This is the first report of an incidence of postoperative seizures of 0.6% in pediatric cranial vault reconstructive surgery. There was no significant difference in postoperative seizures or seizure-like events in those patients who received the tranexamic acid or aminocaproic acid vs those that did not. This report provides evidence of the safety profile of antifibrinolytic in children having noncardiac major surgery. Caution should prevail however in using antifibrinolytic in high-risk patients. Antifibrinolytic dosage regimes should be based on pharmacokinetic data avoiding high doses.

This multicenter study of ESC versus open craniosynostosis repair represents the largest comparison to date. It demonstrates striking advantages of ESC for young infants that may result in improved clinical outcomes, as well as increased safety.

Background: The current incidence of major complications in paediatric craniofacial surgery in North America has not been accurately defined. In this report, the Pediatric Craniofacial Collaborative Group evaluates the incidence and determines the independent predictors of major perioperative complications using a multicentre database. Methods: The Pediatric Craniofacial Surgery Perioperative Registry was queried for subjects undergoing complex cranial vault reconstruction surgery over a 5-year period. Major perioperative complications were identified through a structured a priori consensus process. Logistic regression was applied to identify predictors of a major perioperative complication with bootstrapping to evaluate discrimination accuracy and provide internal validity of the multivariable model. Results: A total of 1814 patients from 33 institutions in the US and Canada were analysed; 15% were reported to have a major perioperative complication. Multivariable predictors included ASA physical status 3 or 4 (P¼0.005), craniofacial syndrome (P¼0.008), antifibrinolytic administered (P¼0.003), blood product transfusion >50 ml kg e1 (P<0.001), and surgery duration over 5 h (P<0.001). Bootstrapping indicated that the predictive algorithm had good internal validity and excellent

Recalling some fundamental concepts would be interesting for the discussion. The basic concept of measuring CVP intraoperatively by inserting a CVC is still a hypothesis. 2 Some published studies to date show an appealing association between a low CVP, a low blood loss and a better outcome in patients undergoing elective liver resection. 2 This finding was contradicted in some other studies in which CVP monitoring did not appear to reduce blood loss in elective liver resection. 3 Globally, the intraoperative clinical value of CVP is questionable. 4 Intraoperative changes of transthoracic pressure by both mechanical ventilation and the pressure of surgical retractors on the thorax and right atrium are likely to alter the CVP interpretation. 4 Ascites in a cirrhotic patient is also likely to increase transthoracic pressure hence altering CVP. 4 Furthermore, liver resection has become safer and associated with low intraoperative bleeding mainly because of improved surgical skill and techniques. 5 The evidence that lowering CVP per se decreases blood loss and therefore improves outcome is strong but still circumstantial. 2,6 To our knowledge, blood loss was demonstrated to be reduced by a low CVP in only one prospective, randomized study of 50 patients. 6 In this study, mean intraoperative blood loss was 2329 ml, a value far above usual blood loss recorded in recent similar series, thus questioning the relevance for the present practice. 6 Furthermore, the causal link between reduced blood loss and improved outcome remains speculative in liver resection similarly as in other surgical fields. 7 Finally, pharmacologic intervention likely to decrease CVP may result in relative hypovolemia, decrease in weak organ vascularization, which has never been convincingly demonstrated to be safe. Many patients undergoing liver resection are old, have coexisting diseases and are likely to have pre-existing organ dysfunction. 7 In this respect, assessing the safety of such practices remains mandatory.In conclusion, a CVC was not contributive in most patients undergoing liver resection in Stephan's series. 1 However, the clinical contributive value of a low CVP in patients undergoing elective liver resection remains unanswered. N. Mansour C. Lentschener Y. Ozier References 1. Stephan F, Bezaiguia-Delclaux S. Usefulness of central venous catheter during hepatic surgery. Acta Anesthesiol Scand 2008; 52: 388-96. 2. Melendez J, Arslan V, Fische ME, Wuest D, Jarnagin WR, Fong Y, Blumgart LH. Perioperative outcomes of major hepatic resections under low central venous pressure anesthesia: blood loss, blood transfusion, and the risk of postoperative renal dysfunction. J Am Coll Surg 1998; 187: 620-5. 3. Niemann CU, Feiner J, Behrends M, Eilers H, Ascher NL, Roberts JP. Central venous pressure monitoring during living right donor hepatectomy. Liver Transpl 2007; 13: 266-71. 4. Gelman S. Venous function and central venous pressure. A physiologic story. Anesthesiology 2008; 108: 735-48. 5. Franco D. Liver surgery has become simpler. Eur J Anae...

Background: Antifibrinolytics such as tranexamic acid and epsilon-aminocaproic acid are effective at reducing blood loss and transfusion in pediatric patients having craniofacial surgery. The Pediatric Craniofacial Collaborative Group has previously reported low rates of seizures and thromboembolic events (equal to no antifibrinolytic given) in open craniofacial surgery. Aims: To query the Pediatric Craniofacial Collaborative Group database to provide an updated antifibrinolytic safety profile in children given that antifibrinolytics have become recommended standard of care in this surgical population. Additionally, we include the population of younger infants having minimally invasive procedures. Methods: Patients in the Pediatric Craniofacial Collaborative Group registry between June 2012 and March 2021 having open craniofacial surgery (fronto-orbital advancement, mid and posterior vault, total cranial vault remodeling, intracranial LeFort III monobloc), endoscopic cranial suture release, and spring mediated cranioplasty were included. The primary outcome is the rate of postoperative complications possibly attributable to antifibrinolytic use (seizures, seizure-like activity, and thromboembolic events) in infants and children undergoing craniosynostosis surgery who did or did not receive antifibrinolytics.Results: Forty-five institutions reporting 6583 patients were included. The overall seizure rate was 0.24% (95% CI: 0.14, 0.39%), with 0.20% in the no Antifibrinolytic group and 0.26% in the combined Antifibrinolytic group, with no statistically reported difference. Comparing seizure rates between tranexamic acid (0.22%) and epsilon-aminocaproic acid (0.44%), there was no statistically significant difference (odds ratio = 2.0; 95% CI: 0.6, 6.7; p = .257). Seizure rate was higher in patients greater than 6 months (0.30% vs. 0.18%; p = .327), patients undergoing open procedures (0.30% vs. 0.06%; p = .141), and syndromic patients (0.70% vs. 0.19%; p = .009).