Tranexamic Acid in Infantile Craniosynostosis Surgery: Friend or Foe?

Abstract

Background: Recent studies support the prophylactic use of tranexamic acid during craniosynostosis surgery to reduce blood loss. The study aims to assess national trends and outcomes of tranexamic acid administration. Methods: The Pediatric Health Information System database was used to identify patients who underwent craniosynostosis surgery over a 9-year period (2010 to 2018). Search criteria included patients younger than 2 years with a primary diagnosis of craniosynostosis (International Classification of Diseases, Ninth Revision, 756.0; International Classification of Diseases, Tenth Revision, Q75.0) and CPT code for craniotomy (61550 to 61559). Tranexamic acid use, complications, length of stay, and transfusion requirements were recorded. Subgroup analysis was performed for fronto-orbital advancements and single-suture surgery. Results: A total of 1345 patients were identified. Mean patient age was 229 ± 145 days. Four hundred fifty-four patients (33.7 percent) received tranexamic acid. Tranexamic acid use increased from 13.1 percent in 2010 to 75.6 percent in 2018 (p = 0.005), and mean blood products per patient increased from 1.09 U to 1.6 U (p = 0.009). Surgical complication rate was higher in those receiving tranexamic acid (16.7 percent versus 11.1 percent; p = 0.004). Tranexamic acid administration was associated with increased transfusion requirements on univariate and multivariate analysis (1.76 U versus 1.18 U; OR, 2.03; p < 0.001). In the fronto-orbital advancement subgroup, those receiving tranexamic acid received more total blood products (2.2 U versus 1.8 U; p = 0.02); this difference was present but not significant within the single-suture group (0.69 U versus 0.50 U; p = 0.06). Conclusions: Tranexamic acid use in craniosynostosis surgery has increased dramatically since 2010. However, it was associated with higher transfusion and complication rates in this data set. Optimization of its use and blood loss mitigation in infant craniosynostosis deserve continued research. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Efficacy of Tranexamic Acid in Pediatric Craniofacial and Orthognathic Surgery: A Meta-Analysis

“…10 The most rigorous examination of the safety profile of tranexamic acid was from a multicenter collaborative study that evaluated perioperative complications in craniosynostosis surgery for patients receiving tranexamic acid (n = 1638). 13 In that study, the authors reported a 0.3% rate of seizures and no thrombotic events related to tranexamic acid. The rate of seizures was similar to the group those did not receive tranexamic acid.…”

“…Many craniofacial surgeons and pediatric anesthesiologists believe that despite the lack of strong evidence to support the use of TXA in craniofacial surgery, there are minimal side effects. 13,22 The studies included in our review did not report any side effects from TXA administration. However, there are many large sample studies from the adult population that reported deleterious sequelae from TXA use.…”

“…The rate of seizures was similar to the group those did not receive tranexamic acid. 13 Nevertheless, it is possible that the rate of reported seizure complications is underestimated given that most children receiving TXA while paralyzed and anesthetized therefore, seizure could be undetected. Future studies should be performed to examine the efficacy of tranexamic acid use in different clinical scenarios and identify the associated risks.…”

“…3,4 Despite a substantial rise in the use of tranexamic acid in plastic surgery procedures, there is a paucity of literature examining the effectiveness of tranexamic acid in craniofacial surgery and particularly in pediatric and orthognathic patients. 13 The purpose of this FACE 3 (1) systematic review was to review the current literature as it pertains to the effectiveness of tranexamic acid administration in pediatric craniofacial and orthognathic surgery.…”

Safety and efficacy of aprotinin versus tranexamic acid for reducing absolute blood loss and transfusion in pediatric patients undergoing craniosynostosis surgery: a randomized, double-blind, three-arm controlled trial

“…Contrary to the results of the current study and previously reported research, 6,8 one meta-analysis on TXA in craniosynostosis surgery showed that increased use of TXA over a period of years increased blood transfusion and complication rates. 18…”