Tranexamic Acid-Associated Cardiovascular Collapse in an Infant Undergoing Cranial Vault Surgery

Introduction: Tranexamic acid (TXA), an antifibrinolytic agent widely used to minimize intraoperative blood loss, is generally considered safe in pediatric populations. However, rare cardiovascular side effects, including hypotension with rapid administration, have been reported, with unclear mechanisms and limited pediatric data. Most described events are transient. We present a case of prolonged cardiovascular collapse following TXA administration in a high-risk infant with complex medical comorbidities.


Description: An 8-month-old ex-22w3d female infant with severe bronchopulmonary dysplasia, pulmonary hypertension on sildenafil, adrenal insufficiency, and bicoronal craniosynostosis was admitted to the PICU pre-operatively for planned cranial vault reconstruction. She was tracheostomy, ventilator, and G-tube dependent. During the immediate pre-operative period of her initial surgery, she received IV TXA. Within minutes, she developed profound bradycardia and hypotension, prompting abortion of the procedure. After immediate transfer to the PICU, she experienced persistent cardiovascular collapse requiring code-dose epinephrine, brief CPR, and several hours of inotropic support. She gradually stabilized, weaning off all support within 12 hours. Other common causes of shock in pediatric patients were evaluated for including hypovolemia/hemorrhage, adrenal insufficiency, anaphylaxis and sepsis; none of which were considered contributory. She returned to the OR four days later and tolerated bilateral strip craniectomies with slow infusion of TXA and was hemodynamic stable. Postoperatively, she remained stable on baseline respiratory support and was transferred back to the NICU in good condition.


Discussion: This case illustrates a rare but severe adverse event associated with TXA, particularly in infants with significant cardiopulmonary disease. Proposed mechanisms include direct myocardial depression, autonomic dysregulation, or idiosyncratic reaction—especially in the setting of pulmonary hypertension. A non–IgE-mediated mechanism is supported by normal tryptase levels. As TXA use expands in pediatric surgical protocols, clinicians should be vigilant when using it in high-risk infants. Multidisciplinary planning, cautious dosing, and preparedness for hemodynamic instability are essential.