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Antifibrinolytic (Haemostatic) Pregnancy: Postpartum use — safe; WOMAN trial established safety

Tranexamic Acid (Surgical / Trauma Haemorrhage)

Brand names: Cyklokapron, Exacyl

Adult dose

Dose: Surgical haemorrhage: 1 g IV over 10 min at incision, repeat at 3h if ongoing bleeding. Trauma (CRASH-2): 1 g IV over 10 min within 3h of injury, then 1 g IV over 8h
Route: IV
Frequency: Loading dose; repeat at 3h if needed
Max: 2 g total (surgical); 2 g in CRASH-2 protocol
CRASH-2 trial: 1 g IV bolus + 1 g infusion reduces all-cause mortality and death from haemorrhage in trauma. Give within 3h — benefit lost after 3h. Elective surgery: prophylactic use (e.g., TKR, THR, cardiac, caesarean) reduces blood loss and transfusion requirements.

Paediatric dose

Dose: 15 mg/kg
Route: IV
Frequency: Loading dose; repeat once if needed
Max: 1000 mg per dose
Concentration: 100 mg/mL mg/ml
Paediatric: 15 mg/kg IV loading (max 1 g). Cardiac surgery: 100 mg/kg loading; 10 mg/kg/h infusion (higher doses per cardiac surgery protocols).

Dose adjustments

Renal

Reduce dose in renal impairment — accumulation risk; monitor

Hepatic

No dose adjustment required

Paediatric weight-based calculator

Paediatric: 15 mg/kg IV loading (max 1 g). Cardiac surgery: 100 mg/kg loading; 10 mg/kg/h infusion (higher doses per cardiac surgery protocols).

Clinical pearls

  • CRASH-2 trial: TXA saves lives in trauma haemorrhage — give within 3h of injury; benefit disappears after 3h and may be harmful if given late
  • Enhanced recovery protocols: TXA routinely used in elective orthopaedic, cardiac, and general surgery to reduce transfusion
  • WOMAN trial (obstetrics): same principle — TXA 1 g IV reduces PPH mortality when given within 3h of delivery
  • Seizure risk at high doses (>30 mg/kg): relevant in cardiac surgery — use standard doses in non-cardiac settings
  • Topical TXA (2 g in 100 mL saline) for wound irrigation: increasingly used in orthopaedic and abdominal surgery

Contraindications

  • Active thromboembolic disease
  • Haematuria from upper urinary tract (risk of ureteric clot obstruction)
  • History of convulsions (high-dose — seizure risk)

Side effects

  • Nausea, vomiting, diarrhoea
  • Hypotension (if IV given too rapidly)
  • Thromboembolic events (rare)
  • Seizures (high-dose in cardiac surgery — direct CNS effect)

Interactions

  • Procoagulant drugs — additive thrombotic risk (use with caution)

Monitoring

  • Haemostasis (blood loss, Hb)
  • Signs of thrombosis
  • Renal function (prolonged or repeated doses)
  • Neurological status (high-dose)

Reference: BNFc; CRASH-2 trial (Lancet 2010); WOMAN Trial (Lancet 2017); BNF; NICE Trauma Haemorrhage Guidelines. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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