Nebulised tranexamic acid took paediatric post-tonsillectomy bleeds from 44% to 15% returning to theatre

Design

single-centre quality improvement project across two Plan-Do-Study-Act cycles with historical controls

Population

501 patients under 18 with post-tonsillectomy haemorrhage, median age 7.2 years, 2020 to 2025

Primary outcome

proportion requiring surgical control of bleeding

Effect

43.9% before, 29.8% after informal use, 15.2% after standardised protocol (P < .0001); no change in length of stay, transfusions, readmissions or complications

A children's hospital ran a quality improvement project across 501 patients under 18 presenting with post-tonsillectomy haemorrhage. The baseline period ran from January 2020 to June 2022 (171 patients). The first Plan-Do-Study-Act cycle, to December 2023 (205 patients), used nebulised tranexamic acid without a standardised protocol. The second, to July 2025 (125 patients), followed implementation of a standardised protocol. Median age was 7.2 years.

The proportion requiring surgical control of bleeding fell at each step: 43.9 per cent, then 29.8 per cent, then 15.2 per cent (P < .0001) — a 65.4 per cent relative reduction. The balancing measures did not move: no change in length of stay, transfusion rates, readmissions or tranexamic acid-related complications.

This is a before-and-after design across five and a half years, not a randomised trial, and secular change in practice over that period cannot be excluded. But the intervention is nebulised tranexamic acid — cheap, available in any hospital that stocks the intravenous preparation, deliverable on a ward by a nurse, and avoiding a return to theatre in a bleeding child. The second cycle's gain over the first is the part worth noting: informal use helped, and a written protocol helped considerably more. For Indian units, where a bleeding child may be several hours from a paediatric anaesthetist, that is a meaningful intervention to have written down.

• Write a standardised nebulised tranexamic acid protocol rather than leaving it to individual judgement
• Stock the nebulised preparation on the ward that receives these children
• Define who prescribes and who administers it, and at what point in the pathway
• Keep the surgical pathway unchanged — this reduces returns to theatre, it does not replace them
• Audit your own return-to-theatre rate before and after; 43.9 per cent is the comparator here

Why it matters

It converts a return to theatre in a bleeding child into a ward-level intervention, at negligible cost.

Don't overread it

A single-centre quality improvement project with historical controls, not a randomised comparison.

The statistics, in plain English

This is a before-and-after comparison, so the 65 per cent reduction includes any other change in how these children were managed between 2020 and 2025. The balancing measures staying flat is the reassuring part: if the protocol were simply delaying necessary surgery, length of stay, transfusions or readmissions should have risen, and none did.

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