Aim and objective: We report our experience with anesthesia management of craniosynostosis surgeries at a tertiary care children\'s hospital.
Materials and methods: We conducted a retrospective analysis of craniosynostosis surgeries performed at our institute over the last 3 years.
Review results: Twelve children underwent reconstructive surgery over a period of 3 years. Eight patients underwent IV induction with propofol followed by atracurium. In four patients where difficult airway was anticipated, an inhalational induction with sevoflurane was performed. Anesthesia was maintained using air, oxygen, and sevoflurane delivered through a closed circuit, and dexmedetomidine @ 0.5 μg/kg/hour. Fentanyl and paracetamol were used for analgesia. Monitoring included standard ASA monitors and additionally, arterial blood pressure and urine output monitoring. Tranexamic acid was used to reduce bleeding. There was no incidence of major intraoperative complications viz. venous air embolism, massive hemorrhage, or hemodynamic instability. No patient needed vasoactive infusion support.
Conclusion: Surgery for craniosynostosis poses several challenges for anesthesia. Having a protocolized approach to anesthesia management and transfusion can result in good outcomes.
Clinical significance: Raised intracranial pressure, obstructive sleep apnea, syndromic associations are common in craniosynostosis. Surgery in infancy poses additional challenges of massive blood loss. The anesthetist has to be vigilant and step up monitoring to detect and manage perioperative complications.
Thomas K, Hughes C, Johnson D, et al. Anesthesia for surgery related to craniosynostosis: a review. Part 1 Paediatr Anaesth 2012;22(11):1033–1041. DOI: 10.1111/j.1460-9592.2012.03927.x.
Stricker PA, Fiadjoe JE. Anesthesia for craniofacial surgery in infancy. Anesthesiology Clin 2014;32(1):215–235. DOI: 10.1016/j.anclin.2013.10.007.
Hughes C, Thomas K, Johnson D, et al. Anesthesia for surgery related to craniosynostosis: a review. Part 2. Paediatr Anaesth 2013;23(1):22–27. DOI: 10.1111/j.1460-9592.2012.03922.x.
Pearson A, Matava CT. Anaesthetic management for craniosynostosis repair in children. BJA Educ 2016;16(12):410–416. DOI: 10.1093/bjaed/mkw023.
Lionel KR, Moorthy RK, Singh G, et al. Anaesthetic management of craniosynostosis repair – a retrospective study. Indian J Anaesth 2020;64(5):422–425. DOI: 10.4103/ija.IJA_823_19.
Mendonca DA, Ramamurthy V, Gopal S, et al. Endoscopic-assisted craniosynostosis surgery: first case series in India. J Cleft Lip Palate Craniofac Anomal 2019;6(1):23–32. DOI: 10.4103/jclpca.jclpca_28_18.
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 2011;59(6):823–828. DOI: 10.4103/0028-3886.91358.
Kumar N, Arora S, Bindra A, et al. Anesthetic management of craniosynostosis repair in patient with Apert syndrome. Saudi J Anaesth 2014;8(3):399–401. DOI: 10.4103/1658-354X.136631.
Garg R, Khanna P, Pandia MP. Anaesthetic considerations in a child with rickets and craniosynostosis for linear strip craniectomy and frontal advancement. Indian J Anaesth 2010;54(4):350–351. DOI: 10.4103/0019-5049.68394.
Prasad C, Dube SK, Chaturvedi A. Be careful to avoid hemodynamic disturbances in craniosynostosis surgery!. Saudi J Anaesth 2020;14(3):420–421. DOI: 10.4103/sja.SJA_148_20.
Tan H, Gozal, Abel F, et al. Craniofacial syndromes and sleep-related breathing disorders. Sleep Med Rev 2016;27:74–88. DOI: 10.1016/j.smrv.2015.05.010.
Hayward R, Gonsalez S. How low can you go? Intracranial pressure, cerebral perfusion pressure, and respiratory obstruction in children with complex craniosynostosis. J Neurosurg 2005;102(1 Suppl):16–22. DOI: 10.3171/ped.2005.102.1.0016.
van Uitert A, Megens JH, Breugem CC, et al. Factors influencing blood loss and allogeneic blood transfusion practice in craniosynostosis surgery. Pediatr Anesth 2011;21(12):1192–1197. DOI: 10.1111/j.1460-9592.2011.03689.x.
Jimenez DF, Barone CM. Multiple-suture nonsyndromic craniosynostosis: early and effective management using endoscopic techniques. J Neurosurg Pediatr 2010;5(3):223–231. DOI: 10.3171/2009.10.PEDS09216.
Isaac KV, Meara JG, Proctor MR. Analysis of clinical outcomes for treatment of sagittal craniosynostosis: a comparison of endoscopic suturectomy and cranial vault remodeling. J Neurosurg Pediatr 2018;22(5):467–474. DOI: 10.3171/2018.5.PEDS1846.
Arts S, Delye H, van Lindert EJ, et al. Evaluation of anesthesia in endoscopic strip craniectomy: a review of 121 patients. Pediatr Anesth 2018;28(7):647–653. DOI: 10.1111/pan.13414.
Dalle Ore CL, Dilip M, Brandel MG, et al. Endoscopic surgery for nonsyndromic craniosynostosis: a 16-year single-center experience. Neurosurg Pediatr 2018;22(4):335–343. DOI: 10.3171/2018.2.PEDS17364.
Duncan C, Richardson D, May P, et al. Reducing blood loss in synostosis surgery: the liverpool experience. J Craniofac Surg 2008;19(5):1424–1430. DOI: 10.1097/SCS.0b013e3181843591.
Stricker PA, Fiadjoe JE, Kilbaugh TJ, et al. Effect of transfusion guidelines on postoperative transfusion in children undergoing craniofacial reconstruction surgery. Pediatr Crit Care Med 2012;13(6):e357–e362. DOI: 10.1097/PCC.0b013e31825b561b.
Goobie SM, Meier PM, Pereira LM, et al. Efficacy of tranexamic acid in pediatric craniosynostosis surgery. Anesthesiology 2011;114(4):862–871. DOI: 10.1097/ALN.0b013e318210fd8f.
Dadure C, Sauter M, Bringuier S, et al. Intraoperative tranexamic acid reduces blood transfusion in children undergoing craniosynostosis surgery: a randomized double-blind study. Anesthesiology 2011;114(4):856–861. DOI: 10.1097/ALN.0b013e318210f9e3.
Goobie SM, Staffa SJ, Meara JG, et al. High-dose versus low-dose tranexamic acid for paediatric craniosynostosis surgery: a double-blind randomised controlled non-inferiority trial. Br J Anaesth 2020;125(3):336–345. DOI: 10.1016/j.bja.2020.05.054.
Fenger-Eriksen C, D’Amore Lindholm A, Nørholt SE, et al. Reduced perioperative blood loss in children undergoing craniosynostosis surgery using prolonged tranexamic acid infusion: a randomised trial. Br J Anaesth 2019;122(6):760–766. DOI: 10.1016/j.bja.2019.02.017.
Faberowski LW, Black S, Mickle JP. Incidence of venous air embolism during craniectomy for craniosynostosis repair. Anesthesiology 2000;92(1):20–23. DOI: 10.1097/00000542-200001000-00009.