When performing craniosynostosis correction on infants, blood loss is a critical consideration. Worldwide, the National Institutes of Health estimates one in 2,000 to 2,500 live births are affected by craniosynostosis each year. Left untreated, the condition can lead to developmental concerns and permanent skull deformation.
While the surgery to correct craniosynostosis has become routine, pediatric craniofacial surgeons continue to develop refined techniques to reduce blood loss and transfusion risk from the procedure. Many of these strategies are informed by practices from adult surgical methods.
Blood Transfusion Concerns within the Infant Population
Infants average about 80 mL/kg of blood volume and typically weigh less than 10 kg at the time of craniosynostosis. This gives them a total blood volume of less than 800 mL. Any loss of blood in these small patients carries a heightened risk of allogenic blood transfusion. The risks of blood transfusion can vary in severity from a minor immune mediated reaction to transmission of hepatitis C or HIV. Several studies within the adult population have also pointed out the potential for increased perioperative infectious complications following blood transfusion; the implications within the pediatric population are less understood.
The Team Approach
From the craniofacial surgeon to the neurosurgeon to the anesthesiologist, increasing communication before and during the procedure, with an emphasis on reducing blood transfusions, can ensure that every surgical team member is working towards the same goal. The neurosurgeon, for example, can talk the anesthesia team through the steps where blood loss is greatest so they are prepared for this critical point in the procedure.
Increasing Red Blood Cell Counts before Surgery
Before craniosynostosis correction, patients are given recombinant erythropoietin (EPO). Typically used in the adult population to address anemia in those with chronic renal failure or myelodysplastic syndromes, EPO can increase blood volume in a dramatic way.
Addressing Blood Loss during Surgery
Pharmacological and mechanical modalities can be implemented to aid in lessening blood loss. Administering epinephrine, a vasoconstrictor, at the incision site encourages blood vessels to clamp down and bleed less. The incision can be a significant source of bleeding, as the scalp is extremely vascular. In our practice, we also use a special type of cautery device to seal the vessels as the scalp is raised. The cautery device uses less heat than traditional electrocautery while providing an excellent hemostatic seal.
Intraoperative Blood Recycling
Another modality borrowed from adult surgical procedures is the use of blood recycling. This process impacts how we set up the operating room and drape the patient so we can capture any blood that might otherwise be lost. Patients are outfitted with a plastic surgical drape secured around the head and neck, and large amounts of saline irrigation are used to dilute any pooled blood so it does not clot before it is collected. Few, if any, sponges are used during the procedure to reduce further blood loss. These strategies help capture almost all of the lost blood, which is then handled and processed using cell-saver technology and returned to the patient.
Over the past few years, significant refinements have occurred in craniosynostosis correction and reduction of exposure to allogenic blood transfusion. Ten years ago, almost 100 percent of patients at our institution required blood transfusions during or after these procedures. Over the last couple of years, as our institution has focused on reducing blood loss, we’ve been able to reduce that rate down to about 20 percent. While none of these approaches to reducing blood loss are unique, combined they represent a significant shift in strategy to avoid allogenic blood transfusions in the infant population.
Dr. Patel is a craniofacial, pediatric plastic and reconstructive surgeon at Akron Children’s Hospital in Akron, Ohio.