurring more than 24 hours postoperatively, complicates up to 5% of cases and presents a risk for life-threatening airway compromise [1, 2]. Emergency management is frequently hindered by poor visualization and the anatomical difficulty of applying direct pressure to the oropharynx, where traditional hemostatic agents like silver nitrate often prove insufficient [1, 3]. Although prophylactic administration of tranexamic acid during the initial surgery has not demonstrated a clear reduction in bleeding rates, there is increasing clinical interest in its role as a rescue therapy [4, 5, 6]. Recent quality improvement data indicate that standardized protocols using this antifibrinolytic, a medication that prevents the enzymatic breakdown of fibrin clots, can significantly reduce the need for return to the operating room [7]. A new retrospective analysis of 19,572 emergency encounters found that tranexamic acid administration was associated with lower adjusted odds of reoperation (adjusted odds ratio 0.66; 95% confidence interval, 0.56 to 0.77), though it did not significantly impact hospital admission rates [8, 9].
Analysis of Pediatric Emergency Encounters
The researchers conducted a retrospective, cross-sectional analysis, a study design that examines data from a specific population at a single point in time to identify associations between treatments and outcomes. This investigation focused on children younger than 18 years old who required an emergency department encounter for posttonsillectomy hemorrhage. By analyzing this specific clinical cohort, the study sought to determine how the administration of tranexamic acid correlates with the need for subsequent surgical intervention or hospital admission, providing clinicians with evidence to guide acute management. Data were extracted from the Pediatric Health Information System, a large administrative database that provides comparative clinical and financial data from leading children's hospitals. The study period spanned nine years, covering encounters from January 1, 2016, to December 31, 2024. This extensive timeframe allowed the authors to observe long-term trends in medication utilization and clinical outcomes across multiple pediatric centers, ensuring the findings reflect broad institutional practices rather than isolated incidents. The analysis included a total of 19,572 emergency department encounters, establishing a substantial sample size for evaluating the efficacy of tranexamic acid in acute settings. The study population had a median age of 7 years, with an interquartile range (the middle 50% of the patient data) of 4 to 11 years. This age distribution aligns with the typical demographic for pediatric adenotonsillectomy, providing clinicians with data directly applicable to the most common patient profiles seen in emergency and otolaryngology departments.
Rising Utilization and Institutional Variation
The primary outcome measured in this study was the treatment with tranexamic acid, an antifibrinolytic agent utilized to stabilize clot formation during acute bleeding episodes. Over the nine year study period, the researchers observed a significant increase in tranexamic acid use for the management of posttonsillectomy hemorrhage. Specifically, the median annual use of the medication rose from 0.0% in 2016 to 30.6% in 2024. To evaluate these shifts, the authors employed the Cochran-Armitage test, a statistical tool used to determine if there is a consistent linear trend in proportions across ordered categories. This test allowed the team to assess trends in tranexamic acid use when institutions were ranked by hospital quartile, confirming a clear upward trajectory in clinical adoption across the participating pediatric centers. Across the total study population, tranexamic acid was administered in 1,892 encounters, representing 9.7% of the 19,572 total encounters analyzed. Despite the overall increase in utilization, the data revealed substantial variation in tranexamic acid use across different hospitals. The frequency of administration was highly inconsistent between facilities, with hospital-level use ranging from a minimum of 1.0% to a maximum of 67.1%. This wide range suggests that while the medication is becoming more common in pediatric emergency settings, standardized protocols for its application in posttonsillectomy bleeding have not yet been universally adopted, leading to highly variable practice patterns depending on the treating facility.
Impact on Surgical Intervention and Admission
The researchers evaluated several secondary outcomes to determine the clinical utility of tranexamic acid, specifically focusing on reoperation rates, hospital admission, and various patient factors. When analyzing the data at the hospital level, the study found that institutional preferences for the medication did not correlate with overall outcomes. Specifically, there was no significant difference in reoperation rates based on the hospital quartile of tranexamic acid use (P=0.941). Similarly, the frequency of hospital admission did not vary significantly across these hospital quartiles (P=0.060), suggesting that a facility's general tendency to use the antifibrinolytic did not shift its aggregate surgical or admission volumes. However, a more granular analysis at the encounter level revealed a distinct clinical benefit for individual patients. The administration of tranexamic acid was associated with significantly lower adjusted odds of reoperation, with an adjusted odds ratio of 0.66 (95% confidence interval: 0.56-0.77). This 34% reduction in the odds of returning to the operating room highlights the potential of the medication to stabilize posttonsillectomy hemorrhage effectively and avoid the risks associated with repeat anesthesia. In contrast, the treatment did not appear to influence the necessity of inpatient care. At the encounter level, tranexamic acid administration was not associated with a significant change in hospital admission, yielding an adjusted odds ratio of 0.93 (95% confidence interval: 0.83-1.04). These findings suggest that while the medication may prevent the need for further surgical intervention, it does not necessarily preclude the need for observational or supportive care in a hospital setting to ensure patient safety following a bleeding event.
References
1. Schwarz W, Lee A, Meyer A, Erwin DZ, Zonfrillo MR. Emergency medicine providers’ experience with posttonsillectomy hemorrhage in the emergency department. Academic Emergency Medicine. 2025. doi:10.1111/acem.15092
2. Liu L, Rodman C, Worobetz N, Johnson J, Elmaraghy C, Chiang T. Topical biomaterials to prevent post-tonsillectomy hemorrhage. Journal of Otolaryngology - Head and Neck Surgery. 2019. doi:10.1186/s40463-019-0368-1
3. Dermendjieva M, Gopalsami A, Glennon NC, Torbati S. Nebulized Tranexamic Acid in Secondary Post-Tonsillectomy Hemorrhage: Case Series and Review of the Literature. Clinical Practice and Cases in Emergency Medicine. 2021. doi:10.5811/cpcem.2021.5.52549
4. Lee AC, Haché M. Pediatric Anesthesia Management for Post-Tonsillectomy Bleed: Current Status and Future Directions. International Journal of General Medicine. 2022. doi:10.2147/ijgm.s312866
5. Smaily H, Cherfane P. The Utility and Safety of Prophylactic Tranexamic Acid in Tonsillectomy: A Systematic Review and Meta‐analysis. Otolaryngology. 2024. doi:10.1002/ohn.973
6. Fuzi J, Budiono GR, Meller C, Jacobson I. Tranexamic acid in otorhinolaryngology – A contemporary review. World Journal of Otorhinolaryngology - Head and Neck Surgery. 2020. doi:10.1016/j.wjorl.2020.05.010
7. Petrauskas L, Sethurathnam J, Kunnath AJ, et al. Reducing Surgery for Pediatric Posttonsillectomy Hemorrhage Using Tranexamic Acid: A Quality Improvement Initiative. Otolaryngology. 2025. doi:10.1002/ohn.1300
8. Bergmann KR, Hall M, Ramgopal S, et al. Tranexamic Acid Use for Posttonsillectomy Hemorrhage Across US Children’s Hospitals. Pediatric Emergency Care. 2026. doi:10.1097/pec.0000000000003604
9. Bergmann KR, Hall M, Ramgopal S, et al. Tranexamic Acid Use for Posttonsillectomy Hemorrhage Across US Children's Hospitals.. Pediatric emergency care. 2026. doi:10.1097/PEC.0000000000003604
