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Perioperative management of craniosynostosis
Rachel M. Segal, B.S.1, George Kamel, M.D.2, Kevin Englar, M.D.3, Amanda Gosman, M.D.3 1UC San Diego School of Medicine, San Diego, CA 2Rady Children's Hospital, San Diego, CA 3Division of Plastic Surgery, Department of Surgery, UC San Diego San Diego, CA

Background: The published rates of complications and mortality following surgical treatment of craniosynostosis are relatively low and have been decreasing over time. Studies have shown that the complication rate is highest in syndromic patients, patients with multiple suture involvement, and patients undergoing re-operation. Traditionally, craniosynostosis patients are sent to the intensive care unit (ICU) postoperatively for monitoring, however recent publications have suggested this may not be necessary for all patients. We describe the perioperative complications associated with surgical treatment of craniosynostosis to offer an algorithm that can be used in conjunction with clinical decision-making for a wider selection of patients who can safely avoid routine ICU admission postoperatively.

Methods: A retrospective chart review of all patients undergoing craniosynostosis treatment at Rady Children's hospital between 2000 to 2019 was performed. The cohort was divided into associated syndrome, affected suture, and type of reconstructive procedure performed. Demographic information, peri-operative data, and postoperative complications were collected. Multivariable regression analysis was used to determine predictors of length of ICU stay across the cohort and subgroups.

Results: A total of 697 patients were identified. 590 (84.7%) were nonsyndromic single suture, 37 (5.3%) were nonsyndromic multisuture, and 70 (10.0%) were syndromic. Multivariable regression analysis of the entire craniosynostosis cohort found that the suture affected, type of surgery performed, ASA class, presence of an associated syndrome, type of associated syndrome, need for intraoperative transfusion, high packed red blood cells per kilogram weight (PRBC/kg) transfusion amount, and the presence of postoperative complications were predictors of increased length of ICU stay (F(18,465) = 21.3, p < 0.001; R2 = 0.45) (Table 1). An analysis of variance (ANOVA) showed that length of ICU stay yielded significant variation among type of syndrome in syndromic patients (F(9, 679) = 11.48, p < 0.001), type of suture affected in nonsyndromic patients (F(9, 678) = 14.77, p < 0.001), and type of surgery performed, age, and weight in the entire cohort (F(9, 678) = 2.75, p < 0.001). Post hoc comparisons using Tukey HSD test showed that the mean length of ICU stay was significantly higher (p < 0.05) for syndromic patients with Apert, Crouzon, and Pfeiffer syndromes; patients with multisuture synostosis; patients with an ASA class greater than or equal to 3, postoperative complications of increased ICP and the need for reintubation, and patients who underwent distraction osteogenesis for treatment of craniosynostosis. For the entire cohort, the rate of postoperative ICU admission was 8.7% (4.9% were planned) and 45.7% 27.1% planned) for the syndromic cohort. The complete cohort complication rate was 7.2%, and 14.3% for the syndromic cohort.

Conclusion: By limiting postoperative ICU admission to patients with any of the identified risk factors and in conjunction with clinical judgement, the majority of the treated patients were able to successfully avoid routine ICU admission postoperatively. The overall complication rate was similar to that reported elsewhere, suggesting that routine ICU admission is not warranted in the vast majority of craniosynostosis cases.

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