Preoperative Administration of Erythropoietin for Craniosynostosis Patients Undergoing Cranial Vault Remodeling: Is There a Benefit?

Abstract

Pediatric patients undergoing corrective surgery for craniosynostosis frequently require intraoperative and postoperative blood transfusions because of low baseline circulating blood volume and significant surgical blood loss.1 Allogenic blood transfusion can have high morbidity associated with its use, including acute hemolytic reactions, immunosuppression, and infection spread.2 Administration of preoperative erythropoietin has been briefly evaluated in the literature as an option for reducing the need for allogenic blood transfusion.1 We believe that this process should be considered for craniosynostosis patients undergoing cranial vault remodeling. Preoperative erythropoietin has demonstrated appreciable success in mitigating the requirement for administering allogenic blood transfusions and should be more embraced by craniofacial surgeons. In a recent meta-analysis, Aljaaly et al. reported that among all studies examining preoperative erythropoietin use in children undergoing craniosynostosis surgery, the proportion of patients and the volume of allogenic blood transfused were reduced.1 Hemoglobin measurements immediately before surgery and following completion of the preoperative erythropoietin protocol have also been demonstrably higher than in controls who do not receive treatment before operative intervention. These collective outcomes result in lower morbidity and significantly reduced hospital stays. Erythropoietin administration in children undergoing calvarial remodeling has also been proven to be safe.3 Naran et al. evaluated 369 patients and concluded that preoperative administration of erythropoietin does not increase the risk of thrombotic events or any other major complication, such as blindness or death, during and after treatment.4 Initiating preoperative erythropoietin in combination with other blood-salvaging techniques such as a cell salvage system has similarly resulted in decreased blood transfusions rates.4 Although the physiologic benefits of administering erythropoietin before surgery appear to be evident despite the paucity of robust clinical data, controversy regarding its cost-effectiveness has prevented universal acceptance of this preoperative protocol (Table 1).1,4 We believe that the costs associated with using preoperative erythropoietin may be comparable to undergoing surgery with no preoperative management, given that the administration of erythropoietin reduces intraoperative and postoperative blood transfusion requirements.5 In addition, preoperative erythropoietin decreases morbidity and reduces hospital length of stay.2 These indirect cost savings may serve to counteract the associated costs of undergoing preoperative erythropoietin management and should be considered within the greater context when deciding which blood salvaging technique to perform. Table 1. - Benefits and Disadvantages of Administering Preoperative Erythropoietin for Craniosynostosis Patients Undergoing Corrective Surgery Pros Reduced proportion of patients requiring blood transfusion Decreased volume of blood transfusion required High safety profile with low risk of complications Indirect cost savings Cons Cost of administering EPO Inconvenience of commuting for management EPO, erythropoietin. Administration of preoperative erythropoietin is a safe and effective technique that deserves recognition as a reputable option for pediatric craniosynostosis patients undergoing cranial vault remodeling. Its associated reduced morbidity, coupled with potential cost savings, provides craniofacial surgeons with another option for blood salvaging. Although studies have reported enhanced outcomes with preoperative erythropoietin, there is significant variation in transfusion protocols between institutions. This lack of uniformity should be addressed in future head-to-head studies to standardize the technique better. Higher quality prospective clinical studies on the use of erythropoietin before craniosynostosis surgery and studies geared toward this technique’s cost-effectiveness are also needed to elucidate its impact on comprehensive patient outcomes further. DISCLOSURE The authors have no financial interest in relation to the content of this article. No funding was received for this work. Rami P. Dibbs, B.A.Division of Plastic SurgeryMichael E. DeBakey Department of SurgeryBaylor College of MedicineDivision of Plastic SurgeryTexas Children’s Hospital João Matheus Bombardelli, M.D.Department of SurgeryHouston Methodist Hospital Andrew M. Ferry, B.S.Renata S. Maricevich, M.D.Division of Plastic SurgeryMichael E. DeBakey Department of SurgeryBaylor College of MedicineDivision of Plastic SurgeryTexas Children’s HospitalHouston, Texas