Use of blood-sparing surgical techniques and transfusion algorithms: association with decreased blood administration in children undergoing primary open craniosynostosis repair

Abstract

<jats:sec> <jats:title>OBJECT</jats:title> <jats:p>Craniofacial reconstruction surgery (CFR) is often associated with significant blood loss, coagulopathy, and perioperative blood transfusion. Due to transfusion risks, many different approaches have been used to decrease allogeneic blood transfusion for these patients during the perioperative period. Protocols have decreased blood administration during the perioperative period for many types of surgeries. The object of this study was to determine if a protocol involving blood-sparing surgical techniques and a transfusion algorithm decreased intraoperative blood transfusion and blood loss.</jats:p></jats:sec> <jats:sec> <jats:title>METHODS</jats:title> <jats:p>A protocol using transfusion algorithms and implementation of blood-sparing surgical techniques for CFR was implemented at Vanderbilt University on January 1, 2013. Following Institutional Review Board approval, blood loss and transfusion data were gathered retrospectively on all children undergoing primary open CFR, using the protocol, for the calendar year 2013. This postprotocol cohort was compared with a preprotocol cohort, which consisted of all children undergoing primary open CFR during the previous calendar year, 2012.</jats:p></jats:sec> <jats:sec> <jats:title>RESULTS</jats:title> <jats:p>There were 41 patients in the preprotocol and 39 in the postprotocol cohort. There was no statistical difference between the demographics of the 2 groups. When compared with the preprotocol cohort, intraoperative packed red blood cell transfusion volume decreased from 36.9 ± 21.2 ml/kg to 19.2 ± 10.9 ml/kg (p = 0.0001), whereas fresh-frozen plasma transfusion decreased from 26.8 ± 25.4 ml/kg to 1.5 ± 5.7 ml/kg (p &lt; 0.0001) following implementation of the protocol. Furthermore, estimated blood loss decreased from 64.2 ± 32.4 ml/kg to 52.3 ± 33.3 ml/kg (p = 0.015). Use of fresh-frozen plasma in the postoperative period also decreased when compared with the period before implementation of the protocol. There was no significant difference in morbidity and mortality between the 2 groups.</jats:p></jats:sec> <jats:sec> <jats:title>CONCLUSIONS</jats:title> <jats:p>The results of this study suggested that using a multidisciplinary protocol consisting of transfusion algorithms and implementation of blood-sparing surgical techniques during major CFR in pediatric patients is associated with reduced intraoperative administration of blood product, without shifting the transfusion burden to the postoperative period.</jats:p></jats:sec>

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

“…This approach, along with intraoperative aminocaproic acid (ACA), resulted in a decrease in EBL and transfusion volume of packed red blood cells and fresh frozen plasma (FFP). 58 Haas et al utilized a patient blood management protocol that was created in collaboration with the anesthesia and hematology teams. Using this protocol, while there was no reduction in the amount of transfused blood required, there was a total avoidance of FFP and a reduction in platelets versus children treated off protocol.…”

Impact of multidisciplinary engagement in a quality improvement blood conservation protocol for craniosynostosis

“…Many have involved some combination of plastic surgery, neurosurgery, and anesthesia specialties or have been largely driven by a single specialty involved in this care. [3][4][5]10 In this study, we sought to evaluate the impact of multidisciplinary stakeholder input, including nonsurgical specialties, on a quality improvement-based blood conservation protocol for open CVR in the treatment of craniosynostosis. We hypothesized that this comprehensive protocol would improve outcomes compared to those in two preprotocol groups undergoing the same surgery, one receiving ACA and the other not receiving ACA.…”

“…Nguyen et al evaluated a protocol developed among plastic surgery, neurosurgery, and anesthesiology specialties, which emphasized intraoperative ACA (bolus dose at 100 mg/kg over 30 minutes, then infused at 33 mg/kg/ hr during surgery). 10 In addition, they utilized thromboelastography (TEG) to determine the need for fresh frozen plasma (FFP) transfusion (infused preprotocol for a threshold international normalized ratio [INR] of 1.5). Implementation of their protocol decreased the volume of blood transfused from a mean intraoperative transfusion of 36.9 ml/kg to 19.2 ml/kg.…”

“…9 A variety of protocols and techniques have been proposed to reduce perioperative blood transfusion. [3][4][5]10 Currently, no evidence-based best-practice guidelines exist, resulting in wide variability in practice patterns. This state was underscored by a recent Pediatric Craniofacial Collaborative Group publication.…”

Changes in Transfusion Practice in Children and Adolescents over Time

“…Although the PBM was primarily introduced in the area of adult care, its individual measures may also have had an impact on pediatrics. The treatment of iron deficiency anemia with iron preparations or the use of erythropoietin; reduction of the number and volume of blood samples; and adherence to physiological conditions of hemostasis (pH, calcium concentration and temperature) can be used, as well as the use of bedside coagulation diagnostics and targeted therapy in children [2,[13][14][15][16][17][18][19][20][21][22][23][24].…”