Child's Nervous System

, Volume 32, Issue 1, pp 143–151 | Cite as

Minimizing blood transfusions in the surgical correction of craniosynostosis: a 10-year single-center experience

  • Christopher M. BonfieldEmail author
  • Julia Sharma
  • D. Douglas Cochrane
  • Ash Singhal
  • Paul Steinbok
Original Paper



Our center previously reported low transfusion rates for craniosynostosis surgery by two experienced neurosurgeons using standard intraoperative techniques and acceptance of low hemoglobin levels. This study evaluated whether low rates were maintained over the last 10 years and if a less experienced neurosurgeon, trained in and practicing in the same environment, could achieve similar outcomes.


All craniosynostosis operations performed in children between 2004 and 2015 were reviewed retrospectively. Transfusion rates were calculated. Analyses examined the relationship of transfusion to craniosynostosis type, surgical procedure, redo operation, surgeon, and perioperative hemoglobin levels.


Two hundred eighteen patients were included: 71 open sagittal, 28 endoscopic-assisted sagittal, 32 unicoronal, 14 bicoronal, 42 metopic, and 31 multisuture. Median age at operation was 9.1 months. Overall transfusion rate was 24 %: 17 % open sagittal, 7 % endoscopic-assisted sagittal, 6 % unicoronal, 21 % bicoronal, 45 % metopic, and 45 % multisuture. The timing of transfusions were 75, 21, and 4 % for intraoperative, postoperative, and both, respectively. Patients not receiving transfusion had a mean lowest hemoglobin of 87 g/l (range 61–111) intraoperatively and 83 g/l (range 58–115) postoperatively. Mean lowest hemoglobin values were significantly lower in those necessitating intraoperative (75 g/l, range 54–102) or postoperative (59 g/l, range 51–71) transfusions. There was no significant difference in transfusion rate between less and more experienced surgeons. There were no cardiovascular complications or mortalities.


In craniosynostosis surgery, reproducible, long-term low blood transfusion rates were able to be maintained at a single center by careful intraoperative technique and acceptance of low intraoperative and postoperative hemoglobin levels in hemodynamically stable patients. Furthermore, low rates were also achieved by an inexperienced neurosurgeon in the group. This suggests that these results may be achievable by other neurosurgeons, who follow a similar protocol.


Craniosynostosis Blood transfusion Craniectomy Craniofacial surgery 



No funding was obtained or used for this study.


