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The Efficacy of Antifibrinolytic Drugs in Children Undergoing Noncardiac Surgery: A Systematic Review of the Literature

Faraoni, David MD, FCCP*; Goobie, Susan M. MD, FRCPC

doi: 10.1213/ANE.0000000000000080
Pediatric Anesthesiology: Review Article

Children undergoing major surgery are frequently exposed to a high risk of blood loss often requiring transfusion. Although the risks associated with blood product transfusion have considerably decreased over the last decade, transfusion is still associated with significant morbidity and mortality. Thus, rigorous efforts should be made to decrease surgical bleeding and the need for blood product transfusion. Antifibrinolytic drugs have been shown to be effective when used in both adult and pediatric surgical patients. While there are data in adults to support safety, data remain limited for pediatric patients. Since the restriction of aprotinin use in 2008, the most commonly used antifibrinolytic drugs have been the lysine analogs, tranexamic acid (TXA), and ε-aminocaproic acid, which inhibit the conversion of plasminogen to plasmin and decrease the degree of fibrinolysis. We performed a systematic review of the literature pertaining to the efficacy of antifibrinolytic drugs in children undergoing noncardiac surgery. During spine surgery, both TXA and ε-aminocaproic acid decrease blood loss and transfusion requirements; however, this information comes from small, mainly retrospective trials. Two prospective, randomized, controlled trials have tested the efficacy of TXA in children undergoing craniofacial surgery and have reported that TXA decreases transfusion requirements. Two pharmacokinetic trials were also recently published and are summarized in this review. No data have been published regarding the efficacy of TXA administration in the pediatric trauma population. Further data are still needed in this field of study, and we discuss some perspectives for future research.

From the *Department of Pediatric Anesthesiology, Queen Fabiola Children’s University Hospital, Free University of Brussels, Brussels, Belgium; and Department of Anesthesia, Perioperative and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts.

Accepted for publication November 15, 2013.

Funding: This work was solely supported by departmental sources and is attributed to the department of Anesthesiology, Perioperative and Pain Medicine, Boston Children’s Hospital, Boston, MA.

The authors declare no conflicts of interest.

Reprints will not be available from the authors.

Address correspondence to Susan M. Goobie, MD, FRCPC, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children’s Hospital, 300 Longwood Ave., Boston, MA 02215. Address e-mail to

© 2014 International Anesthesia Research Society