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Evolution of Perioperative Pathways in Cranial Vault Remodeling

Meghana Brown MD, Rebecca Knackstedt MD,PhD, Ananth Murthy MD, Niyant Patel MD
Akron Children's Hospital

Presenter: Meghan Brown

This project represents original work of the resident (95%).

Director Name: Ananth Murthy

Author Category: Resident Plastic Surgery
Presentation Category: Clinical
Abstract Category: Craniomaxillofacial


Perioperative pathways for cranial vault remodeling (CVR) can improve outcomes. This study highlights the critical aspects and modifications of the pathway over time at our institution.


A retrospective review was conducted for all patients undergoing CVR from 2009-2020. Patients that underwent minimally invasive surgery were excluded. Major changes to the pathway were made in December 2013 and included use of recombinant erythropoietin, cell saver, tranexamic acid, increasing transfusion thresholds, and reducing narcotic use.


We identified 60 children in the control group (2009-2013) and 100 in the pathway (2013-2020) group. Demographics were similar between the groups. EBL was lower in the pathway group (26.9mL/kg vs 48.2mL/kg, p<0.001). In the pathway group, 21 (21%) received intraoperative transfusion compared to 100% in the control group (p<0.001), and when required, pathway children were transfused less (18.6mL/kg vs 49.8mL/kg, p<0.001). In the pathway group 4% received postoperative transfusions compared to 25% in the control, and when required pathway children were transfused less volume (0.6mL/kg vs 4.5mL/kg, p<0.001). The nadir and discharge hemoglobins were lower in the pathway group (8.3 vs 9.9, p<0.001 and 8.6 vs 11.0, p<0.001 respectively) whereas the preoperative hemoglobin was higher in the pathway group (13.3 vs 11.9, p<0.001). Length of stay was lower in the pathway group (2.16 vs 3.22, p<0.001) and which continued to improve from 2.45 to 2.06 to 1.97 when comparing the cohort in 2-year time increments.


A data driven and formalized perioperative pathway can improve several outcome measures, but requires vigilant upkeep and modification.

Author Contact Information:
Meghan Brown
4955 Ridgewood Ct
Apt F
Stow, OH

4194103636 (cell)

Ohio,Pennsylvania,West Virginia,Indiana,Kentucky,Pennsylvania American Society of Plastic Surgeons

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