"No Allogeneic Blood Transfusion" protocol for the surgical correction of craniosynostoses

Abstract

Improved anesthesiological and surgical care has resulted in a progressively declining need for allogeneic blood transfusion. In infants with craniosynostosis, however, allogeneic blood transfusion is still performed as a routine procedure. In the present paper, the authors describe a protocol they have devised with the aim of limiting or even avoiding allogeneic blood transfusion even in very young patients, consequently avoiding the risks of infective or immunologic reactions associated with the procedure. The protocol is based on stimulation of the hematopoietic system with erythropoietin, selection of an appropriate age for operation when a favorable balance between fetal and adult-type hemoglobin is established (that is after 4-6 months), preoperative preparation of the autologous blood supply, and intraoperative blood salvage.

Minimizing transfusion requirements for children undergoing craniosynostosis repair: the CHoR protocol

“…28 In the first clinical experience, Velardi and colleagues developed a protocol to minimize autologous blood transfusion that included treating patients preoperatively with EPO, ANH, and intraoperative blood cell salvage. 35 Hemoglobin concentrations were increased in patients treated with EPO for at least 2 weeks. Krajewski and colleagues administered EPO 3 weeks, 2 weeks, and 1 week preoperatively and used Cell Saver intraoperatively; there was a marked increase in preoperative hematocrit and lower transfusion rates.…”

“…19 The transfusion-minimizing protocol reported by Velardi and colleagues included Cell Saver use. 35 Dahmani and coauthors found a significant decrease in the amount of homologous blood transfused in the continuous autotransfusion group. 5 Fearon described a series of patients who received autologous recycled blood and found a rate of allogenic transfusion of only 18% with no complications associated with the use of cell salvage.…”

“…Two studies, as previously mentioned, found a decreased transfusion rate when ANH was combined with erythropoietin therapy. 24,35 One study had a transfusion rate of 36% after ANH during craniosynostosis corrections. 21 One study found no reduction in transfusion rates or amounts with ANH.…”

“…10,20,26,35 Based on these findings, we instituted a protocol that consisted of lowering the acceptable transfusion trigger level of hemoglobin, initiating EPO/iron treatment prior to surgery to increase the preoperative hemoglobin level, and utilizing an intraoperative blood recycling device such as Cell Saver or OrthoPAT (Haemonetics Corporation) to minimize the overall rate of allogenic blood transfusion at our institution.…”

Preoperative Use of Erythropoietin as a Mean of Blood Saving in Children with Nonsyndromic Craniosynostosis

“…Использование гемо-дилюции, когда расчетное количество донорской крови заменяется препаратами гидроксиэтилкрахмала (рефор-таном, волювеном), приводит к развитию острой или подострой анемии, снижению вязкости крови, при этом сохраняется тканевая перфузия. Применение у детей раннего возраста (до 1 года) не рекомендовано, но тем не менее процедура проводится и дает положительный результат в виде уменьшения объема гемотрансфузии, особенно при реконструктивных операциях для коррек-ции краниосиностозов [16]. Отрицательным моментом является развитие и прогрессирование гипокоагуляции, требующей динамического контроля для профилактики и коррекции нарушений коагуляционного гемостаза [17].…”