- Design
- Quality-improvement study with two PDSA cycles vs pre-intervention baseline
- Population
- 501 children under 18 presenting with post-tonsillectomy haemorrhage
- Primary outcome
- Need for surgical control of bleeding
- Effect
- 43.9% (baseline) vs 29.8% (ad hoc) vs 15.2% (protocol), P < 0.0001; no change in balancing measures
Post-tonsillectomy haemorrhage is the commonest serious complication of the commonest paediatric operation, and many bleeding children go back to theatre. This US quality-improvement project, published in July, tracked 501 children presenting with post-tonsillectomy haemorrhage across three periods: before nebulised tranexamic acid (171), ad hoc nebulised use (205) and a standardised protocol (125).
The proportion needing surgical control of bleeding fell from 43.9% to 29.8% to 15.2% (P < 0.0001) — a 65% relative reduction. Length of stay, transfusion, readmission and tranexamic-acid-related complications did not change.
Nebulised tranexamic acid is cheap and widely available in India, where post-tonsillectomy bleeds often present to hospitals far from an ENT theatre. A protocol that stops a proportion of bleeds without anaesthesia could spare children a second general anaesthetic. The evidence is a before-and-after comparison, so changes in threshold for surgery or in patient mix could contribute; it supports trying a protocol, with audit, rather than proving it works.
- Agree a written nebulised tranexamic acid protocol for post-tonsillectomy haemorrhage with your anaesthetic and paediatric colleagues.
- Give nebulised tranexamic acid early to a child with a minor or settling bleed while preparing for theatre if needed.
- Do not delay surgery for active or heavy bleeding, falling haemoglobin or airway compromise.
- Examine the fossae after nebulisation and admit for observation even if bleeding stops.
- Audit your return-to-theatre rate before and after introducing the protocol.
Why it matters
A cheap, non-invasive first step may spare many bleeding children a second general anaesthetic.
Don't overread it
A before-and-after quality-improvement study, not a randomised trial; changing surgical thresholds could explain part of the fall.
The statistics, in plain English
The 65% figure is relative: 15.2% vs 43.9% needing surgery. In absolute terms, about 29 fewer children in every 100 went to theatre, but because the periods differed in time, practice and patients, not all of that difference can be credited to the drug.
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