Tranexamic Acid in Cardiac Surgery: Efficacy and Safety

Bleeding Reduction Benefits

The Enhanced Recovery After Surgery (ERAS) Society provides a Class I, Level A recommendation for tranexamic acid during on-pump cardiac surgical procedures, representing the highest level of evidence-based recommendation 1, 2
In a large randomized trial of patients undergoing coronary revascularization, tranexamic acid significantly reduced total blood products transfused and major hemorrhage or tamponade requiring reoperation 1

A 2025 meta-analysis of 216 trials involving 125,550 participants across all clinical settings found no evidence of increased thromboembolic complications with tranexamic acid 3
In trauma patients (20,211 participants), tranexamic acid actually showed lower rates of thrombosis, especially myocardial infarction, compared to placebo 3

Maximum total dose should not exceed 100 mg/kg due to seizure risk at higher doses 1
Dose reduction is mandatory in renal dysfunction as tranexamic acid is renally excreted, with higher risk of neurotoxicity in renal impairment 4, 5

Administer tranexamic acid routinely unless contraindications exist (active thromboembolic disease, history of recent thrombosis, DIC) 1, 4, 5
Ensure total dose does not exceed 100 mg/kg 1
Adjust dose in renal dysfunction to prevent neurotoxicity 4, 5

The American Society of Anesthesiologists recommends tranexamic acid for major surgeries with anticipated significant blood loss, including cardiac surgery, major orthopedic procedures, craniosynostosis surgery, and major trauma, as it reduces bleeding by 25-54% without increasing thrombotic complications 6
Tranexamic acid is recommended for major scoliosis surgery and total hip arthroplasty as part of multi-component patient blood management 6
Tranexamic acid can be used in children undergoing cardiac surgery, major scoliosis surgery, and craniosynostosis surgery, with children over 12 years receiving adult dosing 6
Tranexamic acid can be incorporated into massive hemorrhage protocols for major traumatic hemorrhage 6

Alternative acceptable dosing schedules for tranexamic acid exist and are in current use 6
Dosing remains uncertain in pediatric patients, with multiple acceptable schedules 6
Higher infusion rates are also acceptable and currently used in pediatric patients 6
Children over 12 years should receive adult dosing 6

Tranexamic acid reduces the need for blood transfusions, which decreases transfusion-related complications and improves surgical safety, ultimately saving healthcare funds 7