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Excessive bleeding often occurs during pediatric scoliosis surgery and is attributed to numerous factors, including accelerated fibrinolysis. The authors hypothesized that administration of tranexamic acid would reduce bleeding and transfusion requirements during scoliosis surgery.Forty-four patients scheduled to undergo elective spinal fusion were randomly assigned to receive either 100 mg/kg tranexamic acid before incision followed by an infusion of 10 mg · kg−1 · h−1 during surgery (tranexamic acid group) or 0.9% saline (placebo group). General anesthesia was administered according to a standard protocol. Blood loss, transfusion requirements, coagulation parameters, and complications were assessed.In the tranexamic acid group, blood loss was reduced by 41% compared with placebo (1,230 ± 535 vs. 2,085 ± 1,188 ml; P < 0.01). The amount of blood transfused did not differ between groups (615 ± 460 vs. 940 ± 718 ml; P = 0.08). Administration of tranexamic acid was a multivariate predictor of blood loss, as was American Society of Anesthesiologists physical status and preoperative platelet count. No apparent adverse drug effects occurred in any patient.Intraoperative administration of tranexamic acid significantly reduces blood loss during spinal surgery in children with scoliosis.