Intraoperative Autologous Blood Transfusion in the Surgical Correction of Craniosynostosis

To the Editor: We were very interested in the recent article by Jimenez and Barone concerning the use of intraoperative autologous transfusion during surgical correction of craniosynostosis (1). In these small series, which included 18 patients and the same number of control subjects, the authors compared the perioperative blood losses and concluded that the use of the cell saver allowed a significant decrease in the amount of homologous blood transfusion. Moreover, 33% of the patients did not require homologous transfusion with the use of autotransfusion. These results are very impressive and command extensive evaluation of this technique in large series. Before such an evaluation is made, we offer some comments. The first one concerns the method used for evaluating perioperative blood losses. As the authors stated, estimation of blood losses is critical and cannot be only as objective as possible. The method developed by Kearney et al.(2) based on the calculation of red cell volume deficit and not total blood deficit is probably the best way to achieve the goal of precisely evaluating perioperative losses and controlling perioperative hemodilution. When we used this method for evaluating blood losses in a series of 130 patients (4), we found that the mean estimated red cell loss with extensive surgical procedures was 91 ± 66% of estimated red cell volume. This amount is slightly higher than the one reported in these series and others (1, 2) but comparable with the one reported from the Children's Hospital in Denver, dealing with complex procedures (3). This loss varied highly with the type of craniosynostosis and the type of surgical procedure. Consequently, in our series, only 11% of the patients sustaining simple craniectomies did not require transfusion and were managed with only perioperative hemodilution. The second comment concerns the use of cell saver devices in pediatric craniofacial surgery. We (4) and Paccagnella et al.(5) tried to use this same technique in 15 consecutive patients. Our results were different from those presented by Jimenez and Barone (1). Using the same pediatric reservoir of 125 ml, only 6 of our 15 patients did not require homologous transfusion. All of them were children weighing >10 kg who had sustained simple linear craniectomies. Those children probably would not have needed perioperative transfusion anyway. Even though autotransfusion allowed us to reduce significantly the amount of homologous transfusion, the major problem in small children with extensive procedures was to gain sufficient time to collect a full 125-ml reservoir. As stated in the article, this time varied between 1 and 2 hours and, in most instances, homologous transfusion had to be started before preparation of the unit to be used in subsequent transfusion could be performed. Our conclusions were that autotransfusion can reduce the need for autologous transfusion in complex procedures in children weighing >10 kg but that the time required for obtaining one unit of autologous red cell and the amount of red cell saved by this technique (50-60 ml) made the technique inadequate in small children with complex procedures.