Tranexamic acid (TXA) is well-established as a safe intervention for reducing transfusion requirements in surgeries with high-risk for blood loss. However, its role in surgeries classified as low-risk for blood loss remains uncertain. Given the frequency of such procedures, even small clinical benefits could have substantial cumulative impact. We assessed the clinical and cost-effectiveness of TXA in surgeries with low expected blood loss A systematic review and meta-analysis of randomised controlled trials (RCTs) for adults or children undergoing low-risk surgeries, comparing peri-operative TXA (any route or dose) with placebo or standard care informed the clinical effectiveness and a decision model adapted from NICE NG24, focusing on short-term hospital costs informed the cost-effectiveness analysis. We included 82 RCTs comprising 8506 participants. TXA significantly reduced blood loss (ratio of means 0·73, 95% CI 0·68,0·79) and transfusion rates (odds ratio 0·39, 95% CI 0·25,0·61). It also reduced hospital stay by 0·4 days (MD = -0·40 days, 95% CI = -0·77, -0·02) and improved pain scores at 1 and 2 weeks postoperatively. Evidence for thrombotic events was limited and inconclusive. The cost-effectiveness analysis showed TXA was cost-saving (£156 per patient) and had a 99% probability of being cost-effective at the £20lJ000 per QALY threshold. Reduction in bleeding and improved recovery outcomes even in surgeries with low anticipated blood loss support broader use of TXA in surgical care and suggests revisiting existing guidelines to include surgeries with any bleeding risk. Further research should examine long-term safety and patient-reported outcomes.

The authors have declared no competing interest.

This study is funded by the NIHR [NIHR Evidence Synthesis programme (NIHR153934)]. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

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