Safety of antifibrinolytics in 6583 pediatric patients having craniosynostosis surgery: A decade of data reported from the multicenter Pediatric Craniofacial Collaborative Group

Anesthetic Considerations for Pediatric Patients with Craniofacial Anomalies: An Overview of Key Elements

This article reviews the key elements of anesthesia care for patients presenting for craniofacial surgeries, including preoperative evaluation and preparation, intraoperative management, and pain management strategies.

Role of tranexamic acid (TXA) in plastic and reconstructive surgery: A national perspective

PURPOSE

Despite the widespread use of tranexamic acid (TXA) in plastic surgery, guidelines for the safe and effective administration have yet to be established. The present study reports the current practices of TXA usage in plastic and reconstructive surgery procedures among members of the American Society of Plastic Surgeons (ASPS).

METHODS

An online survey was distributed to all active members of the ASPS. The survey was organized into three general parts: (1) demographic data and practice profiles; (2) familiarity, perceptions, and experience with TXA in various plastic surgery fields including craniofacial surgery, aesthetic surgery, burn care, microsurgery, and Mohs surgery; and (3) TXA dosage, mode, and time of administration.

RESULTS

Five hundred two ASPS members completed the survey (21% response rate). Among the respondents, TXA use was most common in aesthetic surgery (90.3%), craniofacial surgery (78.2%), and breast reconstruction (61.8%). The most common procedures performed under TXA were facial procedures, including facelift (83.6%), neck lift (77.1%), forehead and browlift (54.8%), and rhinoplasty (55.0%). TXA administration protocols in aesthetic procedures included IV bolus (52.3%) and topical administration (50.5%). The most common IV bolus dose was 1 g (43.2%) and the most common TXA solution concentration was 3% (36.0). A total of 92.4% of respondents reported that they had never observed any TXA-related complications.

CONCLUSIONS

The results reflect the widespread use of TXA among ASPS members, the preferred administration protocols in plastic surgery, and TXA's efficacy and favorable safety profile across a wide range of procedures.

Perioperative paediatric patient blood management: a narrative review

Patient blood management (PBM) encompasses implementing multimodal evidence-based strategies to screen, diagnose, and properly treat anaemia and coagulopathies using goal-directed therapy while minimising bleeding. The aim of PBM is to improve clinical care and patient outcomes while managing patients with potential or ongoing critical anaemia, clinically significant bleeding, and coagulopathies. The focus of PBM is patient-centred rather than transfusion-centred. Multimodal PBM strategies are now recommended by international organisations, including the World Health Organization, as a new standard of care and a proven means to safely and effectively manage anaemia and blood loss while minimising unnecessary blood transfusion. Compared with adult PBM, paediatric PBM is currently not routinely accepted as a standard of care. This is partly because of the paucity of robust data on paediatric patient PBM. Managing paediatric bleeding and blood product transfusion presents unique challenges. Neonates, infants, children, and adolescents each have specific considerations based on age, weight, physiology, and pharmacology. This narrative review covers the latest updates for PBM in paediatric surgical populations including the benefits and principles of paediatric PBM, current expert consensus guidelines, and important universal multimodal therapeutic strategies emphasising clinical management of the anaemic, bleeding, or coagulopathic paediatric patient in the perioperative period. Practical paediatric rules for PBM in the perioperative period are highlighted, with review of specific PBM strategies including treatment of preoperative anaemia, restrictive transfusion thresholds, antifibrinolytic agents, cell salvage, standardised transfusion algorithms, and goal-directed therapy based on point-of-care and viscoelastic testing.

Perioperative considerations in the paediatric patient with congenital and acquired coagulopathy

