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The Road to Transfusion-free Craniosynostosis Repair in Children Less Than 24 Months Old: A Quality Improvement
Amy B Beethe1,2, Rachel A Spitznagel1,2, Jane A Kugler3
1Department of Anesthesiology, University of Nebraska Medical Center, Omaha, Neb.
Insights
Implementing a bundle of care significantly reduced allogeneic blood transfusions in pediatric craniofacial reconstruction patients. This quality improvement initiative decreased transfusion rates from 100% to 22.7% in young children undergoing craniosynostosis repair.
Area of Science:
- Pediatric Surgery
- Anesthesiology
- Quality Improvement
Background:
- Pediatric craniofacial reconstruction historically involves significant blood loss requiring transfusions.
- A quality improvement initiative aimed to reduce allogeneic transfusions in young children undergoing these procedures.
Purpose of the Study:
- To evaluate the impact of perioperative practice changes on allogeneic transfusion rates in pediatric patients (≤24 months) undergoing craniofacial reconstruction.
Main Methods:
- A single-center, 5-year quality improvement project using Plan-Do-Check-Act methodology.
- Implementation of standardized anesthetic guidelines, temperature management, postoperative transfusion protocols, intraoperative tranexamic acid, and local anesthetic with epinephrine injections.
- Data collection on intraoperative and postoperative allogeneic transfusion rates annually.
Main Results:
- A cohort of 119 pediatric patients (4-24 months) undergoing anterior or posterior vault reconstruction for craniosynostosis was studied.
- Allogeneic blood product transfusion rates decreased from 100% preintervention to 22.7% postintervention.
- The study period was from March 2013 to November 2018.
Conclusions:
- Interdepartmental collaboration and practice modifications resulted in a sustainable decrease in allogeneic blood transfusions for craniosynostosis repair in infants.
- This bundle of care reduces transfusion-related morbidity in pediatric patients.
- The implemented strategies can be adopted by other institutions to improve outcomes.
Introduction:
Pediatric craniofacial reconstruction has historically resulted in extensive blood loss necessitating transfusion. This single-center quality improvement initiative evaluates the impact of perioperative practice changes on the allogeneic transfusion rate for children 24 months and younger of age undergoing craniofacial reconstruction.
Methods:
At project initiation, an appointed core group of anesthesiologists provided all intraoperative anesthetic care for patients undergoing craniofacial reconstruction. Standardized anesthetic guidelines established consistency between providers. Using the Plan-do-check-act methodology, practice changes had been implemented and studied over a 5-year period. Improvement initiatives included developing a temperature-management protocol, using a postoperative transfusion protocol, administering intraoperative tranexamic acid, and a preincisional injection of 0.25% lidocaine with epinephrine. For each year of the project, we acquired data for intraoperative and postoperative allogeneic transfusion rates.
Results:
A cohort of 119 pediatric patients, ages 4-24 months, underwent anterior or posterior vault reconstruction for craniosynostosis at a tertiary children's hospital between March 2013 and November 2018. Intraoperative and postoperative transfusion of allogeneic blood products in this cohort decreased from 100% preintervention to 22.7% postintervention.
Conclusions:
Interdepartmental collaboration and practice modifications using sequential Plan-do-check-act cycles resulted in a bundle of care that leads to a sustainable decrease in the rate of intraoperative and postoperative allogeneic blood transfusions in patients less than 24 months of age undergoing craniosynostosis repair. This bundle decreases the risk of transfusion-related morbidity for these patients. Other institutions looking to achieve similar outcomes can implement this project.
