Anesthesiology, V 122 • No 5 1021 May 2015 P ROCEDURES to correct craniosynostosis have become safer during the last 3 decades. e morbid- ity and mortality rates of these procedures, once reported to be as high as 16.5 and 1.6%, respectively, have declined to approximately 0.1% for each. 1–4 Improvements in opera- tive techniques and training as well as advancements in anes- thesia care and patient blood management strategies have driven this trend. In a retrospective review of 8,101 children undergoing craniofacial surgery in two centers in the United States, Czerwinski et al. 1 reported a mortality of 0.1% with 50% of the deaths being directly attributed to blood loss. A 2013 study, using a national database of 3,426 patients from 131 American teaching hospitals, reported a 10% acute postoper- ative complication rate from craniosynostosis surgical repair, most commonly due to hematological events, hemorrhage or hematoma (4%), and airway/respiratory failure (3%). 2 Lee et al. 3 published in 2012 a 30-yr retrospective review of 796 children having primary cransynostosis surgery from Australia and concluded that there was a combined 14% intraoperative and postoperative complication rate, higher What We Already Know about This Topic • Craniosynostosis surgery is associated with clinically significant postoperative events requiring intensive care unit admission. • This study determined specific postoperative cardiorespira- tory and hematological events after craniosynostosis surgery, which would require intensive care unit admission. What This Article Tells Us That Is New • Children undergoing craniosynostosis surgery are at increased risk for clinically significant postoperative events requiring inten- sive care unit admission if they are less than 10 kg body weight, have American Society of Anesthesiologists physical status 3 or 4, require intraoperative transfusion of greater than 60ml/kg of packed erythrocytes, receive hemostatic blood products, or develop a significant intraoperative complication. Tranexamic acid administration was associated with fewer postoperative events. Copyright © 2015, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. All Rights Reserved. Anesthesiology 2015; 122:1021-32 ABSTRACT Background: Craniosynostosis surgery is associated with clinically significant postoperative events requiring intensive care unit (ICU) admission. e authors investigate specific variables, which might influence the risk for these events, and thereby make recommendations regarding the need for postoperative ICU admission. Methods: A retrospective review of 225 children undergoing open craniosynostosis repair at a single center during a 10-yr period is reported. e primary outcome measure was the incidence of predefined clinically relevant postoperative cardiore- spiratory and hematological events requiring ICU admission. Results: e incidences of postoperative cardiorespiratory and hematological events requiring ICU care were 14.7% (95% CI, 10.5 to 20.1%) and 29.7% (95% CI, 24.0 to 36.3%), respectively. Independent predictors of cardiorespiratory events were body weight less than 10 kg, American Society of Anesthesiologists physical status 3 or 4, intraoperative transfusion of greater than 60 ml/kg packed erythrocytes, and the occurrence of an intraoperative complication. e independent predictors of hematological events were body weight less than 10 kg, American Society of Anesthesiologists physical status 3 or 4, intra- operative transfusion of greater than 60 ml/kg packed erythrocytes, transfusion of hemostatic products (fresh-frozen plasma, platelets, and/or cryoprecipitate), and tranexamic acid not administered. Conclusions: Children undergoing craniosynostosis surgery are at increased risk for clinically significant postoperative events requiring ICU admission if they are less than 10 kg body weight, American Society of Anesthesiologists physical status 3 or 4, require intraoperative transfusion of greater than 60 ml/kg of packed erythrocytes, receive hemostatic blood products, or if they develop a significant intraoperative complication. Tranexamic acid administration was associated with fewer postopera- tive events. A predictive clinical algorithm for pediatric patients having major craniosynostosis surgery was developed and validated to risk stratify these patients. (ANESTHESIOLOGY 2015; 122:1021-32) Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www. anesthesiology.org). Presented at the International Society of Craniofacial Surgery Annual Meeting, September 10-14, 2013, Jackson Hole, Wyoming, and the International Anesthesia Research Society Meeting, May 17-20, 2014, Montreal, Quebec, Canada. Submitted for publication March 1, 2014. Accepted for publication December 15, 2014. From the Department of Anesthesiology, Periop- erative, and Pain Medicine (S.M.G., D.Z., P.M.M., V.J.Y.), Department of Neurosurgery (M.R.P.), and Department of Plastic Surgery (J.G.M.), Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts; and Department of Plastic Surgery, Children’s National Medical Center, Washington, D.C. (G.F.R.). Predictors of Clinically Significant Postoperative Events after Open Craniosynostosis Surgery Susan M. Goobie, M.D., F.R.C.P.C., David Zurakowski, Ph.D., Mark R. Proctor, M.D., John G. Meara, M.D., Petra M. Meier, M.D., Vanessa J. Young, R.N., B.N., Gary F. Rogers, M.D. Downloaded from http://pubs.asahq.org/anesthesiology/article-pdf/122/5/1021/485905/20150500_0-00018.pdf by guest on 14 November 2024