Abstract: Experience with Multidisciplinary Pediatric Blood Management Team in Craniofacial Surgery

Abstract

INTRODUCTION: Pediatric craniofacial procedures are complex and require intensive preoperative, intraoperative, and postoperative care. Transfusions are often required due to both the invasive nature of the procedure as well as the inherently lower blood volume in pediatric patients. We report here our experience with a multidisciplinary Blood Management Team in complex craniofacial surgery. OBJECTIVES: To determine if a Pediatric Blood Management (PBM) program with multimodal approach can reduce transfusion requirements in pediatric patients undergoing craniofacial surgery. METHODS: A collaborative protocol was developed by the PBM team, plastic surgery and anesthesia clinicians in 2016, which involved the pre-operative optimization of hemoglobin levels, the intraoperative use of tranexamic acid and CellSaver™ technology, as well as blood sparing operative techniques. Additionally, patients were preoperatively screened for altered coagulation including hypofibrinogenemia and von Willebrand’s disease. Prospective monitoring of these 17 patients in the intervention arm was collected. Retrospective data on 20 consecutive patients who underwent craniofacial surgery prior to the initiation of the program were used as a control group. The primary endpoint was the transfusion volume of blood products. RESULTS: Groups at baseline were similar in age, weight and reported intraoperative estimated blood loss. Patients post-intervention had a higher mean ASA classification. The rate of transfusion decreased from 80% pre-intervention to 65% post-intervention. Post-intervention, patients received a mean of 106 mL of intraoperative PRBC, while pre-intervention, patients received a mean of 224 mL. (p=0.024). Postoperative hemoglobin measurements were similar, with the control group 10.9 g/dL and the intervention arm 10.5 g/dL (p=0.64). Discharge hemoglobin concentrations also were similar with 9.6 g/dL and 10.6 g/dL in the control and PBM group, respectively (p=0.196). Furthermore, 3 patients were found to have von Willebrand’s disease preoperatively. CONCLUSION: We found that the institution of a Pediatric Blood Management team significantly reduced the transfusion burden of patients undergoing craniofacial procedures, including in complex patients with von Willebrand’s disease. The use of a multimodal approach to hematologic management optimized patients for their procedures and helped minimize exposure to transfusion associated complications.