Craniosynostosis Surgery Research Articles

Role of tranexamic acid in craniosynostosis surgery: Systematic review and meta-analysis

This study aimed to determine the efficacy and harms of using tranexamic acid (TXA) versus placebo/no intervention to reduce blood loss and the need for transfusion in children undergoing surgical correction of craniosynostosis. We searched MEDLINE (OVID), EMBASE, LILACS, CENTRAL, and other sources. We included clinical trials, prospective, retrospective observational studies, case-control studies, and cohort studies. The primary outcomes were blood loss and the need for a transfusion, and secondary outcomes were hemoglobin, hematocrit, and adverse effects. We assessed the risk of bias with the Cochrane Collaboration tool. We performed the statistical analysis in R and reported information about the mean difference (MD) with a 95% confidence interval (CI). We evaluated heterogeneity with the I2 test. We produced forest plots to show the amount of evidence available for each outcome and made subgroup analyses. We included 11 studies in qualitative and quantitative analysis accounting for 752 patients. In general, the risk of all bias was assessed as low for non-randomized studies, and we found high performance and detection bias in one randomized study. TXA significantly reduced blood loss and need for transfusion compared to placebo/no intervention with an MD of -15.47 (95%CI -23.82, -7.11) and -8.18 (95%CI -12.24, -4.11), respectively. These differences were maintained regardless of the type of study, secondary outcomes also favored TXA, and there was no report of adverse effects. TXA reduces blood loss and the need for transfusion when compared to placebo/no intervention. The available studies on this topic suggest its use in these patients and its implementation in surgery protocols.

Craniosynostosis Surgery for Increased Intracranial Pressure.

Craniosynostosis is the premature fusion of 1 or more cranial sutures. The presentation may vary, and there are differing opinions regarding surgical indications and timing. Though increased intracranial pressure (ICP) is a well-established risk of craniosynostosis, its response to treatment is not uniform. This study aims to identify the signs and symptoms indicative of increased ICP that are most likely to improve after craniosynostosis surgery. Pre- and post-operative data were retrospectively collected from patients at our institution with syndromic and non-syndromic craniosynostosis from January 2009 to June 2020. Demographics, symptoms (headache, nausea, emesis, and lethargy), signs (visual disturbances and papilledema), and imaging characteristics (copper beaten changes), if available, were analyzed. One hundred fifty-three children with craniosynostosis were identified, and 56 with preoperative symptoms met inclusion criteria. Older age was significantly correlated with the number of symptoms improved postoperatively ( P = 0.015). Papilledema, headache, nausea, and irritability (if present preoperatively) were the features most likely to improve after craniosynostosis repair. Optic nerve or disc anomalies, feeding difficulties, seizures, and need for glasses were least likely to improve. Older children undergoing craniosynostosis surgery had a greater number of improved symptoms. Classical features of increased ICP were more likely to improve than developmental difficulties and multifactorial causes. These findings may be useful when considering craniosynostosis repair in a symptomatic child.

Long-term Outcomes of Non-syndromic and Syndromic Craniosynostosis: Analysis of Demographic, Morphologic, and Surgical Factors.

In this study, we analyzed the outcomes of patients (followed for 5–38 years, average 17.3 years) with craniosynostosis and evaluated their long-term prognosis. In all, 51 patients who underwent surgery for craniosynostosis between 1982 and 2015, including 12 syndromic and 39 non-syndromic cases, were included. The average age at the initial surgery was significantly lower in the syndromic group than that in the non-syndromic group (9.8 months old vs. 19.9 months, respectively). The surgical procedures did not significantly differ between the two groups, but repeat surgery was significantly more common in the syndromic group than in the non-syndromic group (4 children [30.8%] and 3 children [7.7%], respectively). The children requiring repeat surgery tended to be younger at the initial surgery than those who did not. Those patients who required repeat surgery did not have significantly different surgical procedures initially. The incidence of developmental retardation was 49.0% (43.5% in the non-syndromic group and 66.7% in the syndromic group), and only two children in the non-syndromic group displayed recovery. This study is the first to analyze the prognosis for patients who were followed for at least 5 years after cranioplasty. Repeat surgery was common, especially in syndromic patients. Severity of skull deformity and early initial surgery may be important factors determining the need for repeat surgery. Developmental retardation was also common, and improvement was rare even after surgery.

