Reduced perioperative blood loss in children undergoing craniosynostosis surgery using prolonged tranexamic acid infusion: a randomised trial

Abstract

Background: Tranexamic acid (TXA) reduces intraoperative blood loss and transfusion during paediatric craniosynostosis surgery. Additional reduction of postoperative blood loss may further reduce exposure to allogeneic blood products. We studied the effect of combined intra- and postoperative TXA treatment on postoperative blood loss in children.

Methods: Thirty children admitted for craniosynostosis surgery were randomised to combined intra- and postoperative TXA treatment or placebo. The primary endpoint was postoperative blood loss. Secondary endpoints included total blood loss, transfusion requirements, and clot stability evaluated by tissue plasminogen activator-stimulated clot lysis assay.

Results: TXA reduced postoperative blood loss by 18 ml kg^-1 (95% confidence interval 8.9) and total blood loss from a mean of 52 ml kg^-1 (standard deviation [SD]; 20) ml kg^-1 to 28 (14) ml kg^-1 (P<0.001). Intraoperative red blood cell (RBC) and fresh frozen plasma (FFP) transfusions were reduced in the treatment group from RBC 14.0 (5.2) ml kg^-1 to 8.2 (5.1) ml kg^-1 (P=0.01) and from FFP 13.0 (6.3) ml kg^-1 to 7.8 (5.9) ml kg^-1 (P=0.03). Postoperative RBC transfusion median was 5 (inter-quartile range [IQR] 0-6) ml kg^-1 in the placebo group and 0 (0-5.7) ml kg^-1 in the TXA group. Resistance to lysis was higher in the treatment group (P<0.001).

Conclusions: Combined intra- and postoperative tranexamic acid treatment reduced postoperative and overall blood loss and transfusion requirements. Improved clot stability represents a possible mechanism for blood loss reduction.

Keywords: antifibrinolytics; blood transfusion; coagulation; craniosynostosis; fibrinolysis; general surgery; haemorrhage; paediatric.