Pediyatrik Kraniofasiyal Cerrahide Anestezik Yaklaşım ve Kan Kaybını Azaltan Yöntemler

Cerrahi gerektiren en yaygın kraniofasiyal konjenital amomalilerden biri olan kraniyosinostozis bir veya daha fazla kafa sütürünün erken füzyonudur. Kraniyofasiyal cerrahi için anestezik teknik planlanırken detaylı bir şekilde havayolunun değerlendirilmesi gereklidir. Pediatrik kraniofasiyal düzeltme işlemleri büyük ölçüde kan kaybına bağlı olarak kardiyak arrest, masif transfüzyon, koagülopati, şiddetli hipotansiyon, hava embolisi, dahil olmak üzere önemli morbiditeye sahiptir. Homolog kan transfüzyonu önemli ve iyi bilinen risklerle birliktedir. Sinostotik kalvaryal sütürde cerrahi düzeltme uygulanan pediyatrik hastalarda bildirilen transfüzyon oranları tahmini kan hacminin %20-%500’ ü arasında değişmektedir. Kontrollü hipotansiyon ve normovolemik hemodilüsyon gibi kan koruma teknikleri gibi allojenik transfüzyonu azaltma girişimlerinde karmaşık sonuçlar alınmıştır ve küçük bebeklerde uygulanması her zaman pratik değildir. Kraniyosinostozlarda cerrahi düzeltme yapılan çocuklarda, eritropoietin ile önceden tedavi, ameliyat sırasındaki traneksamid asit uygulaması transfüzyon gereksinimini azaltmaktadır.

Anahtar Kelimeler:

Kranisinostozis, kan kaybı, eritropoietin, traneksamik asit, otolog transfüzyon

Anesthetic Management of Pediatric Craniofacial Surgery and Methods of Reducing Blood Loss

One of the most common craniofacial congenital abnormalities requiring surgery is craniosynostosis where there is premature fusion of one or more cranial sutures. A thorough assessment of the airway is necessary to enable careful planning of the anesthetic technique for craniofacial surgery. Pediatric craniofacial reconstruction procedures, has been associated with significant morbidity including cardiac arrest, massive transfusion, coagulopathy, severe hypotension, air embolism, largely related to blood loss. Transfusion of homologous blood is associated with significant and well-known risks. Reported transfusion rates for pediatric patients undergoing surgical correction of synostotic calvarial sutures vary between 20 and 500% of estimated blood volume. Attempts at reducing exposure to allogeneic transfusions, using blood conservation techniques such as controlled hypotension and normovolemic hemodilution, have met with mixed results and are not always practical in small infants. In children undergoing surgical correction of craniosynostosis, pre-treated with erythropoietin, intraoperative tranexamic acid reduces transfusion requirement.

Keywords:

Craniosynostosis, blood loss, erythropoietin, Tranexamic Acid, otologous transfusion,

