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Intensive Care Unit Monitoring following Fronto-orbital Advancement for Craniosynostosis: Is it Always Necessary?
Mitchel Seruya, MD1, Tina Sauerhammer, MD2, Deniz Basci, BA3, Gary F. Rogers, MD, JD, MBA, MPH2, Michael J. Boyajian, MD2, John S. Myseros, MD2, Amanda L. Yaun, MD2, Robert F. Keating, MD2, Albert K. Oh, MD2.
1Georgetown University Hospital, Washington, DC, USA, 2Children's National Medical Center, Washington, DC, USA, 3George Washington School of Medicine, Washington, DC, USA.

PURPOSE:
Modern resuscitation techniques have greatly reduced the morbidity of open craniofacial repair. Nevertheless, most centers routinely send patients to the intensive care unit (ICU) after this procedure. This study sought to determine the frequency of adverse perioperative events that would justify ICU monitoring following fronto-orbital advancement (FOA) and identify any associated clinical factors.
METHODS: The authors reviewed all infants with craniosynostosis who underwent primary FOA at a single institution from 1997 - 2011. Patient demographics, operative time, and hemodynamic outcomes were recorded. Adverse postoperative events and interventions were identified and graded as none (Group I), minor (Group II; routinely managed on the surgical floor), and major (Group III; requiring ICU care). Statistical analysis compared clinical factors across the groups. Fisher’s exact test was used for contingency data and Kruskal-Wallis test for intergroup comparison of median values. For all tests, a p value less than 0.05 was considered significant.
RESULTS: 107 infants underwent FOA at an average age of 11.3 ± 14.4 months and mean weight of 8.9 ± 6.5 kg. Indications included unicoronal (n=41), metopic (n=36), bicoronal (n=24), and multisutural (n=6) synostoses. Average hospital length of stay (LOS) was 3.7 ± 1.6 days, consisting of 1.3 ± 1.0 days in the ICU and 2.4 ± 1.0 days on the surgical floor. There were 81 patients (75.7%) in Group I, 22 (20.6%) in Group II, and 8 (7.5%) in Group III. Minor postoperative events/interventions in Group II patients included blood product transfusion (n=19); phlebotomy for iatrogenic polycythemia (n=1); hemolytic reaction (n=1); and bronchiolitis (n=1). Major adverse postoperative events/intervention in Group III patients included re-intubation (n=2), prolonged intubation (n=2), sepsis/bacteremia (n=2), continuous positive airway pressure support (n=1), and cardiac arrhythmia (n=1). In comparison to Group I and II patients, Group III had higher levels of intra-operative calculated blood loss (Group I, 29.2% EBV; Group II, 52.0% EBV; Group III, 81.8% EBV; p =0.0015), total fluid resuscitation (Group I, 870.0 ml; Group II, 946.0 ml; Group III, 1465.0 ml; p =0.027), total colloid use (Group I, 0.0 ml; Group II, 67.5 ml, Group III, 312.5 ml; p =0.004), and total red blood cell transfusion (Group I, 42.9% EBV; Group II, 56.2% EBV; Group III, 77.2% EBV; p =0.0002) (Table).
CONCLUSIONS: The majority (75.7%) of patients undergoing fronto-orbital advancement for craniosynostosis recover uneventfully and do not require ICU monitoring. Those patients with greater intraoperative blood loss, fluid resuscitation, and perioperative blood product administration were more likely to experience an adverse postoperative event and require postoperative ICU surveillance.
TABLE:
Group 1Group 2Group 3
No EventsMinor EventsMajor Eventsp value
Number81228
Age (months)8.16.77.00.16
Weight (kg)8.48.08.40.51
Suture type
Metopic (%)30.950.025.00.23
Unicoronal (%)42.027.337.50.47
Bicoronal (%)19.822.737.50.48
Multiple (%)7.40.00.00.58
Syndromic (%)19.84.525.00.14
OR time (hrs)4.34.44.50.28
CBL (% EBV)29.252.081.80.0015*
Intraop RBC (% EBV)42.543.759.90.22
Blood volume change (% EBV)14.0-10.0-7.5<0.05
Postop RBC (% EBV)0.014.73.5<0.0001*
Total RBC (% EBV)42.956.277.20.0002*
Intraop colloid (ml)0.015.0265.50.160
Postop colloid (ml)0.045.520.50.001*
Total colloid (ml)0.067.5312.50.004*
Intraop crystalloid (ml)550.0617.5825.00.200
Total intraop fluid (ml)870.0946.01465.00.027#

* Significant intergroup difference on Kruskal-Wallis test; significant differences on Mann-Whitney test comparing group 1 versus group 2 and group 1 versus group 3.
Significant intergroup difference on Kruskal-Wallis test; significant difference on Mann-Whitney test comparing group 1 versus group 2.
# Significant intergroup difference on Kruskal-Wallis test; significant difference on Mann-Whitney test comparing group 1 versus group 3.


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