The Road to Transfusion-free Craniosynostosis Repair in Children Less Than 24 Months Old: A Quality Improvement Initiative

Abstract

Introduction: Pediatric craniofacial reconstruction has historically resulted in extensive blood loss necessitating transfusion. This single-center quality improvement initiative evaluates the impact of perioperative practice changes on the allogeneic transfusion rate for children 24 months and younger of age undergoing craniofacial reconstruction. Methods: At project initiation, an appointed core group of anesthesiologists provided all intraoperative anesthetic care for patients undergoing craniofacial reconstruction. Standardized anesthetic guidelines established consistency between providers. Using the Plan-do-check-act methodology, practice changes had been implemented and studied over a 5-year period. Improvement initiatives included developing a temperature-management protocol, using a postoperative transfusion protocol, administering intraoperative tranexamic acid, and a preincisional injection of 0.25% lidocaine with epinephrine. For each year of the project, we acquired data for intraoperative and postoperative allogeneic transfusion rates. Results: A cohort of 119 pediatric patients, ages 4–24 months, underwent anterior or posterior vault reconstruction for craniosynostosis at a tertiary children’s hospital between March 2013 and November 2018. Intraoperative and postoperative transfusion of allogeneic blood products in this cohort decreased from 100% preintervention to 22.7% postintervention. Conclusions: Interdepartmental collaboration and practice modifications using sequential Plan-do-check-act cycles resulted in a bundle of care that leads to a sustainable decrease in the rate of intraoperative and postoperative allogeneic blood transfusions in patients less than 24 months of age undergoing craniosynostosis repair. This bundle decreases the risk of transfusion-related morbidity for these patients. Other institutions looking to achieve similar outcomes can implement this project.

Patient Blood Management in Craniosynostosis Surgery

“…Cranial vault remodeling surgery is one of the most hemorrhagic interventions where transfusion rates vary from 20 to 100% depending on studies (1,2,3). Depending on the type of craniosynostosis, intraoperative blood loss has been reported to be higher in syndromic cranial vault remodeling where venous anomalies play a major role in this outcome (4,5).…”

Trends in Outcomes and Variation by Race and Ethnicity in Pediatric Plastic Surgery in the United States

“…Cranial vault remodeling is one of the most hemorrhagic interventions, with postoperative transfusion rates as high as 81.8%. 13 For the craniosynostosis cases in this study, transfusion rates decreased from 59.5% to 47.4% and were found to be the clear driver of decreasing 30-day morbidity. While our study did not discern total blood transfused, growing uncertainty surrounding evaluation of blood loss proportional to suture involvement and surgical techniques has put transfusion threshold rates at the forefront of craniosynostosis surgical management.…”

“…A few interventions that have been shown to decrease intraoperative blood loss in these operations include cell salvage or the use of antifibrinolytic agents such as tranexamic acid. 13 It is reassuring that the widespread adaptation of these interventions has decreased transfusion rates in this nationwide sample, highlighting the importance of discerning long-term trends. It also underscores the importance of continued innovation and additional safety measures for future improvements.…”

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

“…Four studies analyzed erythropoietin (EPO), 24–27 6 analyzed various cell-saver (CS) technologies, 15,28–32 18 analyzed antifibrinolytics, 12,33–49 8 analyzed various alternative mechanisms, 50–57 and 16 analyzed multimodal pathways & protocols. 37,58–72 If a study described multiple modalities, that study was placed in the multimodal section, however, if a study used multiple modalities and was designed to see the effect of one modality it was placed under that particular section as appropriate.…”

“…Four studies analyzed erythropoietin (EPO), [24][25][26][27] 6 analyzed various cell-saver (CS) technologies, 15,[28][29][30][31][32] 18 analyzed antifibrinolytics, 12,[33][34][35][36][37][38][39][40][41][42][43][44][45][46][47][48][49] 8 analyzed various alternative mechanisms, [50][51][52][53][54][55][56][57] and 16 analyzed multimodal pathways & protocols. 37,[58][59][60][61][62][63][64][65][66][67][68][69][70][71]…”