Neonates, infants, and children undergoing major surgery or with trauma can develop severe coagulopathy perioperatively. Neonates and infants are at highest risk because their haemostatic system is not fully developed and underlying inherited bleeding disorders may not have been diagnosed before surgery. Historically, laboratory coagulation measurements have been used to diagnose and monitor coagulopathies. Contemporary dynamic monitoring strategies are evolving. Viscoelastic testing is increasingly being used to monitor coagulopathy, particularly in procedures with a high risk of bleeding. However, there is a lack of valid age-specific reference values for diagnosis and trigger or target values for appropriate therapeutic management. A promising screening tool of primary haemostasis that may be used to diagnose quantitative and qualitative platelet abnormalities is the in vitro closure time by platelet function analyser. Targeted individualised treatment strategies for haemostatic bleeding arising from inherited or acquired bleeding disorders may include measures such as tranexamic acid, administration of plasma, derived or recombinant factors such as fibrinogen concentrate, or allogeneic blood component transfusions (plasma, platelets, or cryoprecipitate). Herein we review current recommended perioperative guidelines, monitoring strategies, and treatment modalities for the paediatric patient with a coagulopathy. In the absence of data from adequately powered prospective studies, it is recommended that expert consensus be considered until additional research and validation of goal-directed perioperative bleeding management in paediatric patients is available.

Advances in pediatric neuroanesthesia practices

The field of pediatric neuroanesthesia has evolved with concurrent changes in pediatric neurosurgical practice. Ongoing pediatric neuroanesthesia investigations provide novel insights into developmental cerebrovascular physiology, neurosurgical technology, and clinical outcomes. Minimally invasive neurosurgical procedures appear to be associated with lower complication rates and length of stay. This review will discuss blood sparing techniques, regional anesthesia, and postoperative disposition. Collectively, these innovations appear to be safe in pediatric neurosurgical patients with potential benefits, but more data is needed for more definitive long-term outcomes.

Use of crushed tranexamic acid tablets in water for paediatric patients with bleeding disorders

BACKGROUND

Ε-Aminocaproic acid oral solution (EACA OS) is the only commercially available antifibrinolytic for patients who cannot swallow tablets. Insurance denials and high costs remain barriers to its use.

OBJECTIVES

To determine the safety and efficacy of crushed tranexamic acid tablets in water (cTXAw) for children with bleeding disorders.

METHODS

We retrospectively reviewed records of children (<10 years) with bleeding disorders who received cTXAw or EACA OS from 1 December 2018, through 31 July 2022, at Mayo Clinic (Rochester, Minnesota). Bleeding outcomes were defined according to ISTH criteria.

RESULTS

Thirty-two patients were included (median age, 3 years; male, n = 23). Diagnoses were VWD (n = 17), haemophilia (n = 5), FVII deficiency (n = 3), inherited platelet disorder (n = 4), ITP (n = 2), and combined FV and FVII deficiencies (n = 1). Thirty-two courses of cTXAw (monotherapy 24/32; mean duration 6 days) and fifteen courses of EACA (monotherapy 12/15; mean duration 5 days) were administered. No surgical procedures (n = 28) were complicated by bleeding. Of the 19 bleeding events, 16 had effective haemostasis, two had no reported outcome, and one had no response. cTXAw and EACA were equally effective in preventing and treating bleeding (p value > .1). No patients had adverse effects. Eight of 19 patients (42%) who were initially prescribed EACA OS did not receive it because of cost or insurance denial. The estimated average wholesale price of one treatment was $94 for cTXAw and $905 for EACA OS.

CONCLUSIONS

CTXAw appears to be an effective, safe, and low-cost alternative option to EACA OS for young children with bleeding disorders.

Technical evolution of pediatric neurosurgery: craniosynostosis from 1972 to 2023 and beyond

Very few clinical entities have undergone so many different treatment approaches over such a short period of time as craniosynostosis. Surgical treatments for this condition have ranged from simple linear craniectomies, accounting for the specific role of cranial sutures in assuring the normal growth of the skull, to more complex cranial vault reconstructions, based on the perceived role of the skull base in affecting the growth of the skull. While a great deal of evolution has occurred, there remains controversy regarding the ideal treatment including the best surgical technique, the optimal age for surgery, and the long-term morphological and neurodevelopmental outcomes. The evolution of the surgical management of craniosynostosis in the last 50 years has been affected by several factors. This includes the awareness of needing to operate on affected children during infancy to achieve the best results, the use of multistage operations, the availability of more sophisticated surgical tools, and improved perioperative care. In some forms of craniosynostosis, the operations can be carried out at a very young age with low morbidity, and with the postoperative use of a molding helmet, springs, or distractors, these operations prove to be as effective as traditional larger cranial reconstructions performed in older children. As a consequence, complex surgical operations have become progressively less utilized. A second relevant advance was the more recent advent of a molecular diagnosis, which allowed us to understand the pathogenesis of some associated malformations and neurodevelopmental issues that were observed in some children despite appropriate surgical treatment. Future research should focus on improving the analysis of longer-term outcomes and understanding the natural history of craniofacial conditions, including what issues persist despite optimal surgical correction. Progress in molecular investigations concerning the normal and pathological development of cranial sutures could be a further significant step in the management of craniosynostosis, possibly favoring a "medical" treatment in the near future. Artificial intelligence will likely have a role in establishing the diagnosis with less reliance on radiographic studies and in assisting with surgical planning. Overall, much progress has been made, but there remains much to do.

