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Does Oxygen Content Play a Role in Spontaneous Closure of Perimembranous Ventricular Septal Defects? CHILDREN-BASEL 2021; 8:children8100881. [PMID: 34682146 PMCID: PMC8534918 DOI: 10.3390/children8100881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 09/28/2021] [Accepted: 09/30/2021] [Indexed: 11/21/2022]
Abstract
(1) Background: the impact of a series of laboratory parameters (haemoglobin, haematocrit, foetal haemoglobin, peripheral oxygen saturation, iron, transferrin, ferritin, and albumin) on perimembranous ventricular septal defects spontaneous healing was tested. (2) Methods: one hundred and seven patients were enrolled in the study (57% males; mean age 2.1 ± 0.4 years) and were subsequently subdivided into two groups: self-healing (n = 36) and in need of intervention (n = 71). Self-healing subjects were defined on the basis of an absence of residual shunts at colorDoppler across the previous defect. (3) Results: no statistically significant differences were reported in the size of perimembranous ventricular septal defects between the two groups (p = ns). Conversely, prevalence of anaemia was significantly higher in those requiring intervention than in the self-healing group (p < 0.03), while haemoglobin, iron, ferritin, and albumin levels were lower (p < 0.001, p < 0.05, p < 0.02, p < 0.007, respectively). In multivariable linear regression analysis, only haemoglobin and albumin were found to be associated with spontaneous closure (p < 0.005 and p < 0.02, respectively). In multiple logistic regression analysis, haemoglobin independently increased the probability of self-healing of perimembranous ventricular septal defects (p = 0.03). All patients needing an interventional closure of perimembranous ventricular septal defects presented with haemoglobin <12.7 g/dL. (4) Conclusion: the self-resolution of perimembranous ventricular septal defects seems to rely on numerous factors, including oxygen content, which is likely to promote cell proliferation as well as tissue regeneration. Haemoglobin blood concentration seems to influence the natural history of perimembranous ventricular septal defects and improvement of anaemia by supplementation of iron intake might represent a simple and reliable method to promote self-healing.
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Boos V, Bührer C, Berger F. Preoperative Anemia and Outcomes After Corrective Surgery in Neonates With Dextro-Transposition of the Great Arteries. J Cardiothorac Vasc Anesth 2021; 35:2900-2906. [PMID: 33745834 DOI: 10.1053/j.jvca.2021.02.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 01/30/2021] [Accepted: 02/12/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The authors aimed to assess whether untreated preoperative anemia was associated with increased risk for adverse outcomes after the arterial switch operation in neonates with dextro-transposition of the great arteries (d-TGA). DESIGN Retrospective cohort study. SETTING Single cardiac surgery center. PARTICIPANTS Eighty-two newborns with d-TGA. INTERVENTIONS The authors categorized the cohort into the following two groups: the infants with preoperative anemia group (defined as a hematocrit <0.40 L/L) and the control group. MEASUREMENTS AND MAIN RESULTS Preoperative anemia was diagnosed in 21 (25.6%) infants. Anemic infants received intraoperative red blood cell transfusions significantly more often than controls (81.0% v 34.4%, p < 0.001). No differences were observed in the incidence of adverse events, duration of hospitalization (median 27 days v 26 days, p = 0.881), and mortality (0% v 4.9%, p = 0.566). Postnatal hematocrit was the only variable independently associated with preoperative anemia in multivariate logistic regression analysis (unit odds ratio, 0.832; 95% confidence interval, 0.743-0.931; p = 0.001). CONCLUSIONS Untreated preoperative anemia was not associated with adverse outcomes in neonates undergoing reparative surgery for d-TGA.
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Affiliation(s)
- Vinzenz Boos
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany; Department of Neonatology, Charité - Universitätsmedizin Berlin, Berlin, Germany; Department of Neonatology, Hospital Zollikerberg, Zollikerberg, Switzerland.
| | - Christoph Bührer
- Department of Neonatology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Felix Berger
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany; German Center for Cardiovascular Research (DZHK), Congenital Heart Diseases, Partner Site Berlin, Berlin, Germany
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Zhou D, Deng LJ, Ling YF, Tang ML. Preoperative Hemoglobin Level, Oxygen Saturation and Postoperative Outcomes in Children With Cyanotic Congenital Heart Disease: A Propensity-Score Matching Analysis. Front Pediatr 2021; 9:762241. [PMID: 35127586 PMCID: PMC8814516 DOI: 10.3389/fped.2021.762241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 12/27/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The optimal preoperative hemoglobin (Hb) level is difficult to define in children with cyanotic congenital heart disease (CHD) due to hypoxemia-induced secondary erythrocytosis. This retrospective study integrated preoperative Hb and pulse oxygen saturation (SpO2) using the product of Hb × SpO2 to predict postoperative outcomes in children with cyanotic CHD. PATIENTS AND METHODS Children aged <18 years undergoing cardiac surgery with cyanotic CHD were included. The cutoff value of Hb × SpO2 was the age-adjusted lower limit of normal Hb (aaHb) in healthy children. The main outcomes were in-hospital death and the composite outcome of severe postoperative events