Perioperative Outcomes and Management in Pediatric Complex Cranial Vault Reconstruction

Abstract

Background The Pediatric Craniofacial Collaborative Group established the Pediatric Craniofacial Surgery Perioperative Registry to elucidate practices and outcomes in children with craniosynostosis undergoing complex cranial vault reconstruction and inform quality improvement efforts. The aim of this study is to determine perioperative management, outcomes, and complications in children undergoing complex cranial vault reconstruction across North America and to delineate salient features of current practices. Methods Thirty-one institutions contributed data from June 2012 to September 2015. Data extracted included demographics, perioperative management, length of stay, laboratory results, and blood management techniques employed. Complications and outlier events were described. Outcomes analyzed included total blood donor exposures, intraoperative and perioperative transfusion volumes, and length of stay outcomes. Results One thousand two hundred twenty-three cases were analyzed: 935 children aged less than or equal to 24 months and 288 children aged more than 24 months. Ninety-five percent of children aged less than or equal to 24 months and 79% of children aged more than 24 months received at least one transfusion. There were no deaths. Notable complications included cardiac arrest, postoperative seizures, unplanned postoperative mechanical ventilation, large-volume transfusion, and unplanned second surgeries. Utilization of blood conservation techniques was highly variable. Conclusions The authors present a comprehensive description of perioperative management, outcomes, and complications from a large group of North American children undergoing complex cranial vault reconstruction. Transfusion remains the rule for the vast majority of patients. The occurrence of numerous significant complications together with large variability in perioperative management and outcomes suggest targets for improvement.

Perioperative outcomes and management in midface advancement surgery: a multicenter observational descriptive study from the Pediatric Craniofacial Collaborative Group

“…Children undergoing Monobloc procedures had significantly longer ICU and hospital lengths of stay. The median ICU lengths of stay in the Le Fort III and Monobloc groups (4 and 6 days, respectively) are longer than what our group reported for children undergoing complex cranial vault reconstruction (median 4 days) . Similarly, the median hospital lengths of stay in the Le Fort III and Monobloc groups (7 and 10 days, respectively) are longer than those in complex cranial vault reconstruction patients above 2 years old, for whom the median stay was median 5 days .…”

“…The median ICU lengths of stay in the Le Fort III and Monobloc groups (4 and 6 days, respectively) are longer than what our group reported for children undergoing complex cranial vault reconstruction (median 4 days) . Similarly, the median hospital lengths of stay in the Le Fort III and Monobloc groups (7 and 10 days, respectively) are longer than those in complex cranial vault reconstruction patients above 2 years old, for whom the median stay was median 5 days . The reasons for longer lengths of stay following midface advancement relative to complex cranial vault reconstruction and following Monobloc procedures compared to Le Fort III procedures are unclear.…”

Cardiac Arrest in Children

“…In addition, cardiac arrest has been reported possibly due to venous CO 2 embolism during craniofacial surgery [43] and neonatal laparoscopic surgery [44,45].…”

Craniofacial surgery and specific airway problems

“…Cervical fusions have also been found to occur in 25% of Crouzon patients; however, fusion involving C 2 ‐C 3 is most common in Crouzon, whereas C 5 ‐C 6 fusion alone or in combination with other fusions is most common in Apert syndrome . In a study of children presenting for complex cranial vault reconstructions for craniosynostosis, difficult airway management was reported in 2.2% of children . The incidence of difficult airway management in children with a craniofacial dysostosis syndrome was 7% vs 1.3% in nonsyndromic children (unpublished data from the Pediatric Craniofacial Surgery Perioperative Registry), where a difficult airway was defined as difficulty with facemask ventilation (requires two providers, unstable/inadequate ventilation with a facemask, or unable to ventilate by facemask) or with tracheal intubation by conventional direct laryngoscopy.…”