  1. 1.
    Ali A, Basaran B, Yornuk M, Altun D, Aydoseli A, Sencer A, Akinci IO (2013) Factors influencing blood loss and postoperative morbidity in children undergoing craniosynostosis surgery: a retrospective study. Pediatr Neurosurg 49:339–46CrossRefPubMedGoogle Scholar
  2. 2.
    Cochrane DD, Woerdeman PA (2016) Sagittal Synostosis Repair Surgery. In Cohen AR (ed) Pediatric Neurosurgery: Tricks of the trade, Thieme, New York, pp 119–124 (forthcoming)Google Scholar
  3. 3.
    Cortellazzi P, Caldiroli D, Lamperti M, Bricchi M, Valentini L (2009) Early transfusion and crystalloid infusion strategy in infants undergoing cranioplasty surgery. Paediatr Anaesth 19:1251–2CrossRefPubMedGoogle Scholar
  4. 4.
    Crantford JC, Wood BC, Claiborne JR, Ririe DG, Couture DE, Thompson JT, David LR (2015) Evaluating the safety and efficacy of tranexamic acid administration in pediatric cranial vault reconstruction. J Craniofac Surg 26:104–7CrossRefPubMedGoogle Scholar
  5. 5.
    D’Errico CC, Munro HM, Buchman SR, Wagner D, Muraszko KM (2003) Efficacy of aprotinin in children undergoing craniofacial surgery. J Neurosurg 99:287–90CrossRefPubMedGoogle Scholar
  6. 6.
    Dadure C, Sauter M, Bringuier S, Bigorre M, Raux O, Rochette A, Canaud N, Capdevila X (2011) Intraoperative tranexamic acid reduces blood transfusion in children undergoing craniosynostosis surgery: a randomized double-blind study. Anesthesiology 114:856–61CrossRefPubMedGoogle Scholar
  7. 7.
    Deva AK, Hopper RA, Landecker A, Flores R, Weiner H, McCarthy JG (2002) The use of intraoperative autotransfusion during cranial vault remodeling for craniosynostosis. Plast Reconstr Surg 109:58–63CrossRefPubMedGoogle Scholar
  8. 8.
    Di Rocco C, Tamburrini G, Pietrini D (2004) Blood sparing in craniosynostosis surgery. Semin Pediatr Neurol 11:278–87CrossRefPubMedGoogle Scholar
  9. 9.
    Duncan C, Richardson D, May P, Thiruchelvam J, Shong DC, Potter F, Grogan J, Caswell M (2008) Reducing blood loss in synostosis surgery: the Liverpool experience. J Craniofac Surg 19:1424–30CrossRefPubMedGoogle Scholar
  10. 10.
    Durán de la Fuente P, García-Fernández J, Pérez-López C, Carceller F, Gilsanz Rodríguez F (2003) Usefulness of tranexamic acid in cranial remodeling surgery. Rev Esp Anestesiol Reanim 50:388–94PubMedGoogle Scholar
  11. 11.
    Faberowski LW, Black S, Mickle JP (1999) Blood loss and transfusion practice in the perioperative management of craniosynostosis repair. J Neurosurg Anesthesiol 11:167–72CrossRefPubMedGoogle Scholar
  12. 12.
    Fearon JA (2004) Reducing allogenic blood transfusions during pediatric cranial vault surgical procedures: a prospective analysis of blood recycling. Plast Reconstr Surg 113:1126–30CrossRefPubMedGoogle Scholar
  13. 13.
    Fearon JA, Cook TK, Herbert M (2014) Effects of hypotensive anesthesia on blood transfusion rates in craniosynostosis corrections. Plast Reconstr Surg 133:1133–6CrossRefPubMedGoogle Scholar
  14. 14.
    Fearon JA, Weinthal J (2002) The use of recombinant erythropoietin in the reduction of blood transfusion rates in craniosynostosis repair in infants and children. Plast Reconstr Surg 109:2190–6CrossRefPubMedGoogle Scholar
  15. 15.
    Gault DT, Renier D, Marchac D, Jones BM (1992) Intracranial pressure and intracranial volume in children with craniosynostosis. Plast Reconstr Surg 90:377–81CrossRefPubMedGoogle Scholar
  16. 16.
    Goobie SM, Meier PM, Pereira LM, McGowan FX, Prescilla RP, Scharp LA, Rogers GF, Proctor MR, Meara JG, Soriano SG, Zurakowski D, Sethna NF (2011) Efficacy of tranexamic acid in pediatric craniosynostosis surgery: a double-blind, placebo-controlled trial. Anesthesiology 114:862–71CrossRefPubMedGoogle Scholar
  17. 17.
    Goodman AM, Pollack MM, Patel KM, Luban NL (2003) Pediatric red blood cell transfusions increase resource use. J Pediatr 142:123–7CrossRefPubMedGoogle Scholar
  18. 18.
    Goodnough LT (2003) Risks of blood transfusion. Crit Care Med 31(12 Suppl):S678–86CrossRefPubMedGoogle Scholar
  19. 19.
    Gunnarsson I, Hlynsson BÖ, Rosmundsson T, Thorsteinsson A (2011) Haemostatic effect of aprotinin during craniosynostotic surgery in children. Acta Anaesthesiol Scand 55:1010–4CrossRefPubMedGoogle Scholar
