Reducing blood loss in pediatric craniosynostosis surgery by use of tranexamic acid

Topical Tranexamic Acid (TXA) Decreases Time to Drain Removal, Wound Healing Complications, and Postoperative Blood Loss in Autologous Breast Reconstruction: A Retrospective Study

Introduction: Drain placement is commonplace after many plastic surgery procedures to evacuate excess blood and fluid. Tranexamic acid (TXA) is an antifibrinolytic that has been shown to decrease bleeding and fluid production at surgical sites and can be administered orally, intravenously, and topically. The purpose of this study is to evaluate the effect of topical TXA on drain removal in abdominally based autologous breast reconstruction (ABABR). Methods: A retrospective chart review was performed on patients who underwent ABABR from August 2018 to November 2019. In 1 cohort, a 2.5% TXA solution was topically applied to the abdominal wall prior to closure. Drains were removed when output was less than 30 mL/day for 2 consecutive days. The primary outcome was days to drain removal. Secondary outcomes include daily inpatient drain output, postoperative hemoglobin levels, blood transfusions, and complications within 30 days postoperatively. Results: Eighty-three patients were included, with 47 in the control group and 36 in the TXA group. Drains were removed significantly earlier in patients who received TXA (16 days vs 23 days, P = .02). Additionally, significantly fewer patients required postoperative blood transfusions in the TXA group (2 vs 14, P = .005). Abdominal complications were fewer in the TXA group with significantly less wound healing complications (22% vs 49%, P = .01). There was no difference in flap loss or systemic thromboembolic events. Conclusion: Topical TXA use in ABABR results in earlier abdominal drain removal, less blood transfusions, and lower abdominal wound complications without an increased risk of flap loss or adverse patient outcomes.

A Transfusion Regimen With Same-donor Packed Red Blood Cells Reduces Exposure to Multiple Blood Donors in Craniosynostosis Surgery

In major craniosynostosis surgery with moderate to severe blood loss, patients may be exposed to multiple donors. We have previously reported a method for reducing donor exposure using mixed pediatric units including plasma. To further reduce donor exposure, we used plasma-free divided pediatric units. The study aimed to investigate the feasibility of the new strategy for reducing donor exposure. This prospective observational study recruited children younger than 1 year who were scheduled for nonsyndromic craniosynostosis surgery. One adult red blood cell unit was divided into 4 equal units on the day before the operation for use intra- or postoperatively. Number of donor exposures, estimated blood loss, crystalloid, colloid, and blood product volumes, and coagulation parameters were evaluated. Nineteen infants were included. The mean estimated blood loss was 19 (3) mL/kg and the transfusion volume was 17 (7) mL/kg. The median donor exposure per patient was 1 (range, 1-3). During surgery, all infants received at least one DPU. Two infants received transfusions from more than one donor during the intraoperative period. In the first 24 hours postoperatively, 14 infants received transfusion; 10 received only DPUs, whereas 4 received from multiple donors. In all, multiple donor exposure was prevented in 14 of 19 infants. Postoperative Pk-INR was 1.33 (0.16); no plasma or platelets were transfused. The plasma-free DPU transfusion protocol may be useful to reduce donor exposure in open craniosynostosis surgery in infants.

Tranexamic acid decreases transfusion requirements during the modified pi-plasty procedure for sagittal craniosynostosis

The aim of our study was to evaluate the effectiveness of intraoperative tranexamic acid (TXA) administration in decreasing transfusion needs in patients undergoing modified pi-plasty. A retrospective study was performed using a population of 59 patients who underwent modified pi-plasty, wherein patients who received TXA during surgery (study group, n = 26) were compared with patients who did not receive TXA (control group, n = 33). The primary study endpoints were intraoperative red blood cell substitution (%), postoperative red blood cell substitution (%), total red blood cell substitution (%), and hematocrit variation. Perioperative administration of TXA significantly decreased the total red blood cell substitution (62.90% vs 86.70%; p = 0.002) and resulted in a higher postoperative hematocrit (29.47% vs 27.53%; p = 0.060). In conclusion, perioperative administration of TXA significantly decreased blood transfusion requirements in patients with sagittal craniosynostosis undergoing modified pi-plasty.

Tranexamic Acid Demonstrates Efficacy without Increased Risk for Venous Thromboembolic Events in Cranial Neurosurgery: Systematic Review of the Evidence and Current Applications in Nontraumatic Pathologies

BACKGROUND

The cautionary stance normally taken towards tranexamic acid (TXA) is rooted in concerns regarding its complication profile, namely its purported risk for venous thromboembolic events (VTEs). In the present review, we intend to bring increased attention to TXA as a remarkably valuable tool that does not appear to increase the risk for VTE when used as indicated in select patients.

METHODS

We queried three databases to identify reporting use of TXA during nontraumatic cranial neurosurgery procedures (excluded traumatic brain injury). Data gathered included VTE complications, deep venous thrombosis, use of allogeneic blood transfusions, estimated blood loss, and operative duration.