The outcomes of using high oxygen concentration in pediatric patients.

Oxygen reserve index, available as part of Masimo Rainbow SET pulse oximetry, is a noninvasive and continuous variable intended to provide insight into a patient's oxygen status in the moderate hyperoxic range (PaO2 > 100 and ≤ 200mm Hg), defined as a patient's oxygen "reserve". When used in conjunction with pulse oximetry, ORi extends the knowledge on a patient's oxygen status providing clinically important information helping to prevent hyperoxemia and hypoxemia. There are limited data on patients undergoing craniosynostosis surgery. Our primary goal was to evaluate the effects of different concentrations of inspiratory oxygen (FiO2) on patient oxygenation status by monitoring ORi. Thirty patients scheduled for craniosynostosis were included in this observational cohort study. Patients were randomized into two equal groups: Group 1 received a fraction of inspired oxygen of 0.8 and group 2 received a FiO2 of 0.6 during induction of anaesthesia. In addition to standard haemodynamic variables with ORi were recorded at baseline 1min, 5min, 60min, and 120min after intubation. Postoperative complications, length of stay in the intensive care unit and hospital were recorded. In total, 14 patients were evaluated in each group. Gender, age, BMI, ASA scores were similar between groups (p > 0.05). In Group 1, ORi values were significantly higher when compared to group 2 at baseline (0.86 ± 0.21 vs 0.45 ± 0.32, p = 0.001), one minute (0.61 ± 0.24 vs 0.27 ± 0.21, p = 0.001), and 5min (0.34 ± 0.31 vs 0.10 ± 0.13, p = 0.033). High inspired oxygen concentration during induction of anesthesia in pediatric patients is associated with higher levels of ORi. Therefore, ORi may provide the means to safely reduce the inspired oxygen fraction during inhalational induction in paediatric patients.

Secondary Surgery in Metopic Craniosynostosis: Outcomes in a Tertiary Care Craniofacial Center in Australia.

Metopic craniosynostosis is a condition in which the metopic suture is prematurely fused. Trigonocephaly and hypotelorism are the major abnormal findings associated with synostosis. Fronto-orbital advancement with cranial remodelling procedure is the widely practised method for correction of the deformities. Previously, a few studies have shown a low incidence of secondary raised intracranial pressure after the primary surgery. Thus, we reviewed our database to investigate the outcomes of metopic craniosynostosis treatment between 1999 and 2020 in Cleft and Craniofacial South Australia. One hundred twelve patients (77 males and 35 females) with metopic synostosis were operated. The mean age of primary surgery was 11.1 months (range 2.8-131.7 months). Ten patients (9%) who had secondary raised intracranial pressure underwent secondary surgery. Among those, the mean age of primary and secondary surgery were 5.4 and 57.1 months, respectively. Syndromic patients were significantly revealed to have a higher incidence of secondary raised intracranial pressure. There were three patients (2.7%) who had other secondary procedures (hardware removal and aesthetic contouring procedures). This cohort identified a higher incidence of secondary raised intracranial pressure requiring secondary surgery than previous studies. Syndromic patients were significantly related to secondary raised intracranial pressure. The patients who had raised intracranial pressure tended to have primary correction at younger age. Long-term multidisciplinary follow-up is mandatory. The demand for secondary surgery for metalwork complications or cosmetic contouring is uncommon.

Optical Coherence Tomography for Assessment of Elevated Intracranial Pressure in Sagittal Craniosynostosis

