Preparation for Surgery for Nonsyndromic Craniosynostosis in Children

Preparation

• Preparation for anticipated blood loss: The blood loss during surgery in these young patients can be significant and should be anticipated. Erythropoietin can be given weekly for 3–5 weeks prior to surgery to reduce the need for blood transfusion during the procedure (18). Packed red blood cells should be available for transfusion during the surgery. This should be available by the time the bone work begins during the surgery. In a patient with increased ICP, a larger than normal amount of blood loss should be expected.
• Cell saver: The author uses a pediatric bowl on the cell saver, thereby decreasing the blood transfusion rate to almost zero.
• Scalp preparation per local routine: Antimicrobial soap can be used to clean the hair and scalp the night prior to and the morning of surgery. Typically, there is no preoperative shaving of the hair (19).

Preoperative Orders

• IVF rate: Normal replacement rates.
• Steroids: None.
• Antibiotic: Standard use of perioperative antibiotics with selection of type per institutional preference.
• Surgical site scrub: There are no special requirements with regard to the surgical site preparation, so local custom should be followed. However, if the pediatric cell saver is used, the betadine scrub and paint must be rinsed off with sterile water at the end. Betadine will lyse red blood cells in the bowl.

Anesthetic Considerations

• Line placement: Two large IVs, no arterial line, Foley catheter for cases where a significant blood loss is anticipated or that will involve an anesthesia of significant length. A Foley catheter is not needed for minimally invasive surgeries.

Devices to Be Implanted

• Resorbable fixation materials: Various resorbable plates are available for fixation of the bone plates, and their stability will maintain the cranial remodeling. The author uses them to decrease the anesthesia time in all cases. They are best used in anterior cranial repairs for coronal and metopic craniosynostosis to maintain the orbital rim advancement.

Ancillary/Specialized Equipment

• Cell saver for salvaging of blood lost: The pediatric cell saver is the same cell saver used in cardiac and spine surgery. A small pediatric bowl allows smaller quantities of blood to be recycled. All suctions on the table are connected to the device. All lap pads are squeezed of blood before they are removed from the table. Any blood collected in the drape’s drainage bag is removed to the cell-saver using suction.
• Distraction device: At this time, the author does not suggest using a distraction device. These devices require a second surgery for removal. Surgeons who have placed them recently have found that many have eroded though the dura on removal (69).
• Minimally invasive: The microscope, endoscope, or thin-lighted retractors are needed based on surgeon preference. A combination suction unipolar cautery instrument may be used. The author uses diamond drill bits to minimize blood loss prior to cutting the bone with scissors.