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Abnormal coagulation during pediatric craniofacial surgery
G D Williams1, R G Ellenbogen, J S Gruss
1Department of Anesthesia, University of Washington, Seattle, WA, USA. jumbo.williams@leland.stanford.edu
Insights
Children undergoing major craniofacial surgery can develop coagulopathy due to coagulation factor depletion. Significant differences in coagulation tests were observed in patients with higher blood loss during craniosynostosis repair.
Area of Science:
- Pediatric Surgery
- Hematology
- Anesthesiology
Background:
- Major craniofacial surgery in children can lead to significant blood loss.
- Assessing perioperative hemostasis and coagulopathy is crucial in this patient population.
Purpose of the Study:
- To determine the occurrence of abnormal hemostasis in children undergoing major craniofacial surgery.
- To characterize the nature of any coagulopathy identified.
Main Methods:
- Prospective study recording coagulation tests, blood loss, and transfusions.
- Comparison of patients with blood loss >100 ml/kg (Group A) versus <100 ml/kg (Group B).
- Statistical analysis using Mann-Whitney U test (p < 0.05).
Main Results:
- Median blood loss was 64 ml/kg in 27 children (age 2.9-27.9 months).
- Significant differences in prothrombin time, partial thromboplastin time, thrombin time, thromboelastograph reaction time, prothrombin fragment F1.2, and platelet count between groups.
- Higher blood loss group (A) received more blood products, including fresh frozen plasma and platelets.
Conclusions:
- Coagulopathy can develop in children undergoing craniosynostosis repair due to coagulation factor depletion.
- Hemorrhage approaching 1.5 times estimated blood volume is a critical threshold for coagulopathy.
Introduction:
This prospective study of children undergoing major craniofacial surgery was undertaken to determine whether abnormal hemostasis occurred and to characterize any coagulopathy found.
Methods:
Coagulation tests, blood loss and blood product transfusions were recorded perioperatively. Packed red blood cells (PRBC) were transfused to maintain target hematocrit. Patients with blood loss >100 ml/kg (group A, n = 5) were compared to patients with blood loss <100 ml/kg (group B, n = 22) using Mann-Whitney U test (p < 0.05).
Results:
Twenty-seven children (age range 2.9--27.9 months) had median total blood loss of 64 ml/kg. At completion of surgery, median coagulation values differed significantly between groups for prothrombin time (A: 16.6 s; B: 13.8 s), partial thromboplastin time (A: 44 s; B: 29 s), thrombin time (A: 28 s; B: 23 s), thromboelastograph reaction time (A: 7 mm; B: 4 mm), prothrombin fragment F1.2 (A: 1.9 nmol/l; B: 3.3 nmol/l) and platelet count (A: 174 K/mm(-3); B: 239 K/mm(-3)). Fibrinolysis was not associated with blood loss. Median units transfused were in group A 3 units and group B 1 unit (p = 0.001). All patients received PRBC transfusions but only group A patients received other blood products (fresh frozen plasma, platelets).
Conclusion:
Children transfused with PRBC during craniosynostosis repair can become coagulopathic from coagulation factor depletion when hemorrhage approaches 1.5 times estimated blood volume.