INTRODUCTION: Children with early diagnosis of isolated sagittal craniosynostosis are candidates for spring-mediated cranioplasty or endoscopic-assisted strip craniectomy. Neurocognitive developmental differences are seen in some children with craniosynostosis, and elevated intracranial pressure (ICP) has been correlated to a lower intelligence. However, no studies have evaluated ICP in children with craniosynostosis younger than 6 months of age. Optical coherence tomography (OCT) of the peripapillary retina is a recently validated noninvasive quantitative modality to predict ICP elevations in pediatric patients with craniosynostosis. The purpose of this study was to utilize OCT data to better understand the incidence of elevated ICP in infants undergoing early surgical correction for sagittal craniosynostosis. METHODS: OCT measurements were obtained in patients undergoing spring-mediated cranioplasty for sagittal craniosynostosis. OCT parameters analyzed included the maximal retinal nerve fiber layer thickness and maximal anterior projection using the OCT cross-section that corresponded most closely to the center of the optic disc.1,2 Previous investigation demonstrated that OCT parameters for predicting ICP elevation above 15 mm Hg required maximal retinal nerve fiber layer thickness thickness of 159.8 µm and maximal anterior projection of 129.1 µm.2 This combination yielded a sensitivity of 77.3% and specificity of 95.0%. Previous investigation demonstrated that OCT parameters for predicting ICP elevation above 20 mmHg required maximal retinal nerve fiber layer thickness thickness of 170.6 µm and maximal anterior projection of 138.3 µm.2 This combination yielded a sensitivity of 90.0% and specificity of 81.3%. RESULTS: Seventy-two patients underwent corrective surgery for sagittal craniosynostosis with OCT scans available. In total, 48.6% (n = 35) patients were younger than 6 months, 15.3% (n = 11) patients were aged between 6 and 12 months, and 36.1% (n = 26) patients were 12 months or older. Retinal parameter measurements demonstrated ICP < 15 mm Hg in 88.6% (n = 31 of 35) patients <6 months of age. Compared with these children, significantly fewer patients were in the age of 6–12 months (54.5%, n = 6 of 11, P = 0.025) and in the age of ≥12 months (46.2%, n = 12 of 26, P < 0.001) had ICP < 15 mm Hg. Retinal parameter measurements demonstrated ICP < 20 mm Hg in 91.4% (n = 32 of 35) patients aged <6 months. Compared with these children, significantly fewer patients were in the age of 6–12 months (54.5%, n = 6 of 11, P = 0.013), and those aged ≥12 months (53.8%, n = 14 of 26, P = 0.001) had ICP < 20 mm Hg. Directly measured intracranial pressure was inversely correlated to the cephalic index (P = 0.009) such that patients with more severe scaphocephaly had a higher intracranial pressure. CONCLUSIONS: The vast majority of patients undergoing early intervention for sagittal craniosynostosis do not have elevated intracranial pressure by OCT measurement, whereas those older than 6 months of age have a significantly higher incidence of elevated intracranial pressure. REFERENCES: 1. Swanson JW, et al. Evaluation of optical coherence tomography to detect elevated intracranial pressure in children. JAMA Ophthalmol. 2017;135(4):320–328. 2. Kalmar CL, et al. Elevated intracranial pressure in patients with craniosynostosis by optical coherence tomography. Plast Reconstr Surg. In press.

Intravenous Tranexamic Acid is Associated With a Clinically Significant Reduction in Blood Loss in Craniosynostosis Surgery.

Blood loss is a potential cause of morbidity and mortality in craniosynostosis surgery. Recent reports have suggested that the use of tranexamic acid (TXA), an antifibrinolytic agent, mitigates this blood loss. A retrospective cohort study of patients undergoing craniosynostosis surgery at a tertiary craniofacial hospital in Sydney was undertaken. Primary outcomes were blood loss and transfusion requirements. Two groups were compared: those who received intravenous prophylactic TXA and those who underwent surgery without TXA. Statistical analysis was performed with Student t test and the Mann-Whitney U test for nonparametric results. We identified 206 patients who underwent craniosynostosis surgery over an 8 year period; 78 control patients and 128 patients that received TXA. Tranexamic acid was found to result in a weight-adjusted calculated blood loss mean difference of 9.6 ml/kg across all procedures (P = 0.0332 95% confidence interval 0.7734-18.4266). The actual blood loss reduction achieved with TXA was 6.7 ml/kg in spring cranioplasties, compared to 15.2 ml/kg in fronto-orbital remodeling procedures. There was a statistically and clinically significant reduction in postoperative transfusion incidence, with transfusions required in 27% of controls and 6% of TXA patients (P < 0.0001). The number needed to treat to prevent giving a unit of blood postoperatively was 4.8. There were no incidences of TXA-specific complications. This study found that TXA is a safe and effective method of decreasing blood loss and transfusion requirements in patients undergoing craniosynostosis surgery. The clinical benefit of TXA is particularly evident in the more invasive craniosynostosis surgeries.