  20. 20.
    Haas T, Goobie S, Spielmann N, Weiss M, Schmugge M (2014) Improvements in patient blood management for pediatric craniosynostosis surgery using a ROTEM(®) -assisted strategy - feasibility and costs. Paediatr Anaesth 24:774–80CrossRefPubMedCentralPubMedGoogle Scholar
  21. 21.
    Hans P, Collin V, Bonhomme V, Damas F, Born JD, Lamy M (2000) Evaluation of acute normovolemic hemodilution for surgical repair of craniosynostosis. J Neurosurg Anesthesiol 12:33–6CrossRefPubMedGoogle Scholar
  22. 22.
    Hebert PC, Wells G, Blajchman MA, Marshall J, Martin C, Pagliarello G, Tweeddale M, Schweitzer I, Yetisir E (1999) A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med 340:409–17CrossRefPubMedGoogle Scholar
  23. 23.
    Helfaer MA, Carson BS, James CS, Gates J, Della-Lana D, Vander Kolk C (1998) Increased hematocrit and decreased transfusion requirements in children given erythropoietin before undergoing craniofacial surgery. J Neurosurg 88:704–8CrossRefPubMedGoogle Scholar
  24. 24.
    Hentschel S, Steinbok P, Cochrane DD, Kestle J (2002) Reduction of transfusion rates in the surgical correction of sagittal synostosis. J Neurosurg 97:503–9CrossRefPubMedGoogle Scholar
  25. 25.
    Howe PW, Cooper MG (2012) Blood loss and replacement for paediatric cranioplasty in Australia - a prospective national audit. Anaesth Intensive Care 40:107–13PubMedGoogle Scholar
  26. 26.
    Jimenez DF, Barone CM (1995) Intraoperative autologous blood transfusion in the surgical correction of craniosynostosis. Neurosurgery 37:1075–9CrossRefPubMedGoogle Scholar
  27. 27.
    Jimenez DF, Barone CM (2012) Endoscopic technique for sagittal synostosis. Childs Nerv Syst 28:1333–9CrossRefPubMedGoogle Scholar
  28. 28.
    Krajewski K, Ashley RK, Pung N, Wald S, Lazareff J, Kawamoto HK, Bradley JP (2008) Successful blood conservation during craniosynostotic correction with dual therapy using procrit and cell saver. J Craniofac Surg 19:101–5PubMedGoogle Scholar
  29. 29.
    Martin DT, Gries H, Diggs BS, Koh JL, Selden NR, Schreiber MA, Kuang AA (2014) Implementation of tranexamic acid to reduce blood loss during cranial vault remodeling for craniosynostosis at a single institution. Plast Reconstr Surg 134(4 Suppl 1):22CrossRefGoogle Scholar
  30. 30.
    Massimi L, Tamburrini G, Caldarelli M, Di Rocco C (2007) Effectiveness of a limited invasive scalp approach in the correction of sagittal craniosynostosis. Childs Nerv Syst 23:1389–401CrossRefPubMedGoogle Scholar
  31. 31.
    Maugans TA, Martin D, Taylor J, Salisbury S, Istaphanous G (2011) Comparative analysis of tranexamic acid use in minimally invasive versus open craniosynostosis procedures. J Craniofac Surg 22:1772–8CrossRefPubMedGoogle Scholar
  32. 32.
    Meara JG, Smith EM, Harshbarger RJ, Farlo JN, Matar MM, Levy ML (2005) Blood-conservation techniques in craniofacial surgery. Ann Plast Surg 54:525–9CrossRefPubMedGoogle Scholar
  33. 33.
    Meneghini L, Zadra N, Aneloni V, Metrangolo S, Faggin R, Giusti F (2003) Erythropoietin therapy and acute preoperative normovolaemic haemodilution in infants undergoing craniosynostosis surgery. Paediatr Anaesth 13:392–6CrossRefPubMedGoogle Scholar
  34. 34.
    Meyer P, Renier D, Arnaud E, Jarreau MM, Charron B, Buy E, Buisson C, Barrier G (1993) Blood loss during repair of craniosynostosis. Br J Anaesth 71:854–7CrossRefPubMedGoogle Scholar
  35. 35.
    Nguyen TT, Hill S, Austin TM, Whitney GM, Wellons JC 3rd, Lam HV (2015) Use of blood-sparing surgical techniques and transfusion algorithms: association with decreased blood administration in children undergoing primary open craniosynostosis repair. J Neurosurg Pediatr 31:1–8Google Scholar
  36. 36.
    Oppenheimer AJ, Ranganathan K, Levi B, Strahle JM, Kapurch J, Muraszko KM, Buchman SR (2014) Minimizing transfusions in primary cranial vault remodeling: the role of aminocaproic acid. J Craniofac Surg 25:82–6CrossRefPubMedGoogle Scholar
  37. 37.
