Introduction
Craniosynostosis, a condition of premature cranial suture fusion, occurs
in approximately 1 in every 2,000 births.1 These
patients often need complex surgical repair to correct skull
deformities, and potentially prevent functional neurologic and
developmental compromise.1,2 Complex cranial vault
reconstruction (CCVR) is performed primarily in infants and young
children and is an intricate and high-risk procedure, often requiring
extensive scalp dissection and multiple skull
osteotomies.1 Children undergoing surgical correction
of craniosynostosis often experience high rates of bleeding and blood
product transfusion, increasing the risk of postoperative complications
including mortality.3–5 The most severe and most
common perioperative issues relate to the rate and extent of blood loss,
which can be up to several times the patient’s total blood
volume.3,6,7Contributing to high blood loss rates are
the large surgical surfaces exposed, hyperfibrinolysis, and dilutional
coagulopathy.6,8–10 This is a type of controlled
traumatic coagulopathy for which the precise underlying mechanisms are
not fully defined.3,6,8 Other reported complications
include intraoperative cardiac arrest, venous air embolism, hypotension,
bradycardia, postoperative seizures, surgical site infections, facial
swelling with airway compromise, and unplanned postoperative mechanical
ventilation.2,7,9,11–13 At our institution,
approximately 30-40 children with craniosynostosis undergo CCVR each
year. In the United States, ~2000 children undergo CCVR
per year, representing a unique opportunity to understand and improve
rates of perioperative blood loss.14
One recently endorsed strategy for decreasing blood loss in
craniosynostosis repair is the intraoperative use of antifibrinolytic
agents. ε-Aminocaproic acid (EACA) and tranexamic acid (TXA) are
synthetic lysine analogs that block the lysine binding sites on
plasminogen, resulting in antifibrinolytic activity through inhibition
of plasmin formation.10,15 Antifibrinolytics have been
shown to reduce transfusion needs in surgical and trauma-related
bleeding.10,16 TXA has been shown to be effective in
limiting blood loss in infants and children undergoing CCVR, and two
recent retrospective reviews suggest a benefit of EACA in this
population as well.5,14,17–19While the use of EACA
and TXA to limit surgically-induced hemorrhage and transfusion
requirements during CCVR has been extensively studied, the comparison of
EACA vs TXA in children undergoing CCVR has not yet been evaluated. The
aim of this study was to compare perioperative blood loss and need for
transfusion in children receiving EACA and TXA. We hypothesized that TXA
is associated with a greater decrease in blood loss and transfusion
requirements when compared to EACA. A secondary aim was to identify
possible laboratory predictors of blood loss in CCVR with the ultimate
goal of trying to better understand surgical-induced coagulopathy in
this population.