Tranexamic Acid in Craniosynostosis Surgery: A Systematic Review and Meta-Analysis.

Blood loss is a potential cause of morbidity and mortality in craniosynostosis surgery. Recent reports have suggested that the use of tranexamic acid (TXA), an antifibrinolytic agent, mitigates this blood loss. A comprehensive systematic review and subsequent meta-analysis was undertaken, with the view to clarify the effectiveness of TXA in reducing blood loss and transfusion requirements in craniosynostosis surgery. Medline and PubMed databases were searched using the preferred reporting items for systematic reviews and meta-analyses technique, and 7003 articles were assessed based on predefined selection criteria. Seven trials were identified, of which 2 were randomized controlled trials and the remainder retrospective cohort studies. All trials were assessed using the Jadad and strengthening the reporting of observational studies in epidemiology scores. The meta-analysis found a clear statistical reduction in blood loss in those patients who received TXA perioperatively, with a combined blood loss reduction of 7.06 ml/kg (95% confidence interval -8.97 to -5.15, P < 0.00001). The blood loss reduction was found to extrapolate to a reduction in perioperative transfusion requirements by 8.47 ml/kg in this cohort (95% confidence interval -10.9 to -6.04, P < 00001). There were no TXA-related adverse outcomes recorded in the 258 patients who received TXA across all trials. The trials included in this meta-analysis were limited by underpowered population sizes and significant heterogeneity in blood loss recording techniques. Further, there was significant heterogeneity amongst operations performed. The current literature appears to support the use of TXA in craniosynostosis surgery, but further high quality randomized controlled trials are indicated, ideally including a subgroup analysis between the operations performed.

Psychosocial Impact of Coronal Access Scars in Craniosynostosis Procedures on Patients and Their Families.

The coronal incision is the mainstay for access in craniosynostosis surgery. Scarring is a common concern of parents whose children are offered an open procedure. To the author's knowledge, there are no previous studies looking at the psychosocial impact of scarring from coronal access incisions for craniosynostosis procedures. The author's study focused on patients undergoing procedures for nonsyndromic single-suture craniosynostosis.This study comprised 3 parts: worldwide survey regarding coronal access incisions for craniosynostosis surgery, questionnaire to determine the psychosocial impact of the scars on patients and their parents, and measurement of postoperative scars in craniosynostosis patients.Survey responses from 46 craniofacial centers worldwide revealed a zig-zag was the most commonly utilized incision. Seventy-two percent of survey responses reported problems with postoperative stretching of the scar; only 20% of centers reported formal data collection of whether families were affected by this.Psychology questionnaires revealed that the majority of patients and their parents were not bothered by the zig-zag coronal scars. Patient felt the scars were less noticeable than the parents. Parent perceptions improved with age and time postsurgery.Coronal access scars following craniosynostosis surgery appear to stretch more in the supra-auricular region compared with the midline.These findings are useful for the craniofacial multidisciplinary team to inform parents contemplating surgery and who may be concerned about the impact of the scar in the future.

Parent and Patient Reported Outcomes for Head Shape in Children Undergoing Surgery for Single Suture Synostosis.

Assessing outcomes following surgery for single suture craniosynostosis is important to ensure minimum standards are being met, but also to compare results using different surgical techniques and treatment protocols. What constitutes an "outcome" and how this is measured remains a challenge, particularly when assessment should include consideration of aesthetic, functional, and psychological domains.The Oxford Craniofacial Unit has initiated routine collection of parents' and patients' ratings of 2 factors that are closely associated with psychological adjustment; how noticeable the child's headshape is and how much this bothers the parent and/or child. A brief Surgical Outcome Questionnaire is completed by parents and children (over 7 years) at their outpatient appointment; parents are also asked to rate the extent to which they feel surgery made a difference to their child's headshape.Data are presented for 519 parents and 248 children with single suture craniosynostosis who attended the Oxford Craniofacial Unit in 2018 and 2019; this represents over 80% of patients seen in the clinic indicating the questionnaire is acceptable for families and the potential for rapid, relevant data on a continuous basis. Analysis of the data is presented to demonstrate the utility of the Surgical Outcome Questionnaire in exploring the views of both parents and patients of the noticeability and level of concern about the child's headshape for different age groups and diagnoses.The Surgical Outcome Questionnaire provides a novel method of collecting routine data for patients across their craniofacial care pathway, using variables which are relevant and meaningful for patients and parents.

