Optimizing Blood Loss and Management in Craniosynostosis Surgery: A Systematic Review of Outcomes Over the Last 40 Years

Abstract

Surgical correction of craniosynostosis can involve significant blood loss. Rates of allogenic blood transfusion have been reported to approach 100%. Multiple interventions have been described to reduce blood loss and transfusion requirements. The aim of this study was to analyze various approaches over the last 4 decades to optimize blood loss and management during craniosynostosis surgery. PRISMA guidelines for systematic reviews were followed. PubMed and Cochrane database searches identified studies analyzing approaches to minimizing blood loss or transfusion rate in craniosynostosis surgery. Primary outcomes included rate or amount of allogenic or autologous blood transfusion, estimated blood loss (EBL), postoperative hemoglobin (Hg), or hematocrit (Hct) levels. Secondary outcomes were examined when reported. Fifty-two studies met inclusion criteria. There was marked heterogeneity regarding design, inclusion criteria, surgical intervention, and endpoints. The majority of the studies were nonrandomized and noncomparative. Four studies analyzed erythropoietin (EPO), 6 analyzed various cell-saver (CS) technologies, 18 analyzed antifibrinolytics (tranexamic acid [TXA], aminocaproic acid [ACA], and aprotinin [APO]), 8 analyzed various alternatives, and 16 analyzed multimodal pathways & protocols. Some studies analyzed multiple approaches. Although the majority of studies reviewed represent level III/IV evidence, several high-quality level I studies were identified and included. Level I evidence supported an improvement in blood outcomes by utilizing EPO, CS, and TXA, individually or in concert with one another. Thus, this review suggests that a multi-prong approach may be the most effective means to optimize blood loss and transfusion outcomes in craniosynostosis surgery.

A Transfusion Regimen With Same-donor Packed Red Blood Cells Reduces Exposure to Multiple Blood Donors in Craniosynostosis Surgery

“…The Hb level at 24 hours postoperatively was 9.1 (1) g/dL, 22% less than the preoperative level. The mean intraoperative transfusion volume reached 135 (69) mL or 17 (7) mL/kg (sagittal: n = 13, 115 [56] mL, 15 [5] mL/kg; fronto-orbital: n = 6, 176 [82] mL, 21 [9] mL/kg). During surgery, all infants received at least one DPU.…”

“…9,12,15 Many craniofacial surgery centers are active in developing new strategies to reduce blood loss and prevent unnecessary blood transfusion and multiple donor exposure. 7,13,[16][17][18][19] These studies include preoperative autologous donation, preoperative erythropoietin, intraoperative cell salvage, acute normovolemic or hypervolemic hemodilution, accepting a lower transfusion trigger, antifibrinolytic drugs (such as tranexamic acid, e-aminocaproic acid and aprotinin, intraoperative fibrinogen substitution, fibrin sealants or fibrin glue, and postoperative drain reinfusion. [16][17][18][20][21][22] Each method has advantages but also side effects, and the optimal transfusion protocol to reduce multiple donor exposure has yet to be established.…”

“…Different surgical techniques, multiple pharmacological agents, and blood conservation strategies are applied to reduce blood loss and transfusion requirements. [6][7][8] Adverse effects and even fatal complications such as transfusion-related acute lung injury (TRALI) and transfusion-related circulatory overload (TACO), can be prevented by avoiding excessive transfusion. [9][10][11][12] Our previous study reported that intraoperative total blood loss and exposure to multiple donors could be reduced by using a mixed pediatric unit (MPU) in infants undergoing craniosynostosis surgery.…”

“…Blood loss typically continues into the early postoperative period when craniotomy techniques are used. Different surgical techniques, multiple pharmacological agents, and blood conservation strategies are applied to reduce blood loss and transfusion requirements 6–8 . Adverse effects and even fatal complications such as transfusion-related acute lung injury (TRALI) and transfusion-related circulatory overload (TACO), can be prevented by avoiding excessive transfusion 9–12 .…”

Frequency and predictors of concurrent complications in multi-suture release for syndromic craniosynostosis

“…Perioperative bleeding is significant during craniosynostosis procedures and comprised 94% of all complications in this study because blood transfusion is considered a complication in the NSQIP-P data. Allogenic blood is commonly transfused during CVR, with some institutions reporting transfusion rates as high as 100% [14]. Although some argue that blood transfusion is "expected," we argue that transfusion should be considered a complication because of the potential consequences of the intervention.…”