Protocolized tranexamic acid use lowers surgical intervention rates after active post-tonsillectomy hemorrhage: A retrospective cohort study.

OBJECTIVE

To evaluate whether a standardized tranexamic acid (TXA) protocol was associated with reduced operative intervention among patients with active post-tonsillectomy hemorrhage (PTH).

METHODS

This retrospective cohort study included patients aged 2 to 21 years with documented active PTH evaluated at a tertiary pediatric otolaryngology service from January 1, 2021, to July 31, 2025. Of 5342 tonsillectomies, 246 patients returned with suspected PTH and 116 met inclusion criteria for active bleeding or clot. A TXA protocol was implemented July 25, 2024. The primary outcome was operative intervention for hemorrhage control. Associations between TXA use, protocol era, route, and operative intervention were analyzed.

RESULTS

Among 116 included patients, operative intervention decreased from 63% before protocol implementation to 40% after implementation (OR 2.50; 95% CI 1.18-5.25; p = .02). Overall, 27 of 30 patients (90%) who did not receive TXA required operative intervention, compared with 33 of 86 patients (38%) who received TXA (OR 0.07; 95% CI 0.02-0.25; p < .001). In adjusted analysis, TXA route was significantly associated with operative intervention (p < .001). Compared with no TXA, nebulized, intravenous, and combined nebulized/intravenous TXA were each associated with lower adjusted odds of operative intervention; stratified analyses suggested nebulized TXA was the most consistent driver.

CONCLUSION

Protocolized TXA use was associated with reduced operative intervention in children and young adults with active PTH, with nebulized TXA showing the strongest association with avoidance of return to the operating room. The study was limited by its retrospective design and utilization of data from a single tertiary center.