Disparities in Craniosynostosis Outcomes by Race and Insurance Status.

Disparities in access to care for surgical intervention in craniosynostosis have been suggested as a cause in discrepancies between the surgical approach and consequently perioperative outcomes following surgery. This work aimed to investigate the influence of race, insurance status, and the presence of craniosynostosis-related conditions on the short-term outcomes after the surgical management of craniosynostosis. Using the National Inpatient Sample database for the years 2010 to 2012, sociodemographic predictors for 30-day postoperative complication rates and requirements for blood transfusion in craniosynostosis surgeries were identified. Medicaid patients were significantly more likely to experience complications (P = 0.013) and higher rates of blood transfusions (P = 0.011). Compared to those without any complications, patients who experienced postoperative complications and blood transfusions were older (191.5 versus 181.7 days old, P < 0.001), had a greater number of chronic diseases (P < 0.001), and had a longer average length of stay (P < 0.001). On multivariable regression, Medicaid patients were 1.7 times more likely to experience any postoperative complication compared to privately insured patients. White patients also experienced a 0.741 times lower likelihood of requiring a blood transfusion. At the hospital level, receiving surgery at government-operated hospitals was found to be a protective factor for postoperative complications compared to for-profit private (P = 0.016) and nonprofit private (P = 0.028). Healthcare providers and policy makers should be cognizant of these sociodemographic disparities and their potential causes to ensure equitable treatment for all patients regardless of insurance status and racial/ethnic background.

Thromboelastography Changes of Whole Blood Compared to Blood Component Transfusion in Infant Craniosynostosis Surgery.

Surgical treatment of craniosynostosis with cranial vault reconstruction in infants is associated with significant blood loss. The optimal blood management approach is an area of active investigation. Thromboelastography (TEG) was used to examine changes in coagulation after surgical blood loss that was managed by transfusion with either whole blood or blood components. Transfusion type was determined by availability of whole blood from the blood bank.This retrospective study examined differences in posttransfusion TEG maximum amplitude (MA), a measure of the maximum clot strength, for patients transfused with whole blood or blood components. We included all patients less than 24 months old who underwent cranial vault remodeling, received intraoperative transfusions with whole blood or blood components, and had baseline and posttransfusion TEG measured. Whole blood was requested for all patients and was preferentially used when it was available from the American Red Cross.Of 48 eligible patients, 30 received whole blood and 18 received blood components. All patients received an intraoperative antifibrinolytic agent. The posttransfusion MA in the whole blood group was 61.8 mm (IQR 59.1, 64.1) compared to 57.9 mm (IQR 50.5, 60.9) in the blood components group (P = 0.010). There was a greater posttransfusion decrease in MA for patients transfused with blood components (median decrease of 7.7 mm [IQR -3.4, 6.3]) compared with whole blood (median decrease of 2.1 mm [IQR -9.6, 7.5] P < 0.001).Transfusion with blood components was associated with a greater decrease in MA that was likely related to decreased postoperative fibrinogen in this group. Patients who received whole blood had higher postoperative fibrinogen levels.

Non-Surgical Touch-Up with Hyaluronic Acid Fillers Following Facial Reconstructive Surgery

The use of hyaluronic acid (HA) injectable fillers has become increasingly widespread in facial recontouring and rejuvenation. We report our experiences to emphasize the role of HA fillers as tools beyond aesthetic treatments in cases of post-surgical facial sequelae. HA fillers are generally used for aesthetic rejuvenation, but one potential new horizon could be their application in trauma, reconstructive, and craniofacial surgery. This study was conducted retrospectively, evaluating medical reports of patients treated at the Maxillofacial Surgery Unit, University of Campania “Luigi Vanvitelli”, Naples, for lip incompetence, trauma, oncological, reconstructive, and craniosynostosis surgery sequelae. Visual analog scale (VAS) evaluation was performed to assess patient satisfaction. No major complications (i.e., impending necrosis or visual loss) were reported. Bruising and swelling was reported for 48 h after lip injection. At the immediate VAS evaluation, 67% of the patients were “extremely satisfied” and 33% “satisfied”. In those 33%, VAS scores changed to “extremely satisfied” at 6–9 weeks and 3–6 months of VAS evaluation (contextually to improvement in tissue flexibility, elasticity, and aesthetic appearance). Results indicate that this minimally invasive approach achieves a high level of aesthetic enhancement, improving patient satisfaction. The concept of HA filler applications could be a frontier that may be applicable to other areas of reconstructive facial plastic surgery.

