Inhaled TXA for post-tonsillectomy hemorrhage
Myron Yaster MD, Melissa Brooks Peterson MD, and Jeremy Prager MD, MBA
“We’ve got a bleeding tonsil coming to the OR STAT”!
You’ve all experienced this either within hours of a tonsillectomy or about 5-10 days later. The decks are cleared and the OR team scrambles for an emergency exploration and hemorrhage control. Is this really necessary? Is there another way? In today’s PAAD we’ll review post tonsillectomy hemorrhage (PTH) and the potential use of inhaled TXA in its non-operative management. I’ve asked the PAAD’s airway queen, Dr. Mel Brooks Peterson and Dr. Jeremy Prager, a pediatric otorhinolaryngologist at the Children’s Hospital Colorado, to assist. Myron Yaster MD
Original Article
Erwin DZ, Heichel PD, Wright LM BS, Goldstein NA, McEvoy TP, Earley MA, Meyer AD. Post-tonsillectomy hemorrhage control with nebulized tranexamic acid: A retrospective cohort study. Int J Pediatr Otorhinolaryngol. 2021 Aug;147:110802. doi: 10.1016/j.ijporl.2021.110802. Epub 2021 Jun 12. PMID: 34146910
Raven Spencer, Maxwell Newby, William Hickman, Nathan Williams, Brian Kellermeyer. Efficacy of tranexamic acid (TXA) for post-tonsillectomy hemorrhage. Am J Otolaryngol. 2022 Sep-Oct;43(5):103582. doi: 10.1016/j.amjoto.2022.103582. Epub 2022 Aug 6. PMID: 35988367
Postoperative tonsillar hemorrhage (PTH) is a potentially serious complication following tonsillectomy and/or adenoidectomy, occurring in up to 7.5% of patients undergoing surgery and customarily occurs within 14 days of surgery.1 It can range from blood-streaked sputum to brisk arterial hemorrhage. Approximately 11% of patients with PTH will have more than one bleed and most but not all recurrences are within 2 weeks after surgery.1 There is little rhyme or reason as to who will bleed.2 Choice of surgical technique, use of NSAIDs, patient gender or age, history of recurrent tonsillitis have NOT been found to increase the risk of PTH.1, 2 Further, unidentified coagulation disorders are extremely rare and were found in <1% of patients with post-tonsillectomy hemorrhage.3
National surveys have documented that 75% of pediatric and adult otolaryngologists’ first intervention for post tonsillar hemorrhage is to return to the operating room for examination under anesthesia, determination of bleeding source, and cauterization of the wound.4, 5 Perhaps you have wondered: Is a non-operative approach possible? Erwin et al. hypothesized and found that “3 doses of nebulized TXA may be a safe first-line therapy to decrease the need for operative control of bleeding.”5 Interestingly, a previous study found that “one-time operative systemic dose, TXA can reduce intraoperative surgical blood loss during pediatric adenotonsillectomy, but it does not reduce the incidence of PTH”.4, 6
How did they administer inhaled TXA? “Weight based doses were 250 mg (0.25 mL, 100mg/mL of the IV solution) ) for patients less than 25 kg and 500 mg (0.5 mL) for over 25 kg. Three sequential nebulized doses were delivered back-to-back with total dose delivered not to exceed maximum systemic dose based on age and weight of the patient. Respiratory therapists prepared the nebulized tranexamic acid treatment by placing a pharmacy verified dose of intravenous TXA solution 1000mg/10 mL (Cyklokapron®, Pfizer, New York, NY) into a nebulizer dispenser. Respiratory therapists used an LCD® Disposable Nebulizer (PARI Respiratory Equipment, Midlothian, VA) with 8 L of gas flow until treatment was complete. Following administration of the three sequential doses, patients were re-evaluated, and the decision was made by the attending surgeon if the patient required surgical hemostatic control for active bleeding.”4 At Children’s Hospital Colorado, nebulized TXA is a part of the clinical care pathway for PTH. It has been specifically useful when our ENT colleagues are asked to consult on a possible PTH patient in our network of care (NOC). Some of these NOC sites are hours away from a pediatric ENT surgeon and a pediatric anesthesiologist, and the use of nebulized TXA is a safe and effective way to “buy time”. Further, if the TXA treatment works, the patient and family are “saved” a return trip to the operating room making this therapy a win-win for the patient, family (for pain, resources utilized, time away from work and school), and the operative team.
