Better for some, maybe not for all: a response to preemptive transfusion and infusion strategy in children during craniofacial reconstruction.


SIR—We read with interest the presentation by Cortellazzi et al. on an early preemptive transfusion (hemoglobin independent) and infusion (EPTI) strategy (1). Their attempts at trying to evaluate quality of patient outcome and anesthetic and surgical management in the pediatric population undergoing craniofacial reconstructive surgery is laudable. Management of anesthetic care of small children during procedures with the possibility of large volume blood loss is difficult and complex. Determination of the amount and rate of blood loss at any given moment is difficult and further complicated by the amount and type of fluid replacement to maintain adequate circulatory volume and hematocrit simultaneously as discussed by Cortellazi. Certainly, one method is to replace all volume loss with appropriate proportions of blood and crystalloid and colloid to maintain hematocrit. This is a reasonable strategy, commonly employed in circumstances where the exposure to blood products is inevitable. However, the stated EPTI strategy was developed from a ‘group of earlier cranioplasties’ and based on the fact that 50% of patients had intraoperative blood loss of >20% of estimated red cell volume (ERCV). The strategy as explained automatically proceeds with transfusion of 20% ERCV at the beginning of the surgery. If 50% of the cases had intraoperative losses of >20% ERCV, then 50% of the cases had blood loss of <20% ERCV. In addition, this strategy was implemented and followed without any stated regard for the starting hematocrit in these children. In fact, in the control (CONT) group, only 22 out of 25 children received blood transfusion. This suggests that 12% of the 34 cases (four children) in the EPTI strategy would not have received blood product transfusion had they not been in the EPTI group. Our concern about this blanket approach is that exposure to blood products is not without risk. Many different complications can occur related to blood product transfusion including exposure to infectious agents and ranging from mild to life-threatening transfusion reactions (2). Great efforts have been made throughout the craniofacial team community to reduce the risks of the procedures through both development of novel surgical techniques as well as blood conservation or sparing interventions (3–5). Efforts to reduce blood exposure in craniofacial reconstructive procedures in children have ranged from preoperative erythropoietin and autologous donation to cell saver and use of antifibrinolytic agents. Surgical advancement has resulted in less invasive surgeries to avoid cranial vault remodeling for scaphocephaly (6,7). The majority of the cases reported in the series by Cortellazzi et al. were for correction of scaphocephaly. Through less invasive procedures, the impact of the anesthetic management has been drastically altered from the traditional cranial vault reconstruction procedure (4). This includes less blood loss, less invasive monitoring requirement, and reduced hospital times. We currently have provided anesthesia for over 100 cases of scaphocephaly (sagittal suture synostosis) correction using the spring-mediated expansion technique. At present, none of the patients required intraoperative transfusion as a result of blood loss during the procedure. Additionally, the children have no need for intensive care unit management postoperatively with an average hospital stay of 36 h. Using a blanket transfusion protocol may have resulted in all of these children being exposed to blood products and the inherent risks. We feel it is critical to continue to provide safe and optimal anesthetic care to all children undergoing craniofacial reconstruction. Adequate oxygencarrying capacity through adequate red cell mass, despite ongoing surgical blood loss, is imperative to assure adequate oxygen delivery and reduce complications. This is eloquently addressed in the quality improvement study by Cortellazzi et al., whereby maintaining adequate red cell mass improved postoperative recovery. However, we feel that caution is to be used in use of protocols that may expose patients to risks that would otherwise not be incurred. Furthermore, continued efforts at reducing blood and blood product exposure in children are mandatory to reduce or prevent life-long effects from exposure to blood products. Differences in the patient, the procedure, the surgeon and even the anesthesiologist should be taken into consideration when deciding the best approach to blood loss and transfusion. D O U G L A S G. R I R I E* T I M O T H Y E. S M I T H* L I S A R. D A V I D† L O U I S C. A R G E N T A† *Department of Anesthesiology †Department of Plastic and Reconstructive Surgery, Wake Forest University School of Medicine and Brenner Children’s Hospital, Winston-Salem, NC, USA (email: Pediatric Anesthesia 2010 20: 574–583

DOI: 10.1111/j.1460-9592.2010.03302.x

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Cite this paper

@article{Ririe2010BetterFS, title={Better for some, maybe not for all: a response to preemptive transfusion and infusion strategy in children during craniofacial reconstruction.}, author={Douglas Gordon Ririe and Timothy E. Smith and Lisa R. David and Louis C. Argenta}, journal={Paediatric anaesthesia}, year={2010}, volume={20 6}, pages={574-5} }