P2.170: Nebulized Tranexamic Acid for Pediatric Post-Tonsillectomy Hemorrhage: A Breath of Fresh Air in Hemostasis

Purpose/Objectives: Post-tonsillectomy hemorrhage (PTH), a significant complication following tonsillectomy, necessitates timely intervention within the emergency department. While definitive management often requires surgical control, effective hemostatic strategies are crucial for initial stabilization and minimizing morbidity. Tranexamic acid (TXA), an antifibrinolytic agent, has emerged as a promising adjunct in managing bleeding disorders. Its nebulized form offers a less invasive and readily administrable route, particularly in the pediatric population where intravenous access can be challenging. However, the use of nebulized TXA in pediatric PTH remains limited, highlighting a knowledge gap in current clinical practice.

Design/Methods: A quality improvement initiative prospectively evaluated a newly developed PTH-specific CPG incorporating nebulized TXA as a frontline intervention for pediatric patients presenting with PTH. The study population comprised pediatric emergency medicine (PEM) attendings and fellows, and pediatric otolaryngology attendings. Before CPG implementation, surveys captured baseline clinical practices in managing PTH, provider comfort, and perspectives on patient outcomes. The PTH-specific CPG recommended nebulized TXA as a first-line intervention for patients presenting with active bleeding within 3 hours or a fresh blood clot in the oropharynx. Patients exhibiting active bleeding or significant blood loss, defined as >250 ml, were placed on an emergent pathway where intravenous (IV) TXA was frequently used with nebulized TXA. Following CPG implementation, the same cohort completed a follow-up survey. Surveys captured the CPG's impact, evaluating clinical practice patterns, provider comfort in managing PTH, guideline adherence, and perceived impact on patient outcomes. Data collected aims to analyze the effectiveness and feasibility of implementing a nebulized TXA protocol in pediatric PTH management.

Results: Post-implementation survey data (n=20) revealed high provider CPG uptake, with 100% reporting practice modifications and 70% demonstrating consistent adherence. Provider confidence in managing PTH significantly improved, with 75% reporting moderate to high comfort. Notably, 95% of surveyed providers integrated nebulized TXA into their initial treatment, often with intravenous TXA (65%). Most respondents (55% PEM attendings, 40% PEM fellows) managed PTH cases monthly (65%). A perceived reduction in time-to-operating room (OR) in select cases suggests a potential clinical benefit warranting further rigorous investigation.

Conclusion/Discussion: The implementation of a standardized nebulized TXA protocol for pediatric PTH management has demonstrated high provider adoption and increased provider confidence, underscoring its feasibility as a valuable frontline intervention within the pediatric ED. The positive provider response and perceived reduction in time-to-OR in select cases are noteworthy. The CPG's emphasis on early otolaryngology involvement, standardized nebulized TXA use, and structured management contributed to more efficient and timely progression to surgical intervention when necessary. Future research should focus on definitively establishing the protocol's clinical efficacy and safety, rigorously quantifying the impact on time-to-OR and other clinical metrics, and further refining the guidelines based on more extensive data.