Craniosynostosis Repair
1. A preoperative Hgb as well as type and screen should be available for these cases - and depending on the exact nature of the case they may be drawn the day before the case. If these labs have not been performed, this should be discussed with the surgeon and either obtained before entering the OR so that (for the major repairs) blood is absolutely available and in the room at the start of the case - or they may be obtained after induction. I personally do not think this practice has to be uniform, but the anesthesia team needs to understand the nature of the repair and the orientation of the surgeon in these cases to be sure that there is no misunderstanding. We currently have a system where the anesthesiologist for a case like this is notified days or weeks ahead of time - a simple email between surgeon and anesthesiologist would probably be all that is needed to clear this up for any given case.
2. Directed donor blood is often available - this should be discussed and confirmed with the family. As always, this should be the first blood administered to the child when transfusion is started. This blood is requested in quad packs. The anesthesia team should be sure that any blood that is not used is kept appropriately chilled and sent back to the blood bank for later use (PICU).
3. A line should be placed that allows intraoperative monitoring of Hgb and blood gasses. This may be an arterial line (preferable) or a large venous line that draws back easily and so that samples may be obtained. Two venous access lines should be available and may include the venous line mentioned above.
4. Hgb should be checked at regular intervals after the start of the case - q30-60 minutes until transfusion is started. After a transfusion is completed, Hgb should be obtained within 30 mins and at regular intervals after that time. Blood loss is hard to quantify in these cases and many cases of inaccurate accounting of total blood loss has been a problem.
5. We have had some discussion on the appropriate Hgb to aim for on ending the case. It appears that the Hgb almost always drifts downwards after some hours in the PICU and further transfusion is required if the Hgb is less than 12-13 on arrival. I am personally not sure if this would not be better handled by appropriate transfusion in the PICU vs. relative overtransfusion by anesthesiology. We will work on this issue - for now I think we should agree that we should aim for a Hgb of at least 10 and perhaps even higher. In any case the PICU should be made aware of the availability of directed donor blood and every effort must be made to be sure that none of this blood is lost due to handling in the OR.
6. Given the overriding considerations of intravascular volume in these cases, some type of Foley catheter is helpful to assure urination during the case and give some guide to fluid requirements.
Extubation after Craniosynostosis Repair:
The decision as to whether of not to extubate a given patient after craniosynostosis repair should be made with input from both the surgical and anesthesia teams. As the primary responsibility for the airway rests with the anesthesia team, they will have to make the final call. We have found that a number of these patients can be extubated in the operating room – even after several hours of surgery – without difficulty. In addition many have been extubated after an hour or two in the PICU with good results. Other patients have been left overnight intubated on the ventilator and extubated the next day. We would like to emphasize that there is no requirement to keep these children intubated, and there may be significant morbidity experienced in keeping a patient intubated and ventilated longer that is necessary.
We would like to emphasize that the significant edema that occurs in these children is often limited to the head. Embarrassment of venous drainage and lymphatics during and immediately following the surgery leads to significant edema around the cranium in the first 24 hours. This does not extend to the airway. Generalized edema can be minimized by optimizing chrystalloid and blood administration during the case (see above).