• Petra M Meier, David Zurakowski, Susan M Goobie, Mark R Proctor, John G Meara, Vanessa J Young, Gary F Rogers, and James A DiNardo.
• Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA.
• Paediatr Anaesth. 2016 Oct 1; 26 (10): 960-9.

BackgroundOperative treatment of craniosynostosis is associated with substantial blood loss, often requiring transfusion of packed red blood cells (PRBC) and coagulation products.AimsThe aim of this prospective study was to analyze thromboelastographic (TEG) parameters and platelet fibrinogen product to determine predictors of substantial blood loss, and the need for PRBC transfusion and coagulation products.MethodsWith IRB approval, we enrolled 120 children undergoing craniosynostosis repair with a standardized anesthetic, fluid management, and TEG measurements at predefined times. Outcomes of interest were intraoperative blood loss, and need for PRBC transfusion and coagulation products. Multivariable logistic regression and receiver operating characteristic (ROC) curve analysis was applied to determine independent predictors of substantial blood loss and need for coagulation products.ResultsOne hundred and eighteen children were included in the analysis. Forty-four required PRBC transfusion (median 26 ml·kg(-1) ; IQR: 22-42) with median blood loss of 56 ml·kg(-1) (IQR: 43-83). Factors associated with the PRBC transfusion included type of surgery, duration of surgery, and three TEG parameters, α-angle, MA, and K-time (all P < 0.001). A predictive algorithm was developed by subgroup analysis of cranial vault reconstruction (CVR) patients for substantial intraoperative blood loss (defined as ≥60 ml·kg(-1) ) and need for coagulation products with ROC-derived cut-off values: platelet fibrinogen product, <343; α-angle, <62°; MA, <55 mm; K-time, >2.1 min. The best prognostic combination included at least two of these four predictors (sensitivity 89%, specificity 90%). Multivariable regression identified MA as the only independent predictor of coagulation product administration (P < 0.001) and ROC analysis identified MA <46 mm as the optimal cut-off (sensitivity 86%, specificity 94%).ConclusionsRisk for substantial intraoperative blood loss can be assessed using TEG parameters and platelet fibrinogen product, whereas the need for coagulation products is strongly related to low MA. Patients susceptible to substantial blood loss can be risk stratified based on their TEG/platelet fibrinogen product profile.© 2016 John Wiley & Sons Ltd.

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