tranexamic acid in general surgery

The POISE-3 (Perioperative Ischemic Evaluation-3) trial demonstrated the efficacy of prophylactic tranexamic acid compared with placebo in preventing major bleeding without increasing vascular outcomes in noncardiac surgery (1):

• reduced the risk of a composite bleeding outcome without increasing the risk of a composite cardiovascular risk outcome
• were no significant interactions between the effects of tranexamic acid vs placebo and the type of surgery (general surgery or nongeneral surgery, and across subcategories of general surgery) or cancer status
• absence of subgroup effects suggests that tranexamic acid reduces bleeding without increasing cardiovascular risk for both general surgery and nongeneral surgery patients

NICE state (2):

Use of tranexamic acid during surgery for adults

• tranexamic acid should be offered to adults having surgery in an operating theatre if:
  • there is any risk of bleeding and
  • the procedure will breach the skin or mucous membranes
• tranexamic acid should be offered to adults having surgery outside an operating theatre (for example, interventional radiology or A&E) who are expected to lose more than 500 ml of blood
• when using tranexamic acid for adults having surgery, administer it just before the start of surgery. Typically give 1 g by slow intravenous injection

Use of tranexamic acid during surgery for children

• consider tranexamic acid for children (aged 1 to 15 years) having surgery in an operating theatre if:
  • there is any risk of bleeding and
  • the procedure will breach the skin or mucous membranes
• consider tranexamic acid for children (aged 1 to 15 years) having surgery outside an operating theatre (for example, interventional radiology or A&E) who are expected to lose more than 10% of their blood volume
• when using tranexamic acid for children (aged 1 to 15 years) having surgery, administer it just before the start of surgery. Typically give 15 mg per kg (maximum 1 g) by slow intravenous injection

Safety measures

• if more than 1 dose of tranexamic acid might be beneficial because of the length of surgery or volume of blood loss, balance this against any risks associated with additional doses
  • risks may include tranexamic acid accumulating in the blood for people with renal impairment
• ensure safety measures are in place to prevent tranexamic acid from being accidentally administered via the intrathecal or epidural route rather than intravenously

Reference:

1. Lark LJ et al. Safety and Efficacy of Tranexamic Acid in General Surgery. JAMA Surg. 2025 Mar 1;160(3):267-274.
2. NICE (February 2026). Blood transfusion.