Improving the timely availability of blood products for patients undergoing craniosynostosis surgery

BackgroundBlood transfusions are common in craniosynostosis surgery and it is critical that packed red blood cells (pRBCs) be available prior to the start of surgery due to the risk of massive hemorrhage during surgical exposure. At our institution, timely availability of pRBCs was inconsistent due to suboptimal pre-operative care coordination. Our aim was to increase the availability of pRBCs before general anesthesia induction, from 47.5% to 100%, in patients undergoing craniosynostosis surgery, by June 2020. MethodsQI methodology adapted from the Institute for Healthcare Improvement (IHI model) was used to improve the process of pre-operative preparation of these patients. A multidisciplinary team was convened to develop a streamlined preoperative pathway to ensure patients had pRBCs available for surgery. The pathway included ensuring patients have their blood type and screen (T&S) drawn within our hospital system and implementing a weekly electronic communication to provide an opportunity to identify patient issues and problem-solve prior to surgery. The main outcome measure was pRBCs availability prior to time of intubation. The timing of blood T&S draw and surgery start time delays were measured as process and balancing measures, respectively. ResultsAn increase in the percentage of craniosynostosis patients with pRBCs available before endotracheal intubation was associated with a centerline shift from an average of 47.5% for the baseline period, to 96.7% (P < .001) by July 2020. The percentage of patients with a blood T&S completed at least 1 hour before the endotracheal intubation increased from a mean of 57.4% for the baseline period, to 100% (P < .001) during the QI initiative period. Lastly, these interventions did not affect the rate of delayed surgeries which remained at the 22.95% baseline through July 2020. ConclusionImplementation of a multidisciplinary approach to pre-operative care coordination led to a meaningful improvement in the timely availability of pRBCs for patients undergoing craniosynostosis surgery.

Strabismus associated with craniosynostosis and related craniofacial surgery

Strabismus associated with craniosynostosis and related craniofacial surgery

Anesthesia Management in Craniosynostosis Surgery: A Retrospective, Single-center Experience

Anesthesia Management in Craniosynostosis Surgery: A Retrospective, Single-center Experience

Real-Time Tool Detection for Workflow Identification in Open Cranial Vault Remodeling.

Deep learning is a recent technology that has shown excellent capabilities for recognition and identification tasks. This study applies these techniques in open cranial vault remodeling surgeries performed to correct craniosynostosis. The objective was to automatically recognize surgical tools in real-time and estimate the surgical phase based on those predictions. For this purpose, we implemented, trained, and tested three algorithms based on previously proposed Convolutional Neural Network architectures (VGG16, MobileNetV2, and InceptionV3) and one new architecture with fewer parameters (CranioNet). A novel 3D Slicer module was specifically developed to implement these networks and recognize surgical tools in real time via video streaming. The training and test data were acquired during a surgical simulation using a 3D printed patient-based realistic phantom of an infant’s head. The results showed that CranioNet presents the lowest accuracy for tool recognition (93.4%), while the highest accuracy is achieved by the MobileNetV2 model (99.6%), followed by VGG16 and InceptionV3 (98.8% and 97.2%, respectively). Regarding phase detection, InceptionV3 and VGG16 obtained the best results (94.5% and 94.4%), whereas MobileNetV2 and CranioNet presented worse values (91.1% and 89.8%). Our results prove the feasibility of applying deep learning architectures for real-time tool detection and phase estimation in craniosynostosis surgeries.