RESULTS

Twenty-eight studies were deemed eligible for inclusion in the present meta-analysis, including nine studies on surgical resection of intracranial neoplasms, ten studies on aneurysmal subarachnoid hemorrhage, and nine studies on craniosynostosis. In brain tumor surgery, TXA appears to successfully reduce blood loss without predisposing patients to VTE or seizure (P < 0.01). However, it does not appear to reduce rates of vasospasm in aneurysmal subarachnoid hemorrhage (P = 0.27), and its administration is not associated with clinically meaningful differences in long term neurological outcomes. For pediatric patients undergoing craniosynostosis procedures, TXA similarly reduces blood loss (P < 0.01). Nonetheless, low dosing protocols should be used because they appear effective and the effects of high dose TXA in children have not been studied.

CONCLUSIONS

TXA is an effective hemostatic agent that can be administered to reduce blood loss and transfusion requirements for a wide range of neurosurgical applications in a broad spectrum of patient populations.

Reviewing the Impact of Topical and Intravenous Tranexamic Acid Use in Breast Plastic Surgery

BACKGROUND

Topical and intravenous uses of tranexamic acid (TXA) have been shown to reduce bleeding and ecchymosis in various surgical fields. However, there is a lack of data evaluating the efficacy of TXA in breast surgery. This systematic review evaluates the impact of TXA on hematoma and seroma incidence in breast plastic surgery.

METHODS

A systematic review of the literature was performed for all studies that evaluated the use of TXA in breast surgery including reduction mammoplasty, gynecomastia surgery, masculinizing chest surgery, or mastectomy. Outcomes of interest included rate of hematoma, seroma, and drain output.

RESULTS

Thirteen studies met the inclusion criteria with a total of 3297 breasts, of which 1656 were treated with any TXA, 745 with topical TXA, and 1641 were controls. There was a statistically significant decrease in hematoma formation seen in patients who received any form of TXA compared with control (odds ratio [OR], 0.37; P < 0.001), and a similar tendency toward decreased hematoma with topically treated TXA (OR, 0.42; P = 0.06). There was no significant difference in seroma formation with any TXA (OR, 0.84; P = 0.33) or topical TXA (OR, 0.91; P = 0.70). When stratified by surgery, there was a 75% decrease in the odds of hematoma formation with any TXA compared with the control for oncologic mastectomy (OR, 0.25; P = 0.003) and a 56% decrease in nononcologic breast surgery (OR, 0.44; P = 0.003).

CONCLUSIONS

This review suggests that TXA may significantly reduce hematoma formation in breast surgery and may also decrease seroma and drain output. Future high-quality prospective studies are required to evaluate the utility of topical and intravenous TXA in decreasing hematoma, seroma, and drain output in breast surgery patients.

Endoscopic treatment of sagittal suture synostosis - a critical analysis of current management strategies

While many centers nowadays offer minimally invasive techniques for the treatment of single suture synostosis, surgical techniques and patient management vary significantly. We provide an overview of how scaphocephaly treated with endoscopic techniques is managed in the reported series and analyze the crucial steps that need to be dealt with during the management process. We performed a review of the published literature including all articles that examined sagittal-suture synostosis treated with endoscopic techniques as part of single- or multicenter studies. Fourteen studies reporting results of 885 patients were included. We identified 5 key steps in the management of patients. A total of 188 patients were female and 537 male (sex was only specified in 10 articles, for 725 included patients, respectively). Median age at surgery was between 2.6 and 3.9 months with a total range from 1.5 to 7.0 months. Preoperative diagnostics included clinical and ophthalmologic examinations as well as neuropsychological and genetic consultations if needed. In 5 publications, a CT scan was routinely performed. Several groups used anthropometric measurements, mostly the cephalic index. All groups analyzed equally recommended to perform endoscopically assisted craniosynostosis surgery with postoperative helmet therapy in children < 3 months of age, at least for non-syndromic cases. There exist significant variations in surgical techniques and patient management for children treated endoscopically for single suture sagittal synostosis. This heterogeneity constitutes a major problem in terms of comparability between different strategies.

Importance of tranexamic acid in pediatric monosutural craniosynostosis surgery

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.

A Technique for Minimizing the Need for Hemotransfusion in Non-Syndromic Craniosynostosis Surgery

ABSTRACT

Surgery for craniosynostosis is associated with excessive blood loss, as well as morbidity and mortality risks. This study investigated the effectiveness of a surgical technique for nonsyndromic craniosynostosis intervention in controlling bleeding, assessed based on the volume of blood transfused. The cohort included 73 children who underwent nonsyndromic craniosynostosis surgery during a 3-year period. Retrospective evaluation of patient parameters included sex, weight, and age at the time of surgery; type of craniosynostosis; duration of surgery; hemoglobin concentration before and after surgery; rate of transfusion; and volume of transfused blood (mL/kg). The surgical technique involved skin incision and subgaleal dissection using electrocautery with a Colorado needle tip. The pericranium was not removed but instead kept in situ, and orbiectomy was performed using piezosurgery. Of the 73 children in the cohort, 75.3% underwent fronto-orbital advancement and were included in the analysis. The average age was 10.9 months (range: 4-96 months), with 68.5% boys and 31.5% girls (P < 0.001). The most common type of craniosynostosis was trigonocephaly (57.5%), followed by scaphocephaly (19.2%). The mean duration of the surgery was 2 hours and 55 minutes. Blood transfusion was needed in 56.2% of patients, with a mean volume of 8.7 mL/kg body weight transfused intraoperatively. No complications or fatalities were observed. These results suggested that meticulous, continuous control of homeostasis is paramount in minimizing blood loss during surgical repair of nonsyndromic craniosynostosis.