Authors: Laurie Lynn Ackerman, MD, FAANS; Anna Snider; Jian Ye, MD (Indianapolis, IN)

INTRODUCTION: In 2017 we adopted tranexamic acid (TXA) infusion and Epinephrine/Triamcinolone scalp injection in open sagittal synostosis surgery. We believe this reduced blood loss and transfusion rates in this population. METHODS: Retrospective review of 102 consecutive patients operated for sagittal synostosis aged <4 months at surgery from 2007 to 2019 was conducted. We collected demographics (age, sex, weight at surgery, and length of stay (LOS)) ; intraoperative information (estimated blood loss (EBL), administration of packed red blood cell (PRBC) transfusion or plasmalyte/albumen in mls, operating time, baseline hemoglobin (Hb) & hematocrit (Hct), type of local anesthetic (1/4% bupivacaine vs Ephinephrine/Triamcinolone)) and use and volume of TXA). Postoperative Hb, Hct, coagulation studies, & platelets at 2 hours postoperatively and postoperative day (POD) 1 were also recorded. RESULTS: There were 3 groups: ¼% Bupivacaine/Epinephrine (N=61), Epinephrine/Triamcinolone (N=11) and Epinephrine/Triamcinolone with TXA bolus/infusion intraoperatively (N=30). Sixty-eight were male, and 34 female. No differences existed between groups for age (x̅ 3.3 mos), weight (x̅ 6.1Kg) or ICU LOS (1 day). Groups receiving Ephinephrine/Triamcinolone or Ephinephrine/Triamcinolone/TXA had lower mean EBL (30 & 25 vs 40 mls p<0.0001), lower rate/amount of PRBC transfusion (127.7 & 83.7 vs 154 mls p<0.0001), and shorter operative time (76.5 & 66.1 versus 91.7 minutes p<0.0001). Eight Ephinephrine/Triamcinolone/TXA patients did not require transfusion. LOS was shortest for Ephinephrine/Triamcinolone /TXA vs the Ephinephrine/Triamcinolone or bupivacaine groups (2 vs 3,3 days, p<0.0001). No significant differences between groups were noted on POD 1 Hb, Hct, PT, PTT, or INR (x̅ Hct 25). CONCLUSION: Use of Ephinephrine/Triamcinolone/TXA significantly reduced EBL, PRBC transfusion, OR Time and LOS in open sagittal synostosis surgery. Given a mean postoperative Hct of 25, it could be argued that even lower rates of transfusion could tolerated. Use of Ephinephrine/Triamcinolone/TXA may be a useful adjunct for other surgical cases.