Perioperative management of pediatric patients undergoing juvenile angiofibroma resection. A case series and educational review highlighting patient blood management

Abstract

Background: Juvenile nasopharyngeal angiofibromas are one of the most enigmatic, bloody tumors encountered by otorhinolarygnologists, head and neck surgeons, neurosurgeons, and anesthesiologists. Juvenile nasopharyngeal angiofibromas are rare, benign, highly vascular tumors with a propensity towards aggressive local invasion. Surgery, open or endoscopic, to remove the growth is the primary treatment of choice for Juvenile nasopharyngeal angiofibromas. Historically, surgical resection was associated with massive, rapid blood loss, traditionally managed by blood product transfusion and deliberate hypotension. Preventative management employing multimodal blood conservation strategies should be an essential standard of perioperative care for patients with Juvenile nasopharyngeal angiofibromas. Methods:We describe a contemporary and comprehensive approach in the management of patients with high grade Juvenile nasopharyngeal angiofibromas. This includes surgical strategies such as preemptive external carotid artery embolization, endoscopic surgical approach, and staged operations, as well as anesthetic strategies including antifibrinolytic therapy and acute normovolemic hemodilution. These surgeries, once synonymous with massive transfusion, may potentially be performed without allogeneic blood transfusion, or deliberate hypotension.Aims: Using a case series, the authors introduce a contemporary approach to multimodal, multidisciplinary blood conservation strategies for Juvenile nasopharyngeal angiofibromas surgery. Results:Here in the authors report on an updated contemporary perioperative clinical approach to patients with Juvenile nasopharyngeal angiofibromas. From an anesthetic perspective, we describe the successful use of normal hemodynamic goals, restrictive transfusion strategy, antifibrinolytic therapy, autologous normovolemic hemodilution, and early extubation in the care of three adolescent males with highly invasive tumors. We demonstrate that new surgical and anesthetic strategies have yielded a significant decrease in intraoperative blood loss and eliminated the need for transfusion of autologous red blood cells, which enable improved outcomes. Conclusions:The perioperative approach to elective surgery for Juvenile nasopharyngeal angiofibromas management is presented from a multidisciplinary patient blood management perspective.

Multimodal blood loss prevention bundle for endoscopic resection of juvenile nasopharyngeal angiofibroma: A case series

“…[ 2 ] A recent report of three cases describes using a comprehensive approach, including acute normovolaemic haemodilution, in patients undergoing endoscopic JNA resection. [ 4 ] Care bundles have been known to improve outcomes in intensive care. [ 10 11 ]…”

“…[ 3 ] Few studies have described the anaesthesia management of JNA. [ 4 5 6 7 8 ] However, a bundle approach has not been studied. This series describes the application of a multimodal blood loss prevention bundle (MBLPB) approach [ Table 1 ] and its effect on blood loss and transfusion requirements in patients undergoing endoscopic resection of JNA.…”

Error traps in Pediatric Patient Blood Management in the Perioperative Period

“…The risk of anemia versus the side effect profile of iron and Epo treatment need to be discussed and weighed against the risk of bleeding and blood transfusion. One option includes employing Acute Normovolemic Hemodilution (ANH), the risks and benefits of which are mentioned below and have recently been described 21 . Other blood conservation strategies that should be discussed and offered to patients and families during the informed consent process include cell salvage and tranexamic acid (TXA) administration.…”

“…ANH has been successfully used in pediatric patients undergoing cardiac bypass surgery, scoliosis surgery and craniosynostosis 27,28 under special protocols and guidelines. A recent report details contemporary guidelines and practical considerations regarding ANH for pediatric elective surgery when major blood loss is expected 21 . Hypocalcemia should be anticipated and treated with calcium administration.…”

“…A recent report details contemporary guidelines and practical considerations regarding ANH for pediatric elective surgery when major blood loss is expected. 21 Hypocalcemia should be anticipated and treated with calcium administration. Contraindications include preoperative anemia, hemodynamically significant arrhythmia, acute infection, poor end-organ reserve, presence of coagulation disorders, and hemoglobinopathies.…”