Admission to the Regular Ward is Safe Following Uncomplicated Craniosynostosis Surgery: A Retrospective Study

Background: At our craniofacial center patients are routinely admitted to a regular ward, or floor, rather an intensive care unit (ICU) after uncomplicated craniosynostosis surgery. In this study, we review the safety of our postoperative placement policy, examining the rate of transfer from floor to ICU. Methods: The charts of patients who underwent craniosynostosis surgery from 2009 through 2017 at a single children’s hospital were reviewed. Postoperative hospital courses were characterized as preoperatively-planned ICU admission, perioperatively-planned ICU admission, or primary floor admission. The primary outcome was transfer from floor to ICU. Secondary outcomes included duration of hospitalization. Results: Chart review yielded 420 patients. Three hundred sixty-eight (88%) were admitted directly to the floor and 52 (12.0%) directly to an ICU. Of patients admitted to the floor, 2 (0.5%) were transferred to an ICU. Twenty-four patients with syndromic and 20 patients with multisutural craniosynostosis were admitted to the floor. Only 1 patient from each group (the same patient; 4.2% and 5.0%, respectively), was transferred to an ICU. Thirty-two ICU admissions were preoperatively planned and 20 were perioperatively planned. Reasons for preoperatively planned ICU admission included significant comorbidities and type of surgery. Reasons for perioperatively planned ICU admissions included significant intraoperative adverse events, excessive blood loss, and failure of clearance from the post-anesthesia care unit (PACU). Patients admitted to the ICU had a statistically significant longer mean length of hospitalization (4.8 days vs 2.7 days) than did patients admitted to the floor. Conclusions: Most postoperative craniosynostosis surgery patients—including patients with syndromic and/or multisutural synostosis—are managed safely on the floor at our center. Some patients still need postoperative ICU admission, but are easily identified preoperatively, intraoperatively, or in the PACU. Our findings should be applicable to other large craniofacial centers.

Anesthetic challenges involved in successful resuscitation of a child from cardiac arrest secondary to massive hemorrhage and possible venous air embolism while undergoing fronto-orbital advancement surgery for metopic craniosynostosis

A one year 3 month old child undergoing fronto-orbital advancement surgery for metopic craniosynostosis had severe bleeding when the surgeon attempted to remove bone flap. Head-end elevation was given at the surgeon’s request to reduce bleeding. Immediately there was a drastic fall in end tidal carbon dioxide (ETCO) and arterial saturation (SpO). Considering air embolism, fraction of inspired oxygen (FiO) was increased to 100% and the surgeon filled the field with saline and covered the area with wet gauze. The operating table was leveled. The child continued to deteriorate with the cardiac rhythm changing to pulseless electrical activity and asystole. Incremental bolus doses of adrenaline, blood products transfusion, fluid bolus and infusion of inotropes were given. Chest compression was not done as the endotracheal tube was fixed to the chest of the patient. Tube dislodgement without access to the head-end of the patient would have been a disaster. The child became hemodynamically stable, the surgery continued and the child was extubated the next day. Other than focal seizures which responded to levetiracetam, the child had no neurological deficits.

The mechanical and microstructural properties of the pediatric skull

The pediatric skull differs drastically from the adult skull in terms of composition, rigidity, and structure. However, there is limited data which quantifies the mechanical properties of the pediatric skull. The lack of mechanical data may inhibit desired pediatric craniofacial surgical outcomes as current methodologies and materials employed for the pediatric population are adapted from those used for adults. In this study, normally discarded parietal bone tissue from eight pediatric craniosynostosis surgery patients (aged 4 to 10 months) was collected during reconstructive surgery and prepared for microstructural analysis and mechanical testing. Up to 12 individual coupon samples of fresh, never frozen tissue were harvested from each specimen and prepared for four-point bending testing to failure. The microstructure of each sample was analyzed using micro-computed tomography before and after each mechanical test. From this analysis, effective geometric and mechanical properties were determined for each sample (n = 68). Test results demonstrated that the pediatric parietal skull was 2.0 mm (±0.4) thick, with a porosity of 36% (±14). The effective modulus of the tissue samples, determined from the initial slope of the sample stress-strain response using Euler beam theory and a nonlinear Ramberg-Osgood stress-strain relationship, was 4.2 GPa (±2.1), which was approximately three times less stiff than adult skull tissue reported in the literature. Furthermore, the pediatric skull was able to bend up to flexural failure strains of 6.7% (±2.0), which was approximately five times larger than failure strains measured in adult skull. The disparity between the measured mechanical properties of pediatric skull tissue and adult skull tissue points towards the need to reevaluate current surgical technologies, such as pediatric cranial surgical hardware, so that they are more compatible with pediatric tissue.