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Azam F, Neerukonda SV, Smith P, Anand S, Mittal S, Bah MG, Barrie U, Detchou D, Aoun SG, Braga BP. Red blood cell transfusion threshold guidelines in pediatric neurosurgery. Neurosurg Rev 2024; 47:555. [PMID: 39240361 DOI: 10.1007/s10143-024-02785-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2024] [Revised: 08/19/2024] [Accepted: 08/31/2024] [Indexed: 09/07/2024]
Affiliation(s)
- Faraaz Azam
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Sanjay V Neerukonda
- McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Parker Smith
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Soummitra Anand
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Sukul Mittal
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Momodou G Bah
- College of Human Medicine, Michigan State University, East Lansing, MI, USA
| | - Umaru Barrie
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Donald Detchou
- School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- University of Pennsylvania School of Medicine, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA.
| | - Salah G Aoun
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Bruno P Braga
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Center for Cerebrovascular Disease in Children, Children's Health, Dallas, TX, USA
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Gutierrez-Pineda F, Franklin BA, Punukollu A, Garcia GG, Duque OEM, Renteria HA, Perez JFP, Gonzalez IA. Efficacy and safety of sagittal synostosis surgery in older (> 12 months) patients: a systematic review and meta-analysis. Childs Nerv Syst 2024; 40:2801-2809. [PMID: 38856746 DOI: 10.1007/s00381-024-06472-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Accepted: 05/23/2024] [Indexed: 06/11/2024]
Abstract
PURPOSE Sagittal synostosis is the most common isolated craniosynostosis. Surgical treatment of this synostosis has been extensively described in the global literature, with promising outcomes when it is performed in the first 12 months of life. However, in some cases, patients older than 12 months arrive at the craniofacial center with this synostosis. A comprehensive study on efficacy and perioperative outcomes has yet to be fully explored in this population. This systematic review and meta-analysis aimed to assess the available evidence of surgical outcomes for the treatment of sagittal synostosis among older patients to analyze the efficacy and safety of synostosis surgery in this unique population. METHODS PubMed, Embase, and Scopus were searched for studies published from inception to March 2024 reporting surgical outcomes of synostosis surgery in older patients (> 12 months) with isolated sagittal synostosis. The main outcome was the reoperation rate, with secondary endpoints including transfusion rates, aesthetic outcomes, and surgical complications. RESULTS Nine studies were included in the final analysis. The pooled proportion of the reoperation rate was 1%. The rate of excellent aesthetic results was 95%. The need for transfusion associated with the procedures was 86%, and finally, surgical complications attained a pooled ratio of 2%, indicating minimal morbidity associated with the surgical repair. CONCLUSION Sagittal synostosis surgery is a safe and effective procedure to perform in older patients; this meta-analysis suggests that open surgery confers a significant rate of excellent aesthetic results with a low reoperation rate and minimal complications associated with the intervention. Future research with direct comparisons among different techniques will validate the findings of this study, which will all contribute to the rigor of synostosis management.
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Affiliation(s)
- Felipe Gutierrez-Pineda
- Department of Neurosurgery, University of Antioquia, School of Medicine, Medellin, Colombia.
- Department of Neurosurgery, Colombian Neurological Institute, Medellin, Colombia.
