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Efficacy of Tranexamic Acid in Pediatric Craniosynostosis Surgery: A Double-blind, Placebo-controlled Trial
Abstract
BACKGROUND: Extensive blood loss is common in pediatric craniosynostosis reconstruction surgery. Tranexamic acid (TXA) is increasingly used to reduce perioperative blood loss in various settings, but data on its efficacy are limited in children. The purpose of this randomized, double-blind, placebo-controlled, parallel trial was to evaluate the efficacy of TXA in pediatric craniosynostosis correction surgery. The primary and secondary outcome variables were reduction in perioperative blood loss and reduction in blood transfusion, respectively. METHODS: Forty-three children, ages 2 months to 6 yr, received either placebo or TXA in a loading dose of 50 mg·kg(-1), followed by an infusion of 5 mg·kg·h(-1) during surgery. TXA plasma concentrations were measured. RESULTS: The TXA group had significantly lower perioperative mean blood loss (65 vs. 119 ml·kg(-1), P < 0.001) and lower perioperative mean blood transfusion (33 vs. 56 ml· kg(-1), P = 0.006) compared to the placebo group. The mean difference between the TXA and placebo groups for total blood loss was 54 ml·kg(-1) (95% CI for the difference, 23-84 ml·kg(-1)) and for packed erythrocytes transfused was 23 ml·kg(-1) (95% CI for the difference, 7-39 ml·kg(-1)). TXA administration also significantly diminished (by two thirds) the perioperative exposure of patients to transfused blood (median, 1 unit vs. 3 units; P < 0.001). TXA plasma concentrations were maintained above the in vitro thresholds reported for inhibition of fibrinolysis (10 μg·ml(-1)) and plasmin-induced platelet activation (16 μg·ml(-1)) throughout the infusion. CONCLUSIONS: TXA is effective in reducing perioperative blood loss and transfusion requirement in children undergoing craniosynostosis reconstruction surgery.
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“They have the advantage of requiring fewer skin incisions and less blood loss and are therefore considered less invasive and more child-friendly [64,65,66,67,68,69,70].”
From Isolated Sagittal Craniosynostosis: A Comprehensive Review (2024) · cites this paper as [65]
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“This is in agreement with the previous findings that showed no significant changes, both in the preoperative as well as the post operative values of PT and PTT when tranexamic acid was used versus placebo in pediatric craniosynostosis surgery [27].”
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Danforth, R. M., Cook, J. A., Bennett, W. E., Tholpady, S. S., & Gerety, P. A. (2020) · Plastic & Reconstructive Surgery · doi:10.1097/prs.0000000000007245 · Cited by 15
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“Numerous pharmacologic and non-pharmacologic strategies for transfusion reduction have been investigated, including erythropoietin (EPO), tranexamic acid (TXA), acute normovolemic hemodilution (ANH) and others [12, 13, 26, 32].”
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Alabdulkarim, A., Qurashi, A. A. A., Odeh, N. B., Hashemi, A. S. A., Arbili, L., AlSwealh, M. S., Shakir, M. N., Banser, S. M., Sharaf, L. A., Alkhonizy, S. W., et al. (2023) · Plastic & Reconstructive Surgery Global Open · doi:10.1097/gox.0000000000005021 · Cited by 13
The role of tranexamic acid in prevention of hemorrhage in major spinal surgeries
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BackgroundStrategies for Blood Product Management, Reducing Transfusions, and Massive Blood Transfusion
Coté, C. J., Grabowski, E. F., & Stowell, C. P. (2019) · Elsevier eBooks · doi:10.1016/b978-0-323-42974-0.00012-4 · Cited by 13
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“A double-blinded study of craniosynostosis patients utilizing a 50-mg/kg bolus, followed by a 5 mg/kg/hr infusion, found 50% lower blood loss and lower transfusion requirements (Goobie et al., 2011).”
