Predictors of transfusion outcomes in pediatric complex cranial vault reconstruction: a multicentre observational study from the Pediatric Craniofacial Collaborative Group

Fernandez, Patrick; Taicher, Brad M.; Goobie, Susan M.; Gangadharan, Meera; Homi, H. Mayumi; Kugler, Jane; Skitt, Rochelle; Cai, Lingyu; Polansky, Marcia; Stricker, Paul A.

doi:10.1007/s12630-019-01307-w

Cited by 26 publications

(27 citation statements)

References 29 publications

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“… 29 – 32 There have yet to be detailed reports of management for complex craniofacial children, beginning with preoperative assessment and optimization to anesthesia, intraoperative management, and intensive care recovery. 22 , 23 As cranial vault remodeling can be associated with significant morbidity and a prolonged length of stay, analyzing surgical techniques and approaches is critical to improving and optimizing recovery. In this study, we chose to analyze only children undergoing FOA, as this complex surgical approach has been associated with a historically high rate of transfusion requirement and hospital length of stay, even within cranial vault remodeling.…”

Section: Discussionmentioning

confidence: 99%

“… 20 , 21 There has yet to be a detailed report of management for complex craniofacial children from an anesthesia or intensive care perspective. 22 , 23 Additionally, most postoperative protocols rely on direct patient examination by a provider that may only occur at certain time points, such as morning rounds, which can delay decision-making and the advancement of a child’s recovery. However, protocols and order sets that allow for decisions to be increasingly made by the bedside nursing team can allow for expedited changes based on the child’s evolving recovery.…”

Section: Introductionmentioning

confidence: 99%

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Enhanced Recovery Protocol after Fronto-orbital Advancement Reduces Transfusions, Narcotic Usage, and Length of Stay

Knackstedt

Patel

2020

Plastic and Reconstructive Surgery - Global Open

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Background: Enhanced recovery after surgery (ERAS) protocols utilize multi-modal approaches to decrease morbidity, narcotic usage, and length of stay. In 2013, we made several changes to our perioperative approach to children undergoing complex craniofacial procedures. The goal of this study was to analyze our protocol for children undergoing fronto-orbital advancement (FOA) for craniosynostosis. Methods: A retrospective chart review was performed after IRB approval, for children who underwent fronto-orbital advancement for craniosynostosis from 2010 to 2018. The ERAS protocol, initiated in December 2013, involves hemoglobin optimization, cell-saver technology, tranexamic acid, specific postoperative fluid titration, and a transfusion algorithm. The analgesic regimen focuses on narcotic reduction through the utilization of scheduled acetaminophen, ibuprofen, or ketorolac, and a dexmedetomidine infusion with opioids only for breakthrough pain. Results: Fifty-five ERAS protocol children and 23 control children were analyzed. ERAS children had a decreased rate (13/53 versus 23/23, P < 0.0001) and volume of intraoperative transfusion (183.4 mL versus 339.8 mL, P = 0.05). Fewer ERAS children required morphine/dilaudid (12/55 versus 22/23 P < 0.0001) and for children who required morphine, fewer doses were required (2.8 versus 11, P = 0.02). For ERAS protocol children who required PO narcotics, fewer doses were required (3.2 versus 5.3, P = 0.02). ERAS children had a decreased length of stay (2.3 versus 3.6 nights, P < 0.0001). No patients were re-admitted due to poor oral intake, pain, hemodynamic, or pulmonary concerns. Conclusions: Our ERAS protocol demonstrated a reduction in the overall and intraoperative allogenic blood transfusion rate, narcotic use, and hospital length of stay. This is a safe and effective multimodal approach to managing complex craniofacial surgical recovery.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Enhanced Recovery Protocol after Fronto-orbital Advancement Reduces Transfusions, Narcotic Usage, and Length of Stay

Knackstedt

Patel

2020

Plastic and Reconstructive Surgery - Global Open

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“…In an observational study examining transfusion practice in children older than 28 days who underwent surgery in different hospitals was found that younger age (29 days to 2 years) among other factors was a preoperative variable associated with increased odds of having an intraoperative or postoperative RBC transfusion [ 7 ]. A recently published register study in pediatric patients undergoing complex cranial vault reconstruction identified that age less than 24 months as one of the factors for increased RBC transfusion [ 24 ].…”