| | | | | | - Gustavo Giraldo Garcia
- Department of Neurosurgery, University of Antioquia, School of Medicine, Medellin, Colombia
- Department of Neurosurgery, Hospital Pablo Tobon Uribe, Medellin, Colombia
| | - Oscar Eduardo Moreno Duque
- Department of Neurosurgery, University of Antioquia, School of Medicine, Medellin, Colombia
- Department of Neurosurgery, Colombian Neurological Institute, Medellin, Colombia
| | - Haiber Arias Renteria
- Department of Neurosurgery, University of Antioquia, School of Medicine, Medellin, Colombia
- Department of Neurosurgery, Colombian Neurological Institute, Medellin, Colombia
| | - Juan Felipe Pelaez Perez
- Department of Neurosurgery, University of Antioquia, School of Medicine, Medellin, Colombia
- Department of Neurosurgery, Colombian Neurological Institute, Medellin, Colombia
| | - Ignacio Alberto Gonzalez
- Department of Neurosurgery, University of Antioquia, School of Medicine, Medellin, Colombia
- Department of Neurosurgery, Hospital Pablo Tobon Uribe, Medellin, Colombia
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Coombs DM, Knackstedt R, Patel N. Optimizing Blood Loss and Management in Craniosynostosis Surgery: A Systematic Review of Outcomes Over the Last 40 Years. Cleft Palate Craniofac J 2023; 60:1632-1644. [PMID: 35903885 DOI: 10.1177/10556656221116007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Surgical correction of craniosynostosis can involve significant blood loss. Rates of allogenic blood transfusion have been reported to approach 100%. Multiple interventions have been described to reduce blood loss and transfusion requirements. The aim of this study was to analyze various approaches over the last 4 decades to optimize blood loss and management during craniosynostosis surgery. PRISMA guidelines for systematic reviews were followed. PubMed and Cochrane database searches identified studies analyzing approaches to minimizing blood loss or transfusion rate in craniosynostosis surgery. Primary outcomes included rate or amount of allogenic or autologous blood transfusion, estimated blood loss (EBL), postoperative hemoglobin (Hg), or hematocrit (Hct) levels. Secondary outcomes were examined when reported. Fifty-two studies met inclusion criteria. There was marked heterogeneity regarding design, inclusion criteria, surgical intervention, and endpoints. The majority of the studies were nonrandomized and noncomparative. Four studies analyzed erythropoietin (EPO), 6 analyzed various cell-saver (CS) technologies, 18 analyzed antifibrinolytics (tranexamic acid [TXA], aminocaproic acid [ACA], and aprotinin [APO]), 8 analyzed various alternatives, and 16 analyzed multimodal pathways & protocols. Some studies analyzed multiple approaches. Although the majority of studies reviewed represent level III/IV evidence, several high-quality level I studies were identified and included. Level I evidence supported an improvement in blood outcomes by utilizing EPO, CS, and TXA, individually or in concert with one another. Thus, this review suggests that a multi-prong approach may be the most effective means to optimize blood loss and transfusion outcomes in craniosynostosis surgery.
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Affiliation(s)
| | | | - Niyant Patel
- Division of Pediatric Plastic and Reconstructive Surgery, Akron Children's Hospital, Akron, OH, USA
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Alabdulkarim A, Al Qurashi AA, Odeh NB, Hashemi AS, Arbili LM, AlSwealh MS, Shakir MN, Banser SM, Sharaf LA, Alkhonizy SW, AlBattal NZ. Effect of Tranexamic Acid on the Reduction of Blood Loss in Craniosynostosis Surgery: A Systematic Review and Meta-analysis. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5021. [PMID: 37383480 PMCID: PMC10299774 DOI: 10.1097/gox.0000000000005021] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 03/20/2023] [Indexed: 06/30/2023]
Abstract
Although many published studies have investigated the benefits of tranexamic acid (TXA) in reducing perioperative bleeding, no large meta-analysis has been conducted to demonstrate its overall benefit. Methods A systematic review was performed by following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. PubMed, Cochrane, Ovid, Embase, Web of Science, ClinicalTraisl.Gov, and Scopus databases were searched for articles reporting the benefit of TXA in reducing perioperative bleeding in craniosynostosis surgery from establishment through October 2022. The results of our meta-analysis were pooled across the studies using a random-effects model, and presented as a weighted mean difference with 95% confidence interval (95% CI). Results The database search yielded 3207 articles, of which 27 studies with a corresponding number of 9696 operations were eligible. The meta-analysis included only 18 studies, accounting for 1564 operations. Of those operations, 882 patients received systemic TXA, whereas 682 patients received placebo (normal saline), no intervention, low dose TXA, or other control substances. This meta-analysis demonstrated a significant beneficial effect of TXA in reducing perioperative bleeding, particularly when compared with other controlled substances, with a weighted mean difference of -3.97 (95% CI = -5.29 to -2.28). Conclusions To our knowledge, this is the largest meta-analysis in the literature investigating the benefit of TXA in reducing perioperative blood loss in craniosynostosis surgery. We encourage implementing TXA-protocol systems in hospitals after the appraisal of the data presented in this study.