MethodTranexamic Acid in Craniosynostosis Surgery: A Systematic Review and Meta-Analysis
Varidel, A., & Marucci, D. D. (2021) · Journal of Craniofacial Surgery · doi:10.1097/scs.0000000000008123 · Cited by 13
Role of tranexamic acid in craniosynostosis surgery: Systematic review and meta-analysis
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Tranexamic Acid in Pediatric Hemorrhagic Trauma
Borgman, M. A., & Nishijima, D. K. (2022) · The Journal of Trauma: Injury, Infection, and Critical Care · doi:10.1097/ta.0000000000003775 · Cited by 12
Role of tranexamic acid (TXA) in plastic and reconstructive surgery: A national perspective
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Ulnar Artery Thrombosis Following Tranexamic Acid Administration for Craniosynostosis Repair
Chung, E., & Karlberg, H. (2018) · Journal of Craniofacial Surgery · doi:10.1097/scs.0000000000004905 · Cited by 12
“Variable dosing regimens have been described in the literature with a median loading dose of 50 mg/kg and a median infusion rate of 5 mg/kg per hour in patients receiving cranial vault reconstructive surgery.(5) Thus, our patient received a dose well within the accepted range previously published for TXA.”
BackgroundTranexamic Acid in Craniomaxillofacial Surgery: A Meta-Analysis and Systematic Review
Fu, R., Liu, C., Yan, Y., Suo, L., Xie, Y., Li, Q., & Huang, R. (2021) · Facial Plastic Surgery & Aesthetic Medicine · doi:10.1089/fpsam.2020.0590 · Cited by 12
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Tranexamic acid in plastic surgery: routes of administration and dosage considerations
AlGhanim, K., Al‐Youha, S., AlWazzan, A., & Alhamad, S. (2021) · European Journal of Plastic Surgery · doi:10.1007/s00238-021-01794-5 · Cited by 11
“Of these, nine were retrospective cohort studies [29–31, 34, 35, 38–40, 42], and six were randomized controlled clinical trials [32, 33, 36, 37, 41, 43].”
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Efficacy and Safety of Antifibrinolytic Drugs in Pediatric Surgery: A Systematic Review
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Tranexamic Acid in Elective Craniosynostosis Surgery
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Reducing Blood Losses and Transfusion Requirements in Craniosynostosis Surgery
Vergnaud, E., Vecchione, A., Blanot, S., DiRocco, F., Arnaud, É., Rénier, D., & Meyer, P. G. (2012) · Anesthesiology · doi:10.1097/aln.0b013e3182449fc8 · Cited by 11
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“The protocol used at the study hospital was based on Goobie et al study.(12) The common protocol implemented was a preoperative bolus of 15 ml/kg and a continuous intraoperative infusion of 5 ml/kg.”
MethodClohisy, J. C. F., Lenke, L. G., Dafrawy, M. H. E., Wolfe, R. C., Frazier, E. P., & Kelly, M. P. (2022) · Spine Deformity · doi:10.1007/s43390-022-00539-z · Cited by 10
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Evaluation of anesthesia in endoscopic strip craniectomy: A review of 121 patients
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“For example, by combining the directly measured blood loss with a calculation based on a formula.(22,23)”
MethodGeographic Financial Analysis of Craniosynostosis Surgery in the United States
Kalmar, C. L., Zapatero, Z. D., Kosyk, M. S., Bartlett, S. P., & Taylor, J. A. (2022) · Journal of Craniofacial Surgery · doi:10.1097/scs.0000000000008627 · Cited by 10
Pediatric Blood Management Protocol in Cranial Vault Surgery
Kelley, J. P., Boville, B. M., Sterken, D. J., Sanfilippo, D. J., Fahrenkopf, M. P., Kelpin, J. P., Polley, J. W., Mann, R. J., & Girotto, J. A. (2019) · Journal of Craniofacial Surgery · doi:10.1097/scs.0000000000005563 · Cited by 10
“Tranexamic acid use has been supported in randomized controlled studies showing both decreased transfusion rates and decreased postoperative adverse events.(11,23) The institution of this PBM protocol increased the use of TXA from 0% to 84% (26/ 31 patients) 13% (4 patients) received aminocaproic acid rather than TXA…”
MethodZhang, T., Feng, H., Xiao, W. L., Li, J., Liu, Q., Feng, X., Qi, D., Fan, X., Shan, Y., Yu, T., et al. (2022) · Frontiers in Pharmacology · doi:10.3389/fphar.2022.916017 · Cited by 9
“…that prophylactic TXA use can reduce blood loss and transfusion requirements in surgeries for pediatric scoliosis, cardiac, and craniosynostosis without apparent morbidity or mortality (Dadure et al., 2011; Goobie et al., 2011; Pasquali et al., 2012; McNicol et al., 2016; Goobie et al., 2018).”
