Tranexamic acid and beyond: A systematic review of pediatric post-tonsillectomy hemorrhage protocols and introduction of a universal management guideline.

چکیده اصلی

INTRODUCTION: Tonsillectomy is one of the most common procedures performed in children. A well-known complication of tonsillectomy is post-tonsillectomy hemorrhage (PTH). PTH is a very serious complication due to the potential for airway compromise and severe bleeding. Most hospital protocols call for observation in scenarios where there is no active bleeding and return to operating room in situations where bleeding is not controlled. In recent years, the use of tranexamic acid (TXA), an antifibrinolytic agent, has been incorporated into the management of post-tonsillectomy bleeds, through nebulization and/or intravenously (IV). The goal of this study is to systematically review publicly available hospital protocols for the management of pediatric PTH, with particular focus on the incorporation of nebulized and/or IV TXA, and to introduce a universally applicable protocol for PTH management. METHODS: A systematic review of publicly available hospital protocols for pediatric PTH was conducted in accordance with PRISMA guidelines. The Children's Hospital Association (CHA) database was used to identify protocols that were publicly available, written in English, and specific to pediatric PTH management. The protocols were analyzed for key management domains including specialist consultation and use and dosing of nebulized and IV TXA. RESULTS: Through this systematic review, we identified 12 publicly available hospital PTH protocols, all developed at quaternary or near-quaternary centers. Of these protocols, 83% of protocols outline when to use nebulized TXA, whereas 67% of protocols outline when to use IV TXA and in total 67% include the use of both IV and nebulized TXA. Nebulized TXA was most consistently recommended for active bleeding, with IV TXA reserved for active or higher-volume bleeding. Our guideline recommends nebulized TXA for all PTH patients, with IV TXA for all active bleeding and on a case by case basis for controlled bleeding. CONCLUSION: This study reveals 12 publicly available pediatric PTH hospital protocols, 67% of which included the use of nebulized and IV TXA. Our guideline combines key practical management guidelines for PTH, including when to consult services like Interventional Radiology and PICU, and is designed for applicability beyond tertiary referral centers, providing a practical framework for frontline providers across a range of clinical settings.

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