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Affiliation(s)
- Abdulaziz Alabdulkarim
- From Plastic Surgery, Department of Surgery, College of Medicine, Prince Sattam Bin Abdulaziz University, Al Kharj, Saudi Arabia
| | - Abdullah A. Al Qurashi
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Nour B. Odeh
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | | | - Lana M. Arbili
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Maab S. AlSwealh
- Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Malak N. Shakir
- Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Sultan M. Banser
- Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Lina A. Sharaf
- Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | | | - Nouf Z. AlBattal
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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Eustache G, Nardi N, Rousseau C, Aouaissia S, Aillet S, Delahaye Larralde S, Wodey E, Riffaud L. Importance of tranexamic acid in pediatric monosutural craniosynostosis surgery. J Neurosurg Pediatr 2022; 29:412-418. [PMID: 34952528 DOI: 10.3171/2021.10.peds21438] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 10/26/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Tranexamic acid (TXA) is an antifibrinolytic drug that has achieved significant reduction in perioperative blood loss and the quantity of blood transfused in many pediatric surgical procedures, without morbidity. Despite the accumulation of evidence regarding its effectiveness in craniosynostosis repair surgery, TXA is not unanimously employed by pediatric neurosurgery teams. The purpose of this study was to evaluate the impact of the routine use of TXA in a homogeneous population of children who underwent open surgery for monosutural craniosynostosis. METHODS The authors retrospectively reviewed 3 cohorts of patients that were subdivided from 2 cohorts surrounding the initiation of TXA (group 1, TXA- [2008-2011] and group 2, TXA+ [2011-2013]) and a third cohort of more recent patients (group 3, TXA+ [2016-2017]). TXA was administered using the same protocol comprising a loading dose of 10 mg/kg over 15 minutes after induction of general anesthesia followed by a 10 mg/kg per hour infusion until skin closure. Patients in all 3 groups underwent similar standardized procedures for scaphocephaly, trigonocephaly, and unicoronal craniosynostosis by the same pediatric neurosurgeon. RESULTS Overall, 102 infants were included in the study: 32 infants in group 1, 36 in group 2, and 34 in group 3. Significant reductions in transfusion of packed erythrocytes (PE) and fresh-frozen plasma (FFP) were observed between the TXA- and TXA+ time periods. The median volume of PE transfusion was reduced by > 50% with the use of TXA (42.8 mL/kg in the TXA- group vs 20.0 in the TXA+ groups, p < 0.0001). Reduction in PE transfusion was 100% postoperatively in the TXA+ groups (20.0 mL/kg in the TXA- group vs 0.0 in the TXA+ groups, p < 0.0001). The median volume of FFP transfusion was reduced by 100% with the use of TXA (12.8 mL/kg in the TXA- group vs 0.0 in the TXA+ groups, p < 0.0001). All children in group 1 received a transfusion, whereas 3 children (8%) and 7 children (20%) in groups 2 and 3, respectively, did not. Significant reductions in postoperative drain output were also noted between the TXA- and TXA+ time periods. The total hospital length of stay was significantly lower in the TXA+ groups (p < 0.0001). CONCLUSIONS Use of TXA reduced blood loss and the need for transfusions but also decreased the hospital length of stay and, thus, minimized overall medical care costs. Intraoperative administration of TXA in craniosynostosis repair surgery should be routinely used in all centers that practice these procedures.
