A cross-sectional analysis of children’s hospitals around the country has shown a significant increase in the use of antifibrinolytics during open craniosynostosis surgery.
When compared to data collected by Stricker et al (Paediatr Anaesth 2011;21:1026-1035), the survey of primary investigators around the country showed a 42% increase in the utilization rate of antifibrinolytics, with the majority (72%) of centers using the drug during the procedure.
While encouraged by the uptrend, the lead author of the abstract, Henry Huang, MD, acknowledged that there is still room for improvement.
“This is a positive sign,” said Dr. Huang, an anesthesiologist at the Baylor College of Medicine, in Houston. “There is a growing body of literature to support the use of antifibrinolytics to decrease perioperative blood loss, so the hope was that utilization rate would come up, and it did so in our study. But 30% of centers have still decided not to use antifibrinolytics despite the increasing evidence.”
As Dr. Huang reported at the 2016 World Congress of Anaesthesiologists (abstract PR241), significant blood loss remains a perioperative concern for patients undergoing craniosynostosis surgery. The Pediatric Craniofacial Collaborative Group (PCCG) was created in 2011 as a prospective, multicenter, observational registry for craniosynostosis procedures, and an important question before the PCCG was utilization rates of antifibrinolytics.
“Because there are a limited number of cases per year for each institute, it’s hard to use just one center’s data to study the surgical complications or anesthetic management outcomes from craniosynostosis operations,” Dr. Huang explained, “and one of the bigger fears of the procedure is bleeding.”
In 2011, Paul Stricker, MD, of the Children’s Hospital of Philadelphia, reported a 30% utilization rate for antifibrinolytics in open craniosynostosis surgeries. Multiple publications have shown decreased blood loss using antifibrinolytics in a number of procedures, Dr. Huang noted.
About One-Fourth Do Not Use Antifibrinolytics
In order to reassess the use of antifibrinolytics, Dr. Huang, in collaboration with his mentor, Chris D. Glover, MD, MBA, created a web-based survey, which was then modified and approved by co-investigators in the PCCG. The survey was then mailed to the 28 primary investigators participating in the PCCG.
Of the 28 investigators surveyed, 25 responded (89%). Although the majority (72%) of centers utilized antifibrinolytics, the researchers observed differences in the choice of antifibrinolytic.
“Most institutes [72%] established tranexamic acid as the antifibrinolytic of choice, but 28% of centers used aminocaproic acid,” said Dr. Huang, who noted that protocols were established in over 70% of participating institutions.
The most common factors cited for use of antifibrinolytics included:
- following a protocol
- surgical complexity
Of the 28% of centers that did not use antifibrinolytics, two factors were predominantly cited: surgeon preference and concerns about side effects. According to investigators from these centers, thrombus formation was the most concerning side effect and deterred the use of antifibrinolytics, despite very few reported thromboembolic events in the survey.
The next step, said Dr. Huang, is convincing the remaining 28% of centers of the surgical benefit and safety of these drugs.
“We are encouraged with the 42% increase, but there is a lot that we can improve,” he concluded. “We need to do a better job of educating our surgical colleagues about the growing body of evidence that shows that antifibrinolytics are safe so that more surgeons will support the use of these drugs in the operating room.”
In the meantime, Dr. Huang and his colleagues are continuing to gather data on open craniosynostosis surgery to examine and improve perioperative management.
“Antifibrinolytics are only part of the story when it comes to the complex care of these children,” he concluded. “As we continue evaluating the data, the hope is to minimize variations in care across participating centers to drive better care for craniosynostosis patients.”