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Literature Review

Erythropoietin Therapy and Acute Preoperative Normovolaemic Haemodilution in Infants Undergoing Craniosynostosis Surgery.

Meneghini L, Zadra N, Vittorio A et.al. Paed Anaesth 13:392-396, 2003

Review: The authors performed a retrospective review of 25 healthy infants who had craniosynostosis (CS) repairs during the first few months of life. The study group included 16 patients who received erythropoietin (EPO) and then had acute pre-operative normovolemic hemodilution (APNH). The control group had received no prior treatment.

The operations all occurred between 1998-2002. The infants in the study group received EPO 300U/kg two times a week and iron 10mg/kg daily starting 3 weeks prior to the time of surgery. At the time of the operation, they all had an arterial line and central venous line placed in addition to all the standard monitors. Patients had APNH performed at the start of the anesthetic according to the formula:

Blood withdrawal volume = EBV x Hct1- Hct 2/Hct 1

EBV = estimated blood volume (80x body weight in kg)

Hct 1 = starting hemotocrit

Hct 2 = target hematocrit (25%)

The blood withdrawal was performed from the arterial or central venous catheter and put in a standard collecting system and weighed on an electronic balance.

The patient's blood was replaced with hydroxyethyl starch 6% in an identical volume.

The authors found that there was a decreased need for homologous blood transfusions in the study group compared to the control group. The decision to transfuse was based on an Hb value <7g/dl. The mean pre-operative Hb in the control group was 11.39 g/dl, and 13.72 g/dl in the study group. The mean volume of blood collected in the study group was 17.7ml/kg. Mean weight was 7.9 in the control group and 7.7 for the study group. The repairs were done for a diagnosis of scaphocephaly, plagiocephaly and trigonocephaly, and there were no significant differences between groups. The mean duration of surgery was 184 minutes in the study group and 175 minutes in the control group.

Interestingly the authors noted a variable response to EPO therapy, but found no complications due to either EPO therapy or APNH. They do note that the treatment is expensive and distressing, but did lower the incidence of homologous transfusion from 7/9 in the control patients to 5/16 in the study patients.

Comments: Central lines are not routinely placed at our institutions for CR, and our surgical repair times are considerably shorter. However, the authors are correct in pointing out that the majority of patients undergoing CR do receive homologous blood transfusions (85-97%, depending on the study) This is an interesting study, there are several differences in our standard practice, however the authors nicely show that EPO and APNH are not only possible, but may be advantageous in some infants undergoing craniosynostosis repair.

Reviewed by: Rita Agarwal, MD

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