PDF

___

Sarılar C, Ünlü A. Kraniyosinoz. Türkiye Klinikleri J Pediatr Sci. 2007;3:50-6.
Tunçbilek G. Kraniyofasiyal cerrahinin temel prensipleri. Hacettepe Tıp Dergisi. 2009;40:32-44.
Thomas K, Hughes C, Johnson D, Das S. Anesthesia for surgery related to craniosynostosis: a review. Part 1. Pediatr Anesth. 2012; 22:1033–41.
Çeltikçi E, Börcek AÖ, Baykener MK. Kraniyosinostozlar. Türk Nöroşirurji Dergisi. 2013;23:132-7.
Rath GP, Dash HH. Anaesthesia for neurosurgical procedures in paediatric patients. Ind J Anaesth. 2012;56:502-12.
Seruya M, Oh AK, Rogers GF, Boyajian MJ. Myseros JS, Yaun AL et al. Controlled systemic hypotension and blood loss during fronto-orbital advancement. J Neurosurg Pediatr. 2012;9:491- 7.
Faberowski LW, Black S, Mickle JP. Blood loss and transfusion practice in the perioperative management of craniosynositosis repair. J Neurosurg Anesthesiol. 1999;11:167-72.
Di Rocco C, Tamburrini G, Pietrini D. Blood sparing in craniosynostosis surgery. Semin Pediatr Neurol. 2004;11:278-87.
Deva AK, Hopper RA, Landecker A, Flores R, Weiner H, McCarthy JG, The use of intraoperative autotransfusion during cranial vault remodeling for craniosynostosis. Plast Reconstr Surg.
Velardi F, Di Chirico A, Di Rocco C, Fundaro C, Genovese O, Rendeli C et al. “No allogeneic blood transfusion” protocol for the surgical correction of craniosynostoses, II: clinical application. Childs Nerv Syst. 1998;14:732–9.
Hans P, Collin V, Bonhomme V, Damas F, Born JD, Lamy M. Evaluation of acute normovolemic hemodilution for surgical repair of craniosynostosis. J Neurosurg Anesthesiol. 2000;12:33-9.
Dahmani S, Orliaguet GA, Meyer PG, Blanot S, Renier D, Carli PA. Perioperative blood salvage during surgical correction of craniosynostosis in infants. Br J Anaesth. 2000;85:550-5.
Lajeunie E, Le Merrer M, Bonaiti-Pellie C, et al: Genetic Study of non-syndromic coronal synostosis. Am J Med Genet. 1995;55:500-4.
Cohen MM Jr. Epidemiology of craniosynostosis. In. Craniosynostosis. 2nd ed. (Eds MM Cohen Jr, RE MacLean):112-8. New York, Oxford University Press, 2000.
Adamo MA, Pollack IF. Current management of craniosynostosis. Neurosurg Q. 2009;19:82–7.
Barnett S, Moloney C, Bingham R. Perioperative complications in children with Apert syndrome: a review of 509 anesthetics. Paediatr Anaesth. 2011;21:72–7.
Kimonis V, Gold JA, Hoffman TL, Panchal J, Boyadjiev SA: Genetics of craniosynostosis. Semin Pediatr Neurol. 2007;14:150–61.
Pietrini D, Ciano F, Forte E. Sevoflurane -remifentanil versus isoflurane-remifentanil for the surgical correction of craniosynostosis in infants. Pediatr Anesth. 2005;15:653–62.
Faberowski LW, Black S, Mickle JP. Incidence of venous air embolism during craniectomy for craniosynostosis repair. Anesthesiology. 2000;2:20-3.
Tobias JD, Johnson JO, Jimenez DF, Barone CM, McBride DS Jr . Venous air embolism during endoscopic strip craniectomy for repair of craniosynostosis in infants. Anesthesiology. 2001;95:340-2.
Cortelazzi P, Caldiroli D, Lamperti M, Bricchi M. Early transfusion and crystalloid infusion strategy in infants undergoing cranioplasty surgery. Pediatr Anesth. 2009;19:1237-52.
Meyer P, Renier D, Arnaud E, Jarreau MM, Charron B, Buy E, et al. Blood loss during repair of craniosynostosis. Br J Anaesth. 1993;71:854-7.
Tuncbilek G, Vargel I, Erdem A, Mavili ME, Benli K, Erk Y . Blood loss and transfusion rates during repair of craniofacial deformities. J Craniofac Surg. 2005;16:59-62.
Williams GD, Ellenbogen RG, Gruss JS. Abnormal coagulation during pediatric craniofacial surgery. Pediatr Neurosurg. 2001;35:5-12.
Chen YL, Wu KH. Airway management of patients with craniofacial abnormalities: 10-year experience at a teaching hospital in Taiwan. J Chin Med Assoc. 2009;72:468–70.
Goyal K, Chaturvedi A, Prabhakar H. Factors affecting the outcome of patients undergoing corrective surgery for craniosynostosis: A retrospective analysis of 95 cases. Neurol India.
Maunermann WJ, Haile Dt, Flick RP. Blood conservation (Chapter 14). In Smith’s Anesthesia for Infants and Children, 8th edition (Eds PJ Davis, FP Cladis, EK Motoyama):395-417. Philadelphia, Mosby, 2011.
Stricker PA, Lin EE, Fiadjoe JE, Sussman EM , Pruitt EY, Zhao H et al. Evaluation of central venous pressure monitoring in children undergoing craniofacial reconstruction surgery. Anesth Analg. 2013;116:411-20.
Stricker PA, Lin EE, Fiadjoe JE, Sussman EM, Jobes DR. Absence of tachycardia during hypotension in children undergoing craniofacial reconstruction surgery. Anesth Analg. 2012;115:139-46.
