Craniosynostosis Surgery: Impact of Timing of Intraoperative Blood Transfusions on Post Operative Course

Background/Objectives:

Cranial vault remodeling for  craniosynostosisis known to result in significant blood loss.  Many centers artificially increase hematocrit pre-operatively, and then tolerate very low post-operative hematocrits in order to avoid transfusion.  However, poor perfusion secondary to inadequate oxygen carrying capacity and low blood pressure can precipitate multi organ dysfunction, as well as delay recovery and discharge. The aim of this study is to determine the impact of timing of intraoperative blood transfusion on metabolic disturbances and on the post-operative course.

Methods:

A retrospective chart review was conducted on 62 children with craniosynostosis who underwent either bifrontal or biparietal-occipital calvarial vault remodelings. Variables included: age, length of stay, operative times, time of first blood transfusion and time and results of lab values. Patients were separated into two groups: those receiving the first blood transfusion in the first 100 minutes of surgery (before 100min group), and those receiving first blood at a later time (after 100min group).  Primary outcome was maximum lactate level. Secondary outcomes were minimum hemoglobin, length of stay, and days in the PICU.

Results:

A total of 32 patients received blood before 100min, and 35 received blood after 100min.  The maximum lactate level was similar between the two groups (1.42 mmol/L v. 1.64 mmol/L, P>0.05).   The length of stay was significantly less for patients with transfusion before 100min (3.70 days v 4.54 days, P<0.05) (Graph 1).  Also, there was a significant difference in the hemoglobin nadir for patients with transfusion before 100min (8.73g/dL v. 8.07g/dL, P<0.05) (Table 1).  No transfusion reactions were encountered in this series of patients.

Conclusion:

Timely intraoperative transfusion within the first one hundred minutes of surgery is correlated with a higher nadir hemoglobin level and shorter length of hospital stay post cranial vault remodeling. Early blood transfusion for open cranial vault remodeling surgery should be considered.  Lactate level was not found to be a useful indictor and further investigation will target other metabolic markers.

Graph 1: Distribution of Length of Stay (Days) Between Groups

Means (-1Standard deviation, +1Standard deviation) are given for continuous measures.  LOS = length of stay, PICU = pediatric intensive care unit

*Two-sided Student's T-test and two-sided Mann-Whitney U test was used for continuous measures.   P<0.05, statistically significant difference.