Safety of preoperative erythropoietin in surgical calvarial remodeling: an 8-year retrospective review and analysis

Plast Reconstr Surg. 2012 Aug;130(2):305e-310e. doi: 10.1097/PRS.0b013e3182589dbf.


Background: Calvarial remodeling is typically associated with significant blood loss. Although preoperative erythropoiesis-stimulating agents have proven to significantly decrease the need for blood transfusions, recent data in adults have raised concerns that elevating hemoglobin levels greater than 12.5 g/dl may increase the risk of thrombotic events. This study was designed to assess the risks of erythropoietin in the pediatric population.

Methods: Records were retrospectively reviewed from 2000 to 2008 at three major metropolitan children's hospitals of all children undergoing calvarial remodeling after receiving preoperative erythropoietin. Demographic and perioperative outcome data were reviewed, including transfusion reactions, pressure ulcer secondary to prolonged positioning, pneumonia, infection, deep vein thrombosis, cerebrovascular accident, pulmonary embolism, sagittal sinus thrombosis, pure red cell aplasia, and myocardial infarction.

Results: A total of 369 patients met the inclusion criteria (mean age, 0.86±1.1 years). On average, three preoperative doses of erythropoietin were administered (600 U/kg). Iron was also supplemented. No complications associated with dosing were noted, there were no thrombotic events identified, and no other major complications were seen (i.e., death or blindness). Thirty-one patients (8.40 percent) experienced one or more postoperative complications. There was no significant correlation between hemoglobin levels greater than 12.5 g/dl and the occurrence of any noted complication.

Conclusions: With zero thrombotic postoperative complications, the authors estimate the risk of a thrombotic event in the pediatric population to be less than 0.81 percent (95 percent confidence). These data suggest that preoperative administration of erythropoietin in children undergoing calvarial remodeling does not appear to increase the incidence of thrombotic events or other significant complications.

Clinical question/level of evidence: Therapeutic, IV.

Publication types

  • Evaluation Study
  • Multicenter Study

MeSH terms

  • Blood Loss, Surgical / prevention & control*
  • Erythropoietin / adverse effects
  • Erythropoietin / therapeutic use*
  • Female
  • Hematinics / adverse effects
  • Hematinics / therapeutic use*
  • Humans
  • Infant
  • Male
  • Orthopedic Procedures*
  • Postoperative Complications / chemically induced
  • Postoperative Complications / epidemiology
  • Preoperative Care / methods*
  • Retrospective Studies
  • Skull / surgery*
  • Synostosis / surgery*
  • Thrombosis / chemically induced
  • Thrombosis / epidemiology
  • Treatment Outcome


  • Hematinics
  • Erythropoietin