Copyright @ 2009 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. Predictors of Blood Loss in Fronto-Orbital Advancement and Remodeling Nicholas White, BSC(Hons), MD, FRCS(Plast), Ritchie Marcus, FRCA, MA, Stephen Dover, FDSRCS, FRCS, Guirish Solanki, FRCSI, FRCS(SN), Hiroshi Nishikawa, MA, MD, FRCS(Plast), Carol Millar, FRCA, and Edmund D. Carver, MRCP, FRCA Abstract: Fronto-orbital advancement and remodeling for cranio- synostosis is extensive surgery and is associated with potential risks; the most significant of these is blood loss. We prospectively studied 116 consecutive patients undergoing fronto-orbital advancement by the same surgical team for a 5-year 6-month period to determine what factors are associated with blood loss and transfusion of blood products. The data collected on the calvarial sutures involved were whether the patient had a diagnosed syndrome, the age at operation, the length of the operation, the estimated blood volume lost during the perioperative course, the number of units of packed cells transfused (donor exposures), and the use of other blood products. The mean (SD) total blood volume lost was 116% (5.4) of the estimated preoperative volume. The median number of whole units of packed cells transfused was 2 units. Other blood products were given in 28% of the cases. There was significantly greater blood loss in those patients with recognized craniofacial syndromes, pansynostosis, an operating time longer than 5 hours, and an age of 18 months or younger at operation. The use of other blood products was associated with those patients losing a blood volume higher than the mean. Key Words: Blood conservation, donor exposures, fronto-orbital advancement, craniosynostosis, craniofacial surgery (J Craniofac Surg 2009;20: 378Y381) C raniosynostosis is the premature closure of the sutures of the skull with an approximate incidence of 1 in 2500 live births; half of these patients have some involvement of either one or both coronal sutures or the metopic suture. 1 The established treatment of patients with early fusion of the anterior calvarial sutures is fronto- orbital advancement and remodeling (FOAR). 2,3 Surgery is performed to provide the best possible cosmetic appearance and treat raised intracranial pressure. 4 Fronto-orbital advancement and remodeling is an extensive surgery performed on young children and, as with all surgery for craniosynostosis, is associated with potential risks. The most significant of these is blood loss. 5Y7 Previous studies have been published describing approaches to minimize blood loss and manage blood replacement during craniofacial surgery. The techniques advocated are wide ranging and can be divided into 2 groups: the first is the organization of the craniofacial team, and the second comprises perioperative blood conservation techniques. The formation of dedicated teams in designated centers performing surgery for craniosynostosis where a higher number of procedures are being performed each year allows a greater degree of competence to be obtained by the surgeons, anesthetists, and nursing staff. 8 Blood conservation methods can include the use of preoperative recombinant erythropoietin, perioperative autologous blood transfusion, and postoperative reinfusion of drained blood. 9Y11 We prospectively studied all our patients undergoing fronto- orbital advancement by the same surgical team for a 5-year 6-month period to determine what factors are associated with blood loss and transfusion of blood products. MATERIALS AND METHODS A prospective study was undertaken of all patients treated surgically with FOAR at our unit for a period from October 2002 to March 2008. We excluded patients who were undergoing a revision procedure after previous FOAR or a combined procedure such as a monobloc advancement. The following data set was collected: the calvarial sutures involved, whether the patient had a diagnosed syndrome, the age at operation, the length of the operation, preoperative and postoperative hemoglobin (Hb) levels and hemat- ocrit (Hct), the estimated blood volume (EBV) lost during the perioperative course, the number of units of packed cells transfused (donor exposures), the volume of packed cells transfused, and the use of other blood products. Following a set of protocols, all patients were preoperatively crossmatched; initially, for 4 units of packed cells at the start of the study period and then, as a result of ongoing audit of blood use, was reduced to 3 and later to 2 units. A preoperative full blood count was measured. Blood was transfused during surgery, dependent upon the patients’ hemodynamic parameters and measured hemoglobin (Hb) level, with the aim of maintaining an intraoperative Hb level of more than 8 g/dL. Intraoperative red cell salvage was performed for 37 of the patients toward the end of the series. Platelet transfusion was given to maintain a platelet count of more than 80. Fresh frozen plasma (FFP) was given if the prothrombin time or activated partial thromboplastin time was longer than 1.5 times the normal or in the presence of microvascular bleeding. Cryoprecipitate was given if the fibrinogen level was less than 1 g/L. Full blood counting, clotting screening, and urea and electrolyte samplings were performed on the evening of the surgery, and full blood counting and urea and electrolyte samplings were repeated on the first postoperative morning. Packed red cells were transfused postoperative if a Hb level lower than 8 g/dL was recorded or if there was hypovolemia that was not responding to crystalloid fluid replacement. ORIGINAL ARTICLE 378 The Journal of Craniofacial Surgery & Volume 20, Number 2, March 2009 From the Departments of Anaesthesia, and Craniofacial Surgery, Birmingham Children’s Hospital, Birmingham, United Kingdom. Received September 17, 2008. Accepted for publication September 26, 2008. Address correspondence and reprint requests to Nicholas White, BSC(Hons), MD, FRCS(Plast), Departments of Craniofacial Surgery, Birmingham Childrens Hospital, Steelhouse Lane, Birmingham B4 6NH, United Kingdom; E-mail: nicholas.white@bch.nhs.uk Copyright * 2009 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0b013e31819b9429