Successful Avoidance of Blood Transfusion in Craniofacial Surgery: The West Virginia University Bloodless Surgery Protocol

Introduction: Children undergoing endoscopic/minimally invasive procedures for the treatment of craniosynostosis commonly avoid allogenic blood transfusion (ABT). However, many children either because of age at presentation, specific diagnosis, or surgeon preference undergo more extensive “open” craniosynostosis procedures resulting in ABT. We crafted a bloodless surgery protocol to allow these children to also avoid ABT.

Methods: A retrospective chart review was conducted on consecutive patients undergoing open (non-endoscopic/minimally invasive) repair of craniosynostosis from 3/2021-9/2024. All surgeries were performed by the same primary team (HSM and SMB). An idealized bloodless surgery protocol was utilized that included epoetin alfa, tranexamic acid, pre-incisional scalp injection (ropivacaine, triamcinolone, hyaluronidase, and epinephrine), meticulous surgical hemostatic technique, intraoperative blood salvage, minimal phlebotomy, and a transfusion threshold of Hgb 6.5.

Results: 61 patients were identified who met the study criteria. Diagnoses included 28 (45.9%) metopic, 18 (29.5%) sagittal, 6 (9.8%) coronal, 1(1.6%) lambdoid, and 8 (13.1%) multi-sutural craniosynostosis. Age at surgery was 8-155 months (median 17 months). 47 (77%) of patients received epoetin alfa preoperatively. Procedures performed included 31(50.8%) fronto-orbital advancement, 20 (32.8%) total cranial vault reconstruction, and 5 (8.2%) posterior cranial vault expansion with and 5 (8.2%) without distraction osteogenesis. The mean operative time was 5 hrs 45 minutes (median 5 hrs 49 minutes) and the mean length of stay was 3.75 days (median 3 days). The mean estimated blood loss (EBL) was 177ml (median 150ml) and mean %EBL was 20.8% (median 17.8%). 9/61 (15%) of patients were transfused intraoperatively and 3 (5%) additional patients were transfused postoperatively for a Hgb of 6.3, 5.1, and 5.9 respectively. 49/61 (80%) of patients avoided ABT. There were no protocol or blood loss associated complications.

Conclusion : Using a bloodless surgery protocol, we were able to safely avoid ABT in patients undergoing major craniofacial procedures. A continued evolution to this treatment expectation is anticipated.