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Affiliation(s)
- Gabriel Eustache
- 1Department of Pediatric Anesthesia, Rennes University Hospital, Rennes
| | - Nicolas Nardi
- 1Department of Pediatric Anesthesia, Rennes University Hospital, Rennes.,2Department of Pediatric Intensive Care, Rennes University Hospital, Rennes
| | - Chloé Rousseau
- 3Clinical Data Center, Rennes University Hospital, Rennes
| | - Sandra Aouaissia
- 4Department of Pediatric Neurosurgery, Rennes University Hospital, Rennes
| | - Sylvie Aillet
- 5Department of Plastic Surgery, Rennes University Hospital, Rennes; and
| | - Severine Delahaye Larralde
- 1Department of Pediatric Anesthesia, Rennes University Hospital, Rennes.,2Department of Pediatric Intensive Care, Rennes University Hospital, Rennes
| | - Eric Wodey
- 1Department of Pediatric Anesthesia, Rennes University Hospital, Rennes.,2Department of Pediatric Intensive Care, Rennes University Hospital, Rennes.,6Inserm U1099 LTSI, University of Rennes 1, Rennes, France
| | - Laurent Riffaud
- 4Department of Pediatric Neurosurgery, Rennes University Hospital, Rennes.,6Inserm U1099 LTSI, University of Rennes 1, Rennes, France
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Meier N. Anesthetic Considerations for Pediatric Craniofacial Surgery. Anesthesiol Clin 2021; 39:53-70. [PMID: 33563386 DOI: 10.1016/j.anclin.2020.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Anesthetic management of craniosynostosis remains a challenging experience. It requires input and collaboration from multiple specialties to improve patient outcomes. Understanding the surgical corrective techniques and the underlying risks of each is essential to providing the best care to this patient population. The propensity for significant blood loss necessitates fundamental knowledge of pediatric resuscitation and the development of perioperative transfusion protocols that have been shown to reduce transfusion requirements in the peri-operative period.
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Affiliation(s)
- Nicholas Meier
- Department of Anesthesiology, Medical College of Wisconsin, Children's Hospital of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI 53226, USA.
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Escher PJ, Tu AD, Kearney SL, Linabery AM, Petronio JA, Kebriaei MA, Chinnadurai S, Tibesar RJ. A protocol of situation-dependent transfusion, erythropoietin and tranexamic acid reduces transfusion in fronto-orbital advancement for metopic and coronal craniosynostosis. Childs Nerv Syst 2021; 37:269-276. [PMID: 32388812 DOI: 10.1007/s00381-020-04654-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 04/28/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Assess the effect of a protocol of preoperative erythropoietin (EPO) and ferrous sulfate in addition to perioperative tranexamic acid (TXA) on blood transfusions in patients with coronal or metopic craniosynostosis undergoing cranial vault remodeling (CVR) with fronto-orbital advancement (FOA). METHODS Retrospective review of all coronal and metopic craniosynostosis patients undergoing CVR and FOA from March 2010 to June 2019 was performed. Before 2014 ("Control group"), all patients received blood transfusion at the start of surgery. In 2014, a protocol of preoperative EPO and ferrous sulfate with perioperative TXA and non-automatic transfusion was instituted ("Study group"). Patient demographics and anthropometrics, perioperative hemoglobin (Hb) levels, and transfusion details were collected and compared. RESULTS Thirty-six patients met inclusion criteria. Twenty-one patients were in the control group, and 15 in the Study group. Nineteen patients had metopic synostosis, 11 had unicoronal synostosis, and 6 had bicoronal synostosis. There were no significant differences between groups in demographics, operative time, intraoperative crystalloid volume, craniofacial syndromes, or sutures affected. The Study group had higher preoperative Hb (13.9 ± 1.0 vs. 12.6 ± 0.8 g/dL, p < 0.001), lower intraoperative Hb nadir (7.4 ± 1.8 vs. 9.2 ± 1.2 g/dL) lower intraoperative transfusion rate (66.7% vs. 100%, p = 0.008), lower postoperative transfusion rate (0% vs 28.6%, p = 0.03), and exposure to fewer unique units of packed red blood cells (0.7 ± 0.6 vs. 1.5 ± 0.9 units). CONCLUSION Our protocol resulted in decreased transfusion needs. These results add valuable information to the growing body of work on transfusion reduction in craniosynostosis surgery.