BackgroundEconomic Aspects and Organization
Görlinger, K., & Kozek‐Langenecker, S. A. (2014) · Springer eBooks · doi:10.1007/978-3-642-55004-1_24 · Cited by 9
van Nunen, D. P. F., Janssen, L. E., Stubenitsky, B. M., Han, K. S., & Muradin, M. S. M. (2014) · Journal of Cranio-Maxillofacial Surgery · doi:10.1016/j.jcms.2014.01.017 · Cited by 9
“Given the inherent difficulty of accurately measuring perioperative blood loss in craniosynostosis surgery (Stricker et al., 2010; Goobie et al. 2011), a second estimate of the perioperative blood loss was calculated following the methodology of Kearney et al. (1989) (Table 1).”
MethodKüçük, A., Tümtürk, A., Gergin, I. S., Oral, Ş., Görkem, S. B., Kurtsoy, A., Madenoğlu, H., & Öktem, İ. S. (2015) · Turkish Neurosurgery · doi:10.5137/1019-5149.jtn.14751-15.2 · Cited by 9
South African Society of Anaesthesiologists Perioperative Patient Blood Management Guidelines 2020
Wise, R., Bishop, D. G., Gibbs, M., Govender, K., James, M. F., Kabambi, K. F., Louw, V. J., Mdladla, N., Moipalai, L., Chakane, P. M., et al. (2020) · Southern African Journal of Anaesthesia and Analgesia · doi:10.36303/sajaa.2020.26.6.s1 · Cited by 9
Achondroplasia and Multiple-Suture Craniosynostosis
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“One significant challenge related to the treatment of our patient was the massive intraoperative blood loss; the blood loss occurred primarily during the craniotomy portions of the patient and was calculated at 280% of his total blood volume.(14,15) The formulas and values used for the calculation are as follows:”
MethodMuhly, W. T., Tan, J. M., Hsu, G., Sesok‐Pizzini, D. A., Fiadjoe, J. E., Taylor, J. A., Bartlett, S. P. P., & Stricker, P. A. (2018) · Hospital Pediatrics · doi:10.1542/hpeds.2018-0027 · Cited by 9
Blood transfusion trends by disease category in the United States, 2000 to 2014
Roberts, N. L. S., James, S. L., Delaney, M., & Fitzmaurice, C. (2020) · Transfusion and Apheresis Science · doi:10.1016/j.transci.2020.103012 · Cited by 8
“5 rates as observed in our study is possibly related to the multimodal approaches aimed to reduce the need for blood transfusions in the perioperative setting like the use of tranexamic acid, treatment of preoperative anemia, optimization of hydration, or minimally invasive surgical techniques [25,26].”