Section: Discussionmentioning

confidence: 99%

Intraoperative transfusion practice in burned children in a university hospital over four years: a retrospective analysis

et al. 2021

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Background Patient blood management programs should be applied to the pediatric population, but little is known about the current transfusion practice of pediatric burn injury patients. This retrospective study was performed to evaluate the practice of red blood cell (RBC) transfusion in children with burn injury, their predictive factors, and adherence to the German transfusion guideline. Methods We reviewed the RBC transfusion practice of all children younger than 8 years with burn injury who were operated during a four-year period in a German university medical center. We analyzed the data associated with transfusion and guideline conformity of transfusion triggers for RBCs from the beginning to the end of hospital stay using logistic regression. Results During the four-year period, 138 children (median age 21 months, minimum-maximum 9–101 months) with burn injury needed surgery, 31 children were transfused with RBCs. During their hospital stay, the median hemoglobin concentrations (Hb) of transfused and non-transfused children were 8 g/dL (6.3–11.3 g/dL) and 10.7 (7–13.8 g/dL), respectively. Total body surface area burned (TBSA) (OR = 1.17 per % TBSA, 95% CI = [1.05; 1.30], p = 0.0056), length of surgery (OR = 1.016 per minute, 95% CI = [1.003; 1.028], p = 0.0150), and Hb (OR = 0.48 per 1 g/dl in Hb, 95% CI = [0.24; 0.95], p = 0.0343) were associated with transfusion while other factors (age, gender, ASA, and catecholamines) did not show notable association. Length of stay was mainly influenced by TSBA (+ 1.38 days per %, p < 0.0001), age (+ 0.21 days per month, p = 0.0206), and administering of catecholamines (+ 14.3 days, p = 0.0118), but not by RBC transfusion. The decision to transfuse was in 23% too restrictive and in 74% too liberal according to the German guidelines. Conclusions Amount of TBSA, length of surgery, and Hb influenced the RBC transfusion rate in burned children. However, age and length of stay were not affected by transfusion of RBCs. In clinical practice of burned children, physicians follow a more liberal transfusion strategy than the proposed in guidelines.

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“…1 Children undergoing surgical correction of craniosynostosis often experience high rates of bleeding and blood product transfusion, increasing the risk of postoperative complications including mortality. [3][4][5] The most severe and most common perioperative issues relate to the rate and extent of blood loss, which can be up to several times the patient's total blood volume. 3,6,7 Contributing to high blood loss rates are the large surgical surfaces exposed, hyperfibrinolysis, and dilutional coagulopathy.…”

Section: Introductionmentioning

confidence: 99%

“…10,16 TXA has been shown to be effective in limiting blood loss in infants and children undergoing CCVR, and two recent retrospective reviews suggest a benefit of EACA in this population as well. 5,14,[17][18][19] While the use of EACA and TXA to limit surgically-induced hemorrhage and transfusion requirements during CCVR has been extensively studied, the comparison of EACA vs TXA in children undergoing CCVR has not yet been evaluated. The aim of this study was to compare perioperative blood loss and need for transfusion in children receiving EACA and TXA.…”

Section: Introductionmentioning

confidence: 99%

ε-Aminocaproic acid (EACA) vs. tranexamic acid (TXA) in children undergoing complex cranial vault reconstruction for repair of craniosynostosis

Borst

Bonfield

Deenadayalan

et al. 2021

Preprint

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INTRODUCTION: Children undergoing complex cranial vault reconstruction (CCVR) for craniosynostosis experience high rates of bleeding and transfusion, increasing risk for perioperative complications. ε-Aminocaproic acid (EACA) and tranexamic acid (TXA) are antifibrinolytic agents that have been shown to reduce intraoperative hemorrhage and transfusion requirements during CCVR. However, the relative efficacy of these two agents has not yet been evaluated. The aim of this study was to compare perioperative blood loss and transfusion rates in children receiving EACA vs. TXA. METHODS: All patients who underwent CCVR from September 2015 to December 2019 at a single center were retrospectively evaluated. Primary outcome measures included intraoperative estimated blood loss, postoperative drain output, transfusion volumes, and calculated blood loss. Secondary outcome measures included hematologic and coagulation parameters. RESULTS: 95 patients were included, with 47 patients in the EACA cohort and 48 patients in the TXA cohort. There were no significant differences in demographics, surgical outcomes, blood loss, transfusion requirement, or perioperative hematologic and coagulation laboratory values between the two cohorts. Adverse events were similar between the groups, but did include two seizure events and two thromboembolic events related to vascular access devices. DISCUSSION: We found no significant difference in blood loss, transfusion requirements, hematologic parameters, or outcomes between pediatric CCVR patients who received EACA vs. TXA. Further research is needed to define optimal antifibrinolytic dosing and duration of therapy. While standard laboratory parameters were similar between groups, future studies investigating coagulation-based and inflammatory assays may be useful in defining surgical-induced coagulopathy.

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Predictors of transfusion outcomes in pediatric complex cranial vault reconstruction: a multicentre observational study from the Pediatric Craniofacial Collaborative Group

Cited by 26 publications

References 29 publications

Enhanced Recovery Protocol after Fronto-orbital Advancement Reduces Transfusions, Narcotic Usage, and Length of Stay

Enhanced Recovery Protocol after Fronto-orbital Advancement Reduces Transfusions, Narcotic Usage, and Length of Stay

Intraoperative transfusion practice in burned children in a university hospital over four years: a retrospective analysis

ε-Aminocaproic acid (EACA) vs. tranexamic acid (TXA) in children undergoing complex cranial vault reconstruction for repair of craniosynostosis

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