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Tranexamic acid and perioperative bleeding in children

what do we still need to know?

Goobie, Susan M.a; Faraoni, Davidb

Current Opinion in Anesthesiology: June 2019 - Volume 32 - Issue 3 - p 343–352
doi: 10.1097/ACO.0000000000000728
PEDIATRIC ANESTHESIA: Edited by Tom G. Hansen
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Purpose of review Perioperative bleeding and blood product transfusion are associated with significant morbidity and mortality. Prevention and optimal management of bleeding decreases risk and lowers costs. Tranexamic acid (TXA) is an antifibrinolytic agent that reduces bleeding and transfusion in a broad number of adult and pediatric surgeries, as well as in trauma and obstetrics. This review highlights the current pediatric indications and contraindications of TXA. The efficacy and safety profile, given current and evolving research, will be covered.

Recent findings Based on the published evidence, prophylactic or therapeutic TXA administration is a well-tolerated and effective strategy to reduce bleeding, decrease allogeneic blood product transfusion, and improve pediatric patients’ outcomes. TXA is now recommended in recent guidelines as an important part of pediatric blood management protocols.

Summary Based on TXA pharmacokinetics, the authors recommend a dosing regimen of between 10 to 30 mg/kg loading dose followed by 5 to 10 mg/kg/h maintenance infusion rate for pediatric trauma and surgery. Maximal efficacy and minimal side-effects with this dosage regime will have to be determined in larger prospective trials including high-risk groups. Furthermore, future research should focus on determining the ideal TXA plasma therapeutic concentration for maximum efficacy and minimal side-effects.

aDepartment of Anesthesiology, Critical Care and Pain Medicine. Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA

bDepartment of Anesthesia and Pain Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada

Correspondence to Susan M. Goobie, MD, FRCPC, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, USA. E-mail: susan.goobie@childrens.harvard.edu

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