BackgroundFarsani, D. M., Mazaheri, Z., & Shafa, A. (2023) · Anesthesiology and Pain Medicine · doi:10.5812/aapm-130462 · Cited by 8
“In this regard, numerous studies were performed and are in progress, indicating successful outcomes of TXA for controlling blood loss during craniosynostosis surgery (1, 7, 34-36), which is consistent with our”
BackgroundManagement of perioperative bleeding in children. Step by step review
Giraldo, M. Z. (2012) · Colombian Journal of Anesthesiology · doi:10.1016/j.rcae.2012.10.006 · Cited by 8
Stehrer, R., Hunger, S., Schotten, K., Parsaei, B., Malek, M., Jacob, M., Geiselseder, G., & Meier, J. M. (2016) · Journal of Cranio-Maxillofacial Surgery · doi:10.1016/j.jcms.2016.06.028 · Cited by 8
“…group, the mean amount of perioperatively transfused PRBC was 54 ml/kg, which is comparable to findings in other studies (Stricker et al., 2010, Goobie et al., 2011, van Uitert et al., 2011, Oppenheimer et al., 2014), in contrast to a rate of 25 ml/kg in the SeraSeal® group resulting in a…”
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Intraoperative Blood and Coagulation Factor Replacement During Neurosurgery
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Plastic and Reconstructive Surgery
Stricker, P. A., Fiadjoe, J. E., & Lerman, J. (2019) · Elsevier eBooks · doi:10.1016/b978-0-323-42974-0.00035-5 · Cited by 8
Effects of Tranexamic Acid on Bleeding in Pediatric Surgeries: A Systematic Review and Meta-Analysis
Wei, Y., Zhang, Y., Jin, T., Wang, H., Li, J., & Zhang, D. (2021) · Frontiers in Surgery · doi:10.3389/fsurg.2021.759937 · Cited by 7
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“Idade (anos) 51,15 (15,4) 53,7 (16,72) 52,8 (15,9) 53,32 (19,99) 51 (15,4) 0,927a”
Transfusion support: Considerations in pediatric populations
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Vavilala, M. S., Soriano, S. G., & Krane, E. J. (2017) · Elsevier eBooks · doi:10.1016/b978-0-323-34125-7.00028-0 · Cited by 7
Thiele, R. H., Huffmyer, J. L., & Raphael, J. (2012) · Current Opinion in Critical Care · doi:10.1097/mcc.0b013e3283552af9 · Cited by 7
Roumeliotis, G. A., Campbell, S., Das, S., Hildebrand, G. D., Issa, P. C., Jayamohan, J., Lawrence, T. P., Magdum, S. A., Wall, S. A., & Johnson, D. (2020) · Journal of Craniofacial Surgery · doi:10.1097/scs.0000000000006512 · Cited by 7
“In 2 double-blind, placebo-controlled trials tranexamic acid use during calvarial remodeling procedures was found to significantly decrease intraoperative blood loss and transfusion rates and was not associated with thromboembolic events.(19,20) Similarly, retrospective cohort studies describing the adverse events ass…”
BackgroundPostoperative cerebral arterial thrombosis following cranial surgery in an infant
Sjoblom, M. D., Busso, V. O., Linscott, L. L., & Sadhasivam, S. (2013) · Pediatric Anesthesia · doi:10.1111/pan.12270 · Cited by 7
Gutierrez-Pineda, F., Franklin, B. A., Punukollu, A., García, G. A. G., Duque, O. E. M., Renteria, H. A., Perez, J. F. P., & Gonzalez, I. A. (2024) · Child s Nervous System · doi:10.1007/s00381-024-06472-y · Cited by 6
“Our findings also revealed high transfusion rates during the perioperative period among the evaluated patients, consistent with existing literature that highlights the significant blood loss and transfusion requirements associated with [40, 41].”
Sobey, J. H., Menser, C. C., Hartzog, A. J., Hocking, K. M., Niconchuk, J. A., Bonfield, C. M., Stricker, P. A., & Reddy, S. K. (2021) · Journal of Craniofacial Surgery · doi:10.1097/scs.0000000000008378 · Cited by 6
Bolufer, A., Iwai, T., Baughn, C., Clark, A. C., & Olavarria, G. (2022) · Cureus · doi:10.7759/cureus.25185 · Cited by 6
Temperance With Tranexamic Acid: Increased Risk of Venous Thromboembolism in Abdominoplasty
Mess, S. A., & Stephanos, K. (2024) · Aesthetic Surgery Journal Open Forum · doi:10.1093/asjof/ojae044 · Cited by 6
Treatment of bleeding upper aerodigestive tract tumor—A novel approach with antifibrinolytic agent
Low, T.-H. H., Huang, J., Reid, C., Elliott, M., & Clark, J. R. (2013) · The Laryngoscope · doi:10.1002/lary.24064 · Cited by 6
Kurnik, N. M., Bristol, R. E., Maneri, C., Singhal, R., & Singh, D. (2017) · Journal of Craniofacial Surgery · doi:10.1097/scs.0000000000003803 · Cited by 6
“Finally, even though TXA can reduce the amount of blood transfused in craniosynostosis operations, it does not eliminate the need for transfusion.(4,5) Because of the incomplete success of blood conservation strategies and the difficulty associated with autologous blood donation, many centers use techniques to minimiz…”
BackgroundPerioperative Management and Factors Associated With Transfusion in Cranial Vault Reconstruction
Hall, B. R., Barrientos, S., Flores, L. E., Cemaj, S., Kugler, J. A., & Miller, J. J. (2019) · Journal of Craniofacial Surgery · doi:10.1097/scs.0000000000005666 · Cited by 6
“With regards to the efficacy of antifibrinolytic agents, our results are in accordance with 2 randomized clinical trials which were both published in 2011.(13,14) Dadure and colleagues reduced both the transfusion incidence (70% versus 37%) and volume (16.”
