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Minimizing Transfusions in Primary Cranial Vault Remodeling for Craniosynostosis: The Role of Amicar and Aprotinin
Adam J. Oppenheimer, MD, Jennifer M. Strahle, MD, Joseph Kapurch, BS, Karin M. Muraszko, MD, Steven R. Buchman, MD.
University of Michigan, Ann Arbor, MI, USA.

PURPOSE:
Cranial vault remodeling (CVR) for craniosynostosis is an invasive procedure with the potential for significant blood loss. The preferred timing of surgical intervention during infancy compounds the deleterious effects of hemorrhage due to low circulating blood volumes. Aprotinin and ε-aminocaproic acid (amicar) have been used at our institution during CVR for their procoagulant effects. The purpose of this study was to determine whether these agents, a) decreased estimated blood loss, and b) minimized blood transfusion volumes during the primary surgical correction of craniosynostosis.
METHODS:
IRB approval was obtained for this retrospecitve review. Over a 15-year period, 383 patients with craniosynostosis underwent primary CVR at a single institution. Either aprotinin or amicar was given intravenously during CVR at the surgeon's discretion. In some cases, no procoagulants were administered. The estimated blood loss (EBL) was recorded for each case. In patients requiring intraoperative transfusions, the volume of packed red blood cells (PRBCs) given was noted. Thrombotic-related complications were identified. Comparisons were made between the three subgroups using one-way ANOVA and pairwise Student’s t-tests.
RESULTS:
Of the 383 primary CVR cases, rigorous transfusion data was available in 370 patients. Amicar was given to 30 patients (8.1%) and aprotinin was given to 222 patients (60%) intraoperatively. The remaining 118 patients received no procoagulant (31.9%). The average EBL was lower in the aprotinin subgroup (241cc), than both the amicar (323cc, p = 0.008) and control subgroups (326cc, p < 0.0001). Patients who received amicar experienced the lowest average intraoperative transfusion volumes (25.5cc/kg, p < 0.0001), followed by patients who received aprotinin (39.3cc/kg, p = 0.001). Control patients received the highest average intraoperative transfusion volumes (53.3cc/kg, p < 0.0001).
CONCLUSION:
Aprotinin decreased estimated blood loss during primary CVR for craniosynostosis. In addition, amicar and aprotinin independently minimized intraoperative transfusion volumes during primary CVR. While aprotinin has been removed from clinical use, amicar should be considered as a means to minimize perioperative transfusion requirements.


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