Implementation of a Nebulized Tranexamic Acid Protocol for Pediatric Post-Tonsillectomy Hemorrhage: A Quality Improvement Initiative.

Abstract

We hypothesized that initiation of a standardized nebulized TXA protocol for posttonsillectomy hemorrhage (PTH) would reduce the need for surgical control of bleeding without increasing adverse clinical outcomes. This quality improvement project included patients under 18 years of age who presented with PTH. Preintervention data were collected between January 1, 2020, and June 30, 2022. Plan-Do-Study-Act (PDSA) cycle 1, between July 1, 2022, and December 31, 2023, included patients who received nebulized TXA without a standardized protocol, based on emerging evidence supporting its use in PTH. PDSA cycle 2, between January 1, 2024, and July 13, 2025, followed the implementation of a standardized TXA protocol. Data included need for surgical control of bleeding, length of stay, transfusions, readmissions, and TXA-related complications. A total of 501 patients were included, with a median age of 7.2 years, distributed across the preintervention group (n = 171), PDSA 1 (n = 205), and PDSA 2 (n = 125). The proportion of patients requiring surgical control of bleeding decreased with each intervention (43.9% vs 29.8% vs 15.2%, P < .0001). There were no changes in the length of stay, transfusion rates, readmissions, or TXA-related complications. Across 2 PDSA cycles, we achieved a 65.4% reduction in the need for surgical control of bleeding for PTH without an increase in balancing measures, used as surrogates for unintended consequences of the interventions. Implementation of a nebulized TXA protocol may be a safe and effective management option for PTH.