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.

Error traps in Pediatric Patient Blood Management in the Perioperative Period

Patient blood management is a patient-centered evidence-based approach to improve patient outcomes by harnessing the patient's own hematopoietic system to optimize blood health while promoting patient safety and empowerment. Perioperative patient blood management is a standard of care in adult medicine, yet it is not commonly accepted in pediatrics. Raising awareness may be the first step in improving perioperative care for the anemic and/or bleeding child. This article highlights five preventable perioperative blood conservation error traps for children. The goal is to provide practical clinical guidance to improve preoperative diagnosis and treatment of anemia, facilitate recognition and treatment of massive hemorrhage, reduce unnecessary allogeneic blood transfusions, and decrease associated complications of anemia and blood component transfusions utilizing a patient/family-centered informed consent and shared decision-making approach.

Selected 2022 Highlights in Congenital Cardiac Anesthesia

This article is a review of the highlights of pertinent literature of interest to the congenital cardiac anesthesiologist, and was published in 2022. After a search of the United States National Library of Medicine PubMed database, several topics emerged in which significant contributions were made in 2022. The authors of this manuscript considered the following topics noteworthy to be included in this review-intensive care unit admission after congenital cardiac catheterization interventions, antifibrinolytics in pediatric cardiac surgery, the current status of the pediatric cardiac anesthesia workforce in the United States, and kidney injury and renal protection during congenital heart surgery.

Perioperative management of pediatric patients undergoing juvenile angiofibroma resection. A case series and educational review highlighting patient blood management

BACKGROUND

Juvenile nasopharyngeal angiofibromas are one of the most enigmatic, bloody tumors encountered by otorhinolarygnologists, head and neck surgeons, neurosurgeons, and anesthesiologists. Juvenile nasopharyngeal angiofibromas are rare, benign, highly vascular tumors with a propensity towards aggressive local invasion. Surgery, open or endoscopic, to remove the growth is the primary treatment of choice for Juvenile nasopharyngeal angiofibromas. Historically, surgical resection was associated with massive, rapid blood loss, traditionally managed by blood product transfusion and deliberate hypotension. Preventative management employing multimodal blood conservation strategies should be an essential standard of perioperative care for patients with Juvenile nasopharyngeal angiofibromas.

METHODS

We describe a contemporary and comprehensive approach in the management of patients with high grade Juvenile nasopharyngeal angiofibromas. This includes surgical strategies such as preemptive external carotid artery embolization, endoscopic surgical approach, and staged operations, as well as anesthetic strategies including antifibrinolytic therapy and acute normovolemic hemodilution. These surgeries, once synonymous with massive transfusion, may potentially be performed without allogeneic blood transfusion, or deliberate hypotension.

AIMS

Using a case series, the authors introduce a contemporary approach to multimodal, multidisciplinary blood conservation strategies for Juvenile nasopharyngeal angiofibromas surgery.

RESULTS

Here in the authors report on an updated contemporary perioperative clinical approach to patients with Juvenile nasopharyngeal angiofibromas. From an anesthetic perspective, we describe the successful use of normal hemodynamic goals, restrictive transfusion strategy, antifibrinolytic therapy, autologous normovolemic hemodilution, and early extubation in the care of three adolescent males with highly invasive tumors. We demonstrate that new surgical and anesthetic strategies have yielded a significant decrease in intraoperative blood loss and eliminated the need for transfusion of autologous red blood cells, which enable improved outcomes.

CONCLUSIONS

The perioperative approach to elective surgery for Juvenile nasopharyngeal angiofibromas management is presented from a multidisciplinary patient blood management perspective.