Park Y, Lee J, Song H, Byon H, Kim H, Kim J. The accuracy of noninvasive hemoglobin monitoring using the Radical-7 Pulse CO-Oximeter in children undergoing neurosurgery. Anesth Analg. 2012;115:1302–7.
Lavoie J. Blood transfusion risks and alternative strategies in pediatric patients. Pediatr Anesth. 2011;21:14–24.
Klein HG. Allogeneic transfusion risks in the surgical patient. Am J Surg. 1995;170:21–6.
Degoute CS. Controlled hypotension: a guide to drug choice. Drugs. 2007;67:1053–76.
Tobias JD. Controlled hypotension in children: a critical review of available agents. Paediatr Drugs. 2002;4:439–53.
Joseph SA, Berekashvili K, Mariller MM, Rivlin M, Sharma K, Casden A et al. Blood conservation techniques in spinal deformity surgery. Spine 2008;33:2310–45.
Rierie D, Smith T, David L, Argenta LC. Better for some, may be not for all: a response to preemptive transfusion and infusion strategy in children during craniofascial reconstruction. Pediatr Anesth. 2010;20:574-83.
Rando K, Zunini G, Negroto A. Intraoperative hyponatremia during craniofacial surgery. Pediatr Anesth. 2009;19:358–63.
Hosking J, Dowling K, Kosti D. Intraoperative and postoperative hyponatremia with craniosynostosis surgery. Pediatr Anesth. 2012;22:654-60.
Fearon JA, Weinthal J. The use of recombinant erythropoietin in the reduction of blood transfusion rates in craniosynostosis repair in infants and children. Plast Reconstr Surg. 2002;109:2190–6.
Helfaer MA, Carson BS, James CS, Gates J, Della-Lana D, Vander Kolk C. Increased hematocrit and decreased transfusion requirements in children given erythropoietin before undergoing craniofacial surgery. J Neurosurg. 1998;88:704–8.
Meara JG, Smith EM, HarsbargerRJ, Farlo JN, Matar MM, Levy ML. Blood-conservation tecniques in craniofascial surgery. Ann Plast Surg. 2005; 54:525-9.
Krajewski K, Ashley RK, Pung N, Wald S, Lazareff J, Kawamoto HK et al. Successful blood conservation during craniosynostotic correction with dual therapy using procrit and cell saver. J Craniofac Surg. 2008;19:101-6.
Naran S, Cladis F, Fearon J, Bradley J, Michelott B, Cooper G et al. Safety of preoperative erythropoietin in surgical calvarial remodeling: An 8-year retrospective review and analysis. Plast. Reconstr. Surg. 2012;130:305-10.
Fearon JA, Weinthal J. Rare reaction to recombinant erythropoietin. Plast Reconstr Surg. 2003;112:1732–3.
Dunn CJ, Goa KL: Tranexamic acid: A review of its use in surgery and other indications. Drugs. 1999;57:1005–32.
Dura’n de la Fuente P, Garcia-Ferna’ndez J, Pe’rez-Lo’oez C, Carceller F, Gilsanz Rodriguez F. Usefulness of tranexamic acid in cranial remodelling surgery. Rev Esp Anestesiol Reanim. 2003;50:388-94.
Dadure, C, Sauter M, Bringuier S, Bigorre M, Raux O, Rochette A et al. Intraoperative Tranexamic acid reduces blood transfusion in children undergoing craniosynostosis surgery: a randomized double-blind study. Anesthesiology. 2011;114:856-61.
Goobie SM, Meier PM, Pereira LM, Mcgowan FX, Prescilla RP, Scharp LA et al. Efficacy of tranexamic acid in pediatric craniosynostosis surgery: A double-blind, placebo-controlled trial. Anesthesiology. 2011;114:862-71.
Pieters BJ, Singhal VK. Does early administration of fresh frozen plasma (FFP) in the operating room decrease blood loss and transfusion needs? Plast Reconst Surg. 2012;130:67-70.
Nielsen VG, Cohen BM, Cohen E. Effects of coagulation factor deficiency on plasma coagulation kinetics determined via thrombelastography: critical roles of fibrinogen and factors II, VII, X and XII. Acta Anaesthesiol Scand. 2005;49:222–31.
51- Haas T, Fries D, Velik-Salchner C, Oswald E, Innerhofer P. Fibrinogen in craniosynostosis surgery. Anesth Analg. 2008;106:725–31.
D’Errico C, Munro H, Buchman S, Wagner D, Muraszko KM. Efficacy of aprotinin in children undergoing craniofacial surgery. J Neurosurg. 2003;99:287-90.
Ahmed Z, Stricker L, Rozzelle A, Zestos M. Aprotinin and transfusion requirements in pediatric craniofacial surgery. Pediatr Anaesth. 2014;24:141-5.
Kozek-Langenecker SA, Afshari A, Albaladejo P, Santullano CA, De Robertis E, Filipescu DC et al. Management of severe perioperative bleeding Guidelines from the European Society of Anaesthesiology. Eur J Anaesthesiol. 2013;30:270–382.
Correspondence Address / Yazışma Adresi Ebru Biricik
Çukurova Üniv. Tıp Fakültesi
Anesteziyoloji ve Reanimasyon Anabilim Dalı. Adana, Turkey
e-mail: ebrubiricik@mynet.com