    Orliaguet GA, Bruyere M, Meyer PG, Blanot S, Renier D, Carli PA (2003) Comparison of perioperative blood salvage and postoperative reinfusion of drained blood during surgical correction of craniosynostosis in infants. Paediatr Anaesth 13:797–804CrossRefPubMedGoogle Scholar
  38. 38.
    Pieters BJ, Conley L, Weiford J, Hamilton M, Wicklund B, Booser A, Striker A, Whitney S, Singhal V (2015) Prophylactic versus reactive transfusion of thawed plasma in patients undergoing surgical repair of craniosynostosis: a randomized clinical trial. Paediatr Anaesth 25:279–87CrossRefPubMedGoogle Scholar
  39. 39.
    Seal SK, Steinbok P, Courtemanche DJ (2015) Cranial orbital buttress technique for nonsyndromic unicoronal and metopic craniosynostosis. Neurosurg Focus 38:E4CrossRefPubMedGoogle Scholar
  40. 40.
    Seruya M, Oh AK, Rogers GF, Han KD, Boyajian MJ, Myseros JS, Yaun AL, Keating RF (2012) Blood loss estimation during fronto-orbital advancement: implications for blood transfusion practice and hospital length of stay. J Craniofac Surg 23:1314–7CrossRefPubMedGoogle Scholar
  41. 41.
    Stainsby D, Jones H, Wells AW, Gibson B, Cohen H, SHOT Steering Group (2008) Adverse outcomes of blood transfusion in children: analysis of UK reports to the serious hazards of transfusion scheme 1996–2005. Br J Haematol 141:73–79CrossRefPubMedGoogle Scholar
  42. 42.
    Steinbok P (2016) Techniques for limiting blood loss and blood transfusions in pediatric neurosurgery. In Cohen AR (ed) Pediatric Neurosurgery: Tricks of the trade, Thieme, New York, pp 867–873 (forthcoming)Google Scholar
  43. 43.
    Steinbok P, Heran N, Hicdonmez T, Cochrane DD, Price A (2004) Minimizing blood transufusions in the surgical correction of coronal and metopic craniosynostosis. Childs Nerv Syst 20:445–52PubMedGoogle Scholar
  44. 44.
    Stricker PA, Fiadjoe JE, Kilbaugh TJ, Pruitt EY, Taylor JA, Bartlett SP, McCloskey JJ (2012) Effect of transfusion guidelines on postoperative transfusion in children undergoing craniofacial reconstruction surgery. Pediatr Crit Care Med 13:e357–62CrossRefPubMedGoogle Scholar
  45. 45.
    Stricker PA, Shaw TL, Desouza DG, Hernandez SV, Bartlett SP, Friedman DF, Sesok-Pizzini DA, Jobes DR (2010) Blood loss, replacement, and associated morbidity in infants and children undergoing craniofacial surgery. Paediatr Anaesth 20:150–9CrossRefPubMedGoogle Scholar
  46. 46.
    Székely A, Cserép Z, Sápi E, Breuer T, Nagy CA, Vargha P, Hartyánszky I, Szatmári A, Treszl A (2009) Risks and predictors of blood transfusion in pediatric patients undergoing open heart operations. Ann Thorac Surg 87:187–97CrossRefPubMedGoogle Scholar
  47. 47.
    van Uitert A, Megens JH, Breugem CC, Stubenitsky BM, Han KS, de Graaff JC (2011) Factors influencing blood loss and allogeneic blood transfusion practice in craniosynostosis surgery. Paediatr Anaesth 21:1192–7CrossRefPubMedGoogle Scholar
  48. 48.
    Vega RA, Lyon C, Kierce JF, Tye GW, Ritter AM, Rhodes JL (2014) Minimizing transfusion requirements children undergoing craniosynostosis repair: the CHoR protocol. J Neurosurg Pediatr 30:1–6Google Scholar
  49. 49.
    White N, Bayliss S, Moore D (2015) Systematic review of interventions for minimizing perioperative blood transfusion for surgery for craniosynostosis. J Craniofac Surg 26:26–36CrossRefPubMedGoogle Scholar
  50. 50.
    White N, Carver ED, Rodrigues D, Dover S, Magdum S, Nishikawa H, Solanki G (2009) Calvarial remodelling for sagittal synostosis: does fibrin glue (Tisseel) reduce post-operative blood transfusion requirements? Childs Nerv Syst 25:867–9CrossRefPubMedGoogle Scholar
  51. 51.
    White N, Marcus R, Dover S, Solanki G, Nishikawa H, Millar C, Carver ED (2009) Predictors of blood loss in fronto-orbital advancement and remodeling. J Craniofac Surg 20:378–81CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2015

Authors and Affiliations

  • Christopher M. Bonfield
    • 1
    Email author
  • Julia Sharma
    • 1
  • D. Douglas Cochrane
    • 1
  • Ash Singhal
    • 1
  • Paul Steinbok
    • 1
  1. 1.Division of Pediatric Neurosurgery, Department of SurgeryUniversity of British Columbia and BC Children’s HospitalVancouverCanada

Personalised recommendations