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Affiliation(s)
- Paul J Escher
- University of Minnesota Medical School, Minneapolis, MN, USA
| | - Albert D Tu
- Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Susan L Kearney
- Children's Minnesota Center for Bleeding and Clotting Disorders, Minneapolis, MN, USA
| | - Amy M Linabery
- Children's Minnesota Research Institute, Minneapolis, MN, USA
| | - Joseph A Petronio
- Department of Neurosurgery, Children's Minnesota, Minneapolis, MN, USA
| | - Meysam A Kebriaei
- Department of Neurosurgery, Children's Minnesota, Minneapolis, MN, USA
| | - Sivakumar Chinnadurai
- Department of ENT and Craniofacial Surgery, Children's Minnesota, 2530 Chicago Ave. S, CSC 450, Minneapolis, MN, 55404, USA
| | - Robert J Tibesar
- Department of ENT and Craniofacial Surgery, Children's Minnesota, 2530 Chicago Ave. S, CSC 450, Minneapolis, MN, 55404, USA.
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Complications of erythropoietin in navigated brain gene therapy: A case report. INTERDISCIPLINARY NEUROSURGERY 2020. [DOI: 10.1016/j.inat.2020.100698] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Steinbok P. Letter to the Editor Re: Escher PJ, Tu A, Kearney S, Wheelwright M, Petronio J, Kebriaei M, Chinnadurai S, Tibesar RJ (2019) Minimizing transfusion in sagittal craniosynostosis surgery: the Children's Hospital of Minnesota Protocol. Child's nervous system: 35: 1357-1362. Childs Nerv Syst 2020; 36:3-4. [PMID: 31659480 DOI: 10.1007/s00381-019-04393-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 09/26/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Paul Steinbok
- Division of Neurosurgery, BC Children's Hospital and University of British Columbia, 4480 Oak St., Room K3-159, Vancouver, BC, V6H 3V4, Canada.
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Eustache G, Riffaud L. Reducing blood loss in pediatric craniosynostosis surgery by use of tranexamic acid. Neurochirurgie 2019; 65:302-309. [PMID: 31586574 DOI: 10.1016/j.neuchi.2019.09.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Revised: 09/27/2019] [Accepted: 09/28/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Craniosysnostosis surgical corrections are routine procedures in the pediatric neurosurgical field. However, these procedures result in significant blood loss. Tranexamic acid (TXA) is an antifibrinolytic drug, which has demonstrated a significant reduction in perioperative blood loss in many pediatric surgical procedures such as cardiac surgery and scoliosis surgery. We conducted a systematic review to evaluate protocols of TXA use in pediatric craniosynostosis procedures and its effect on intraoperative blood loss and transfusions. MATERIAL AND METHODS A comprehensive literature review of the National Library of Medicine (PubMed) database was performed to identify relevant studies. We included any clinical study reporting on blood loss or blood transfusion for pediatric craniosynostosis surgery with intraoperative use of tranexamic acid, with the following limits: publication date from inception to May 2019; reports in English. RESULTS Thirteen studies were eligible for our review. Of the 13 studies, 4 were prospective, randomised, double-blind controlled trials, 9 were retrospective studies, tailored as a "before-after" studies, comparing blood loss and transfusion without/with TXA. TXA significantly decreases the number and volume of packed red blood cell transfusions and the rate of transfusion in children undergoing craniosynostosis surgery. Significantly fewer fresh frozen plasma transfusions were required in the TXA groups in 2 randomised studies. Length of stay in hospital was significantly lower with the use of TXA in three studies. Advantages of TXA administration also include an excellent patient tolerance of side effects, ease of administration and low cost. CONCLUSION TXA significantly reduces blood loss and the need for transfusions in children undergoing craniosynostosis surgery. TXA administration should be a routine part of strategy to reduce blood loss and limit transfusions in these procedures.
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Affiliation(s)
- G Eustache
- Rennes University, CHU of Rennes, Department of Anesthesiology, 35000 Rennes, France
| | - L Riffaud
- Rennes University, CHU of Rennes, Department of Neurosurgery, 35000 Rennes, France; INSERM MediCIS, Unit U1099 LTSI, Rennes 1 University, 35000 Rennes, France.
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