BackgroundResultInfluentialManagement of perioperative bleeding in children. Step by step review☆
Giraldo, M. Z. (2013) · Colombian Journal of Anesthesiology · doi:10.1097/01819236-201341010-00009 · Cited by 6
An Audit of the Statistical Validity of Conclusions of Clinical Superiority in Anaesthesia Journals
Gibbs, N. M., & Weightman, W. M. (2014) · Anaesthesia and Intensive Care · doi:10.1177/0310057x1404200509 · Cited by 5
Yuksel, S. S., Kearney, A. M., Taub, P. J., & Gosain, A. K. (2021) · Journal of Craniofacial Surgery · doi:10.1097/scs.0000000000007592 · Cited by 5
Menon, G., George, M., Kumar, P., Nair, S., Udayakumaran, S., Krishnadas, A., Subash, P., & Vasudevan, A. (2022) · Journal of Neuroanaesthesiology and Critical Care · doi:10.1055/s-0041-1740203 · Cited by 5
The Top 100 Most-Cited Publications in Clinical Craniofacial Research
Braud, S. C., Treger, D., Lizardi, J. J., Boghosian, T., ElAbd, R., Arakelians, A. R. L., Jabori, S. K., & Thaller, S. R. (2024) · Journal of Craniofacial Surgery · doi:10.1097/scs.0000000000010185 · Cited by 5
“12,33 LIMITATIONS Bibliometric analysis is a powerful tool for analyzing the impact of research; however, there are shortcomings worth discussing.”
MethodOptimizing Perioperative Red Blood Cell Utilization and Wastage in Pediatric Craniofacial Surgery
Reddy, S. K., Volpi-Abadie, J., Gordish‐Dressman, H., Chao, J. W., Luban, N. L. C., & Deutsch, N. (2020) · Journal of Craniofacial Surgery · doi:10.1097/scs.0000000000006523 · Cited by 5
“Goobie et al conducted a double-blind, placebo-controlled trial in 2011 to study the efficacy of tranexamic acid and found significantly lower total blood loss, RBC transfusion volume, and decreased blood donor exposures in patients who received tranexamic acid.(7) These findings have been corroborated by other author…”
ResultBlood Conservation and Transfusion Medicine
Nemergut, M. E., Haile, D. T., Mauermann, W. J., & Flick, R. P. (2017) · Elsevier eBooks · doi:10.1016/b978-0-323-34125-7.00020-6 · Cited by 5
Varidel, A., Meara, J. G., Proctor, M. R., & Goobie, S. M. (2023) · Current anesthesiology reports · doi:10.1007/s40140-023-00567-z · Cited by 5
Lam, H. V., Austin, T. M., Nguyen, T. T., Martus, J. E., & Schoenecker, J. G. (2018) · Journal of Pediatric Orthopaedics B · doi:10.1097/bpb.0000000000000545 · Cited by 5
Hemorrhage Control and Thrombosis Following Severe Injury
Zimrin, A. B., Bai, Y., Holcomb, J. B., & Hess, J. R. (2019) · Elsevier eBooks · doi:10.1016/b978-0-323-46202-0.00040-6 · Cited by 6
Clearing the Smoke: The Evidence behind Risk of Electrocautery Smoke and Mitigation Strategies
Tyle, M. R., Olafson, A., Hiro, M. E., & Payne, W. G. (2024) · Plastic & Reconstructive Surgery Global Open · doi:10.1097/gox.0000000000006039 · Cited by 4
Rapaport, B. H. J., Burnside, G., Parks, C., Duncan, C. A., Richardson, D., Ellenbogen, J. R., Sinha, A., Craig, R., Diwan, R., & Hennedige, A. A. (2023) · Journal of Craniofacial Surgery · doi:10.1097/scs.0000000000009878 · Cited by 4
“37,38 The theoretical risk of increased arterial and venous thrombosis have not been borne out in the evidence although it has been noted that previous studies may have been underpowered in this regard.”
