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Case Report: Activation of Massive Blood Transfusion Protocol in a 1-Year-Old Patient for Cranial Vault Reduction Surgery

Dear Editor, In macrocephaly (Figure 1), the volume of the cranium is disproportional to the size of the brain. Disproportion may result from megalencephaly (macrencephaly), hyperostosis, cysts, or hydrocephalus, and other complications associated with an abnormally large head size, all of which can lead to loss of head control, psychosocial development, and shunting issues.1 Macrocephaly secondary to hydrocephalus is uncommon today due to adequate prenatal detection and treatment of hydrocephalus.2 Though uncommon, surgical intervention typically involves the placement of a ventriculoperitoneal shunt (VPS) early in life to allow diversion of excess cerebrospinal fluid (CSF), followed by reconstructive surgery later.3 Cranial vault reduction surgery (CVRS) is a method of treating macrocephaly that aims to reduce intracranial volume and remove excess CSF.1,2 Anesthetic management of CVRS includes careful management of blood loss. Small children pose a particular challenge due to their relatively larger head sizes, providing a greater surface area for blood loss and containing a greater percentage of total blood volume than adults.4 We present the anesthetic management of a 1-year-old patient who presented for CVRS and required the replacement of greater than 9 blood volumes and describe the professional interaction required of the participants. The guardian of the patient gave written consent to publish this case report. The case occurred in October 2018. Case Report: A 13-kg, 12-month-old patient with macrocephaly presented for CVRS. Past medical history was significant for cranial size, VPS placements, and seizures. Our patient did not present with an elevated intracranial pressure. The indications for surgery were the extreme macrocephaly (greater than 4 standard deviations [SD] from an adult cranial volume) and the physical exam presentations (cannot hold head up, delayed gross motor development [sitting, standing], and the development of secondary pressure ulcers). The preoperative CT Scan and MRI/MRA delineated abnormal brain, ventricles, and dura venous systems; but no large transcranial collateral veins were observed. Before surgery, type and cross match was obtained and antithrombolytic therapy was discussed with the surgeon. After induction with fentanyl, propofol, and rocuronium, two 22-gauge peripheral intravenous lines and a 22-gauge radial arterial line were secured. Intraoperative, the patient was positioned prone with careful padding for pressure distribution. After adequate epinephrine subdermal infiltration, a Gullwing bicoronal incision was made. Skin edge hemostasis was obtained with Raney clips. Subperiosteal hemostasis was accomplished with bone wax, thrombin spray, and electrocautery and sinus pericranii were controlled with bipolar diathermy, Surgicell and Gelfoam. Multiple craniectomies were performed with ex vivo bone graft contouring. No injuries to major dura sinuses or veins were noted. Previously bleeding controlled sites would bleed spontaneously or with minor manipulation. With stable vital signs and after consultation among the anesthesia team, neurosurgery, and plastic surgery, surgery proceeded. With pre-computed volumetric analysis, CSF was evacuated. CVRS followed with autogenous bone grafts and resorbable fixation hardware (ResorbX, KLS-Martin, Jacksonville, FL). Excess scalp was excised by progressive tailoring and immediately suturing to minimize bleeding from rich dermal anastomotic network. As surgery progressed, hemorrhage from the craniectomy resulted in marked hypotension and tachycardia (Figure 2). For CVRS, we routinely have 2 units of packed red blood cells available in the OR prior to the start of surgery. Intraoperatively, vasopressors were not administered since vital signs (blood pressure, pulse oximeter, and heart 1048901 FACXXX10.1177/27325016211048901FACEde Armendi et al letter20212021