A few other points of discussion: We have talked in the PAAD before about “on-label” and “off-label” uses of medications; it is important that we recognize that TXA, not just inhaled TXA, is often used “off-label” when we use it in our pediatric patient population. This serves as yet another call for our specialty to be leaders and work with the FDA in getting appropriate pediatric labeling for all of the medications we use in our practice. The notion of “well everything is off label, but we use it anyhow, and everyone uses it so it is ok,” needs to cease – and pediatric anesthesiologists like Drs. Charles Cote, Lynne Maxwell, Randy Flick, and Greg Hammer can, and have been, the leaders in this change.
A final thought, the use of TXA in its many forms is a potential gold mine for study in the many hemorrhagic conditions we encounter in our every day clinical practices. In previous PAADs we’ve discussed the use of TXA in massive hemorrhage, craniosynostosis surgery, or in the control of pulmonary hemorrhages. Other potential uses are limited only by imagination. For example, can the topical application of TXA to lacerations in the emergency department or operating room promote hemostasis prior to laceration repair or wound closure or even preclude the need for surgical repair in some instances? Could topical TXA be used in burn dressing changes? Indeed, the possibilities are limitless…
In closing, one thing to keep clearly in mind: this study by Erwin et al. is a retrospective cohort study with all of its limitations. So before jumping on the “TXA fixes all bleeding problem bandwagon”, we agree with the authors that “a prospective, randomized controlled trial is necessary”. Because of the large number of patients who undergo tonsillectomy and develop PTH, we think that a prospective study using inhaled TXA in PTH patients is low lying fruit and could be easily accomplished in a multi-institutional study. We hope that the leaders of the Society for Pediatric Anesthesia Improvement Network (SPAIN) or other interested committee will read this PAAD, pick this up as an initiative, and lead the way to perform the proper trial. Finally, in reading these papers I (MY) was astonished at the effectiveness of inhaled TXA in minimizing the need for an operative approach. If you’ve used inhaled TXA for PTH or any other purpose, please let Myron know the circumstances and what your thoughts are about its use. Send your responses to Myron (myasterster@gmail.com) and we’ll publish in a future reader response.
References
1. Cheung PKF, Walton J, Hobson ML, et al. Management of Recurrent and Delayed Post-Tonsillectomy and Adenoidectomy Hemorrhage in Children. Ear Nose Throat J. Mar 9 2021:145561321999594. doi:10.1177/0145561321999594
2. van der Meer G, Gruber M, Mahadevan M. Recurrent post tonsillectomy bleeds: Presentation and characteristics in the paediatric population. International journal of pediatric otorhinolaryngology. Jul 2017;98:68-70. doi:10.1016/j.ijporl.2017.04.046
3. Windfuhr JP, Chen YS, Remmert S. Unidentified coagulation disorders in post-tonsillectomy hemorrhage. Ear Nose Throat J. Jan 2004;83(1):28, 30, 32 passim.
4. Erwin DZ, Heichel PD, Wright LB, et al. Post-tonsillectomy hemorrhage control with nebulized tranexamic acid: A retrospective cohort study. International journal of pediatric otorhinolaryngology. Aug 2021;147:110802. doi:10.1016/j.ijporl.2021.110802
5. Clark CM, Schubart JR, Carr MM. Trends in the management of secondary post-tonsillectomy hemorrhage in children. International journal of pediatric otorhinolaryngology. May 2018;108:196-201. doi:10.1016/j.ijporl.2018.03.004
6. Robb PJ, Thorning G. Perioperative tranexamic acid in day-case paediatric tonsillectomy. Annals of the Royal College of Surgeons of England. Mar 2014;96(2):127-9. doi:10.1308/003588414x13814021676477