Tranexamic Acid Dosing in Craniosynostosis Surgery: A Systematic Review with Meta-analysis

Trends in Open Versus Minimally Invasive Craniosynostosis Repair: A 10-Year National Analysis

OBJECTIVE

Techniques for cranial vault reconstruction for craniosynostosis have increasingly shifted towards minimally invasive methods. The present study sought to identify trends in surgical approaches based on demographics and surgical outcomes over the past decade.

METHODS

The National Surgical Quality Improvement Program-Pediatrics was queried to identify patients with craniosynostosis who underwent cranial vault repair between January 2013 to December 2022. Patient demographics, surgical characteristics, and postoperative outcomes were gathered for both open surgery (OS) and minimally invasive surgery (MIS) groups per year. Trend analysis was performed by linear regression and predictors for MIS were identified using univariable statistics and multivariable logistic regressions.

RESULTS

Among 12,104 patients identified, OS rates decreased from 96% to 91%, while the use of MIS increased from 3% to 9% ( P <0.001). MIS patients were younger, primarily White, and had fewer comorbidities, overall complications, blood transfusions, shorter operative time, anesthesia duration, and length of stay ( P <0.001). From 2013 to 2022, the number of overall complications, operative time, and length of stay significantly decreased in the OS group, while the number of patients with comorbidities increased in the MIS group ( P <0.001). Importantly, access to MIS for Hispanic patients improved significantly ( P <0.001).

CONCLUSION

The prevalence of MIS for craniosynostosis repair increased over a 10-year period. MIS patients benefit from reduced complication rates, operative time, anesthesia duration, and length of stay. As MIS becomes a more common treatment modality for craniosynostosis, access has expanded to include more complex and diverse patients, though opportunities for improvement still remain.

Tranexamic Acid is Associated With Reduced Blood Loss and Transfusion Requirement in Pediatric Midface Reconstruction

BACKGROUND

Midface reconstruction poses challenges due to significant blood loss and difficulty in achieving intraoperative hemostasis, often necessitating blood transfusions. Various agents, most notably tranexamic acid (TXA), have been utilized intraoperatively to mitigate this risk of bleeding and transfusion-related complications.

PURPOSE

The study purpose was to measure the association of TXA with blood loss and transfusion requirements during craniofacial procedures involving the midface.

STUDY DESIGN, SETTING, SAMPLE

This project was designed as a retrospective cohort study. Patients who underwent midface reconstruction at Children's Hospital Los Angeles between 2010 and 2023 were included, and a retrospective chart review was conducted.

INDEPENDENT VARIABLE

The independent variable was weight-adjusted TXA exposure divided into 2 groups: subjects who received TXA preoperatively and intraoperatively and those that did not.

MAIN OUTCOME VARIABLES

The main outcome variables were weight-adjusted intraoperative blood loss and transfusion requirements. Secondary outcomes included intraoperative and postoperative complications and length of stay.

COVARIATES

Demographic covariates included age at surgery, sex, weight, and syndromic status. Operative covariates covered the type of surgical approach and main procedure performed. Perioperative covariates included anesthesia time and operative time.

ANALYSES

Parametric and nonparametric variables were analyzed using independent t-test and Wilcoxon rank-sum test, respectively. χ2 analysis was used to analyze categorical variables, and multivariable linear regressions were performed. A P value of less than .05 was considered statistically significant.

RESULTS

A total of 80 patients underwent midface reconstruction surgery, 37 (46.3%) of whom received TXA and 43(53.7%) did not. The mean age at surgery was 8.7 ± 3.8 years in the TXA cohort and 11.6 ± 5.1 years in the non-TXA cohort (P = .02). Multivariable regression analysis further demonstrated a statistically significant association between the administration of TXA and both reduced blood loss (coefficient -0.14 [95% CI -0.20 to -0.07], P < .01) as well as reduced transfusion requirement (coefficient -0.14 [95% CI -0.19 to -0.08], P < .01). There was no increased risk of complications, such as thromboembolic events or seizures, in patients who were administered TXA (P = .14).

CONCLUSION AND RELEVANCE

TXA is likely a valuable adjunct for improving intraoperative and postoperative outcomes of craniofacial procedures involving the midface.

Frequency and predictors of concurrent complications in multi-suture release for syndromic craniosynostosis

PURPOSE

Understanding the complication profile of craniosynostosis surgery is important, yet little is known about complication co-occurrence in syndromic children after multi-suture craniosynostosis surgery. We examined concurrent perioperative complications and predictive factors in this population.

METHODS

In this retrospective cohort study, children with syndromic diagnoses and multi-suture involvement who underwent craniosynostosis surgery in 2012-2020 were identified from the National Surgical Quality Improvement Program-Pediatric database. The primary outcome was concurrent complications; factors associated with concurrent complications were identified. Correlations between complications and patient outcomes were assessed.

RESULTS

Among 5,848 children identified, 161 children (2.75%) had concurrent complications: 129 (2.21%) experienced two complications and 32 (0.55%) experienced ≥ 3. The most frequent complication was bleeding/transfusion (69.53%). The most common concurrent complications were transfusion/superficial infection (27.95%) and transfusion/deep incisional infection (13.04%) or transfusion/sepsis (13.04%). Two cardiac factors (major cardiac risk factors (odds ratio (OR) 3.50 [1.92-6.38]) and previous cardiac surgery (OR 4.87 [2.36-10.04])), two pulmonary factors (preoperative ventilator dependence (OR 3.27 [1.16-9.21]) and structural pulmonary/airway abnormalities (OR 2.89 [2.05-4.08])), and preoperative nutritional support (OR 4.05 [2.34-7.01]) were independently associated with concurrent complications. Children who received blood transfusion had higher odds of deep surgical site infection (OR 4.62 [1.08-19.73]; p = 0.04).

CONCLUSIONS

Our results indicate that several cardiac and pulmonary risk factors, along with preoperative nutritional support, were independently associated with concurrent complications but procedural factors were not. This information can help inform presurgical counseling and preoperative risk stratification in this population.

Tranexamic Acid Use in Pediatric Craniotomies at a Large Tertiary Care Pediatric Hospital: A Five Year Retrospective Study

Tranexamic acid (TXA), a synthetic antifibrinolytic drug, has proven efficacy and is recommended for major pediatric surgery to decrease perioperative blood loss. Accumulating evidence suggests that TXA reduces bleeding and transfusion in a variety of adult neurosurgical settings. However, there is a paucity of research regarding TXA indications for pediatric neurosurgery and thus, there are currently no recommendations for its use with this specific population. The objective of this study is to evaluate the existing practice of TXA administration for pediatric neurosurgery at a U.S. tertiary care pediatric hospital over a five-year period. The authors conclude that TXA administration is feasible and should be considered for pediatric neurosurgical cases where potential blood loss is a concern.

Effect of Tranexamic Acid on the Reduction of Blood Loss in Craniosynostosis Surgery: A Systematic Review and Meta-analysis

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.