BackgroundTranexamic Acid: Safeguarding Children with Craniosynostosis from Bleeding. A Review Article
Firdaus, K. M., Andriyanto, L., Muhammad, A. J., & Bisri, T. (2024) · The Cleft Palate-Craniofacial Journal · doi:10.1177/10556656241239527 · Cited by 4
Manasyan, A., Roohani, I., Wolfe, E. M., Turk, M., Urata, M. M., & Hammoudeh, J. A. (2024) · Journal of Oral and Maxillofacial Surgery · doi:10.1016/j.joms.2024.10.021 · Cited by 4
Manejo del sangrado perioperatorio en niños. Revisión paso a paso
Giraldo, M. Z. (2012) · Colombian Journal of Anesthesiology · doi:10.1016/j.rca.2012.07.011 · Cited by 4
Efficacy of Tranexamic Acid in Pediatric Craniosynostosis Surgery
Goobie, S. M., Meier, P. M., Pereira, L. M., McGowan, F. X. J., Prescilla, R. P., Scharp, L. A., Rogers, G. F., Proctor, M. R., Meara, J. G., Soriano, S. G., et al. (2011) · Survey of Anesthesiology · doi:10.1097/01.sa.0000407025.78528.81 · Cited by 4
Wilton, N. C. T., & Anderson, B. J. (2019) · Elsevier eBooks · doi:10.1016/b978-0-323-42974-0.00032-x · Cited by 4
Ackerman, L. L., Snider, A. A., & Ye, J. (2023) · Journal of Craniofacial Surgery · doi:10.1097/scs.0000000000009443 · Cited by 4
Kolodziej, J. H., Leeper, C. M., Leonard, J. C., Josephson, C. D., Zenati, M. S., & Spinella, P. C. (2023) · Transfusion · doi:10.1111/trf.17373 · Cited by 4
Metadata
- Authors
- Goobie, S. M., Meier, P. M., Pereira, L. M., McGowan, F. X., Prescilla, R. P., Scharp, L. A., Rogers, G. F., Proctor, M. R., Meara, J. G., Soriano, S. G., Zurakowski, D., & Sethna, N. F.
- Affiliations
- Boston Children's Hospital (US)
- Instructor in Anesthesia.
- Massachusetts College of Pharmacy and Health Sciences (US)
- Professor of Anesthesia.
- Research Technician, †† Professor.
- Assistant Professor.
- Associate Professor, Department of Plastic and Oral Surgery.
- Assistant Professor of Anaesthesia (Director of Biostatistics).
- Associate Professor of Anesthesia, Department of Anesthesia, Perioperative, and Pain Medicine.
- ORCID
- Venue
- Anesthesiology
- Published
- 2011-04-01
- Volume
- 114
- Issue
- 4
- Pages
- 862-871
- ISSN
- 0003-3022 (ISSN-L)
- OpenAlex
- W2016016217
- Cited by
- 313
- References
- 46
- Citations by year
- 2026: 10 · 2025: 13 · 2024: 21 · 2023: 16 · 2022: 22 · 2021: 25 · 2020: 20 · 2019: 26 · 2018: 20 · 2017: 17 · 2016: 19 · 2015: 30 · 2014: 28 · 2013: 17 · 2012: 21
- FWCI
- 15.44
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Anesthesiology (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Hematology › Blood transfusion and management
- Health Sciences › Medicine › Surgery › Craniofacial Disorders and Treatments
- Health Sciences › Medicine › Hematology › Hemostasis and retained surgical items
- Keywords
- tranexamic acid, pediatric craniosynostosis, perioperative blood loss, blood transfusion, fibrinolysis inhibition, plasma drug concentration, children
- MeSH terms
- Antifibrinolytic Agents, Blood Transfusion, Child, Child, Preschool, Craniosynostoses, Double-Blind Method, Female, Humans, Infant, Intraoperative Care, Male, Tranexamic Acid, Blood Loss, Surgical, Treatment Outcome
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