There are a lot of terrific things that the Society for Pediatric Anesthesia has done and continues to do. One, that many of you may or may not know about, are special interest groups and databases that have been developed to leverage the data, expertise, and experiences of our members to improve the perioperative care of children.
One of the most productive of the special interest groups is the Pediatric Craniofacial Collaborative group currently chaired by Dr. Chris Glover. This group established the Pediatric Craniofacial Surgery Perioperative Registry (PSCPR) in 2010 and has been at the forefront of studies on the perioperative anesthetic management of patients with cranial vault pathology and the results of their most recent analysis are presented in today’s PAAD. Another is the Society for Pediatric Anesthesia Improvement Network (SPAIN), chaired by Dr. Allison Fernandez, founded in 2014, whose mission is to evaluate perioperative management and postoperative recovery for surgical procedures where perioperative care is variable and outcomes are uncertain or inconsistent, such as their examination of perioperative analgesia for the Nuss procedure. The results of those efforts were published in 2019.1 (See more about SPAIN on SPA’s website: http://www3.pedsanesthesia.org/newsletters/2018summer/spain.html )
More about SPA’s registries and databases in tomorrow’s PAAD. Myron Yaster MD
PS: As we enter into the holiday season, we would like to ask all of you, our reader/subscribers, to offer “what you are grateful for”? Send your responses to Myron (myasterster@gmail.com) and we will publish them on Christmas eve.
Original article
Michael R King, Steven J Staffa, Paul A Stricker, Carolina Pérez-Pradilla, Olivia Nelson, Hubert A Benzon, Susan M Goobie, Pediatric Craniofacial Collaborative Group. Safety of antifibrinolytics in 6583 pediatric patients having craniosynostosis surgery: A decade of data reported from the multicenter Pediatric Craniofacial Collaborative Group. Paediatr Anaesth. 2022 Dec;32(12):1339-1346. PMID: 35925835
“Despite recent advancements in perioperative care and surgical techniques, bleeding continues to be a significant cause of morbidity in patients undergoing craniosynostosis repair.2 Antifibrinolytics such as tranexamic acid (TXA) and epsilon-aminocaproic acid (EACA) have been shown to be effective at reducing blood loss and blood product transfusion in pediatric patients undergoing craniosynostosis surgery3. Further, the absence of antifibrinolytic administration has been identified as an independent predictor of major perioperative complications in pediatric complex cranial vault reconstruction surgery4.”5 A persistent question and barrier for the universal adoption of anti-fibrinolytics in craniosynostosis surgery: “is it safe”? Specifically, does it increase the incidence of seizures and thromboembolic events? These concerns derived from reports of the increased incidence of seizures and thromboembolic events after TXA exposure in pediatric patients having cardiac surgery. This study by the Society for Pediatric Anesthesia’s Pediatric Craniofacial Collaborative Group PSCPR reported their findings on 6583 patients having craniofacial surgery at 45 institutions. A total of 16 patients in the database experienced clinical postoperative seizures or seizure-like movements. The overall reported seizure rate was 0.24% (95% CI: 0.14%–0.39%) with a rate of 0.20% (95% CI: 0.05%–0.50%) in patients not receiving antifibrinolytics and 0.26% (95% CI: 0.14%–0.46%) in patients receiving either EACA or TXA. Thus, “there was no increase in seizures or thromboembolic events in those that received antifibrinolytics (tranexamic acid and epsilon-aminocaproic acid) versus those that did not.”5 Interestingly and we think unexpectedly, “they found a higher rate of reported seizures in children older than 6 months of age, those having open procedures, syndromic patients, and ASA PS III and IV patients.”5 Finally, “a total of four patients in the database were reported as having a postoperative thromboembolic event (TEE). Two occurred in patients who did not receive antifibrinolytics (0.10%, 95% CI: 0.01%–0.36%) and two occurred in patients who received TXA (0.05%, 95% CI: 0.01%–0.20%).”5
How much TXA to administer to patients for both craniosynostosis surgery or for major hemorrhage remains confusing to us, with loading doses in the literature ranging from 10-100 mg/kg and infusion rates ranging from 1-30 mg/kg/hour.6 Age and cardiac disease affect these decisions and higher blood levels have been associated with seizures. In this study “the median TXA initial bolus dose (mg/kg) and infusion rate (mg/kg/h) was 10.3 mg/kg (IQR: 10, 30.5) and 5 mg/kg/h (IQR: 5, 5) respectively.”5 This is in line with Goobie et al.’s previous study that found “considering 20 μg/ml as the maximum target therapeutic TXA plasma concentration, with a 95% confidence interval (CI) centered on this threshold, a most efficacious and rational dosing regimen of 10 mg/kg dose and 5 mg/kg/h maintenance infusion rate. If one desires “70 μg/ml as the maximum target therapeutic TXA plasma concentration, with a 95% CI centered on this threshold, a most efficacious and rational dosing regimen of 30 mg/kg loading dose and 10 mg/kg/h maintenance infusion rate can be recommende”6
References
1. Muhly WT, Beltran RJ, Bielsky A, et al. Perioperative Management and In-Hospital Outcomes After Minimally Invasive Repair of Pectus Excavatum: A Multicenter Registry Report From the Society for Pediatric Anesthesia Improvement Network. Anesthesia and analgesia. Feb 2019;128(2):315-327. doi:10.1213/ane.0000000000003829
2. Stricker PA, Goobie SM, Cladis FP, et al. Perioperative Outcomes and Management in Pediatric Complex Cranial Vault Reconstruction: A Multicenter Study from the Pediatric Craniofacial Collaborative Group. Anesthesiology. Feb 2017;126(2):276-287. doi:10.1097/aln.0000000000001481
3. Goobie SM, Meier PM, Pereira LM, et al. Efficacy of tranexamic acid in pediatric craniosynostosis surgery: a double-blind, placebo-controlled trial. Anesthesiology. Apr 2011;114(4):862-71. doi:10.1097/ALN.0b013e318210fd8f
4. Goobie SM, Zurakowski D, Isaac KV, et al. Predictors of perioperative complications in paediatric cranial vault reconstruction surgery: a multicentre observational study from the Pediatric Craniofacial Collaborative Group. British journal of anaesthesia. Feb 2019;122(2):215-223. doi:10.1016/j.bja.2018.10.061
5. King MR, Staffa SJ, Stricker PA, et al. Safety of antifibrinolytics in 6583 pediatric patients having craniosynostosis surgery: A decade of data reported from the multicenter Pediatric Craniofacial Collaborative Group. Pediatric Anesthesia. 2022;32(12):1339-1346. doi:https://doi.org/10.1111/pan.14540
6. Goobie SM, Faraoni D. Tranexamic acid and perioperative bleeding in children: what do we still need to know? Current opinion in anaesthesiology. Jun 2019;32(3):343-352. doi:10.1097/aco.0000000000000728