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DP46: AEROSOLIZED HEMOSTASIS: NEBULIZED TRANEXAMIC ACID FOR AIRWAY BLEEDING AFTER TRANSESOPHAGEAL ECHOCARDIOGRAPHY
Marc Levine, MD; Harry Kranichfeld, DO; Pedro Garcia Quintero, MD; Gerald Rosen, MD
Mount Sinai Medical Center
Background: Hereditary Hemorrhagic Telangiectasia (HHT) is an autosomal dominant disorder that causes abnormal enlargement of veins and arteries. Transesophageal echocardiography (TEE) is commonly used to demonstrate high resolution images of a patient’s heart structure and blood flow. Insertion of a TEE probe can cause mechanical trauma that in some cases has led to oropharyngeal bleeding. Nebulized tranexamic acid (TXA), an antifibrinolytic medication that stabilizes blood clots to prevent excessive bleeding, has been found to be a beneficial treatment for non-massive hemoptysis.[1] However, the role of nebulized TXA in pharyngeal hemorrhage caused by mechanical trauma from instrumentation has not been well described.
Case Presentation: We report a case of a 66 year old female with known HHT who underwent a TEE with MAC sedation to evaluate for endocarditis prior to a right total knee surgery. After the TEE probe was inserted approximately 1-2 inches into the oral cavity just distal to the base of the tongue, the patient developed a significant gag reflex. The probe was withdrawn and the plan was to increase sedation, however, blood was noted in the oral cavity. The procedure was immediately aborted and the airway was aggressively suctioned. Visualization with direct laryngoscopy demonstrated intact dentition and no obvious trauma. Otolaryngology (ENT) was consulted and recommended nebulized TXA. Nebulized TXA (500mg in 5mL) was placed into a jet nebulizer and attached to a simple face mask with oxygen flowing at 6L/min with the patient breathing normally. 10 minutes after receiving nebulized TXA, the posterior pharyngeal bleeding subsided. ENT evaluated the patient at bedside and recommended one more nebulized TXA treatment 8 hours from the initial treatment.
Discussion: Nebulized TXA has been found to be beneficial treatment for non-massive hemoptysis in several studies, and may also have minimal side effects compared with other treatments.[1,2,3] This case highlights how airway instrumentation and insertion of TEE probes may carry a higher risk for airway bleeding, especially in patients with HHT, and vigilance is important for rapid identification and treatment. Nebulized TXA represents a quick and effective adjunct for achieving hemostasis in scenarios where it is difficult to localize the source of pharyngeal bleeding.
Conclusion: Nebulized TXA may be an effective rescue medication for pharyngeal bleeding after insertion of a TEE probe in a patient with HHT. Future studies should be completed to further elucidate guidelines for treatment including dosing and frequency. This case supports nebulized TXA as another tool in the anesthesiologists’ toolbox for the management of airway bleeding.
[1]Ye M, Chen M, Wang C, Jiang Z, Luo H, Ren Y. Nebulized Tranexamic Acid in the Management of Hemoptysis: An Integrative Review. Lung. 2025 Jan 22;203(1):28.
[2] Alabdrabalnabi F, Alshahrani M, Ismail N. Nebulized tranexamic acid for recurring hemoptysis in critically ill patients: case series. Int J Emerg Med. 2020 Aug 20;13(1):45.
[3] Mahalingam S, Rajendran G, Ramkumar A, Elanjeran R, Krishnamoorthy Y, Dinesh V, Thirthar Palanivelu E, Salih A, Ponnaeasu SP. Effectiveness of Inhalational Tranexamic Acid in Patients with Nonmassive Hemoptysis-A Systematic Review and Meta-Analysis. Lung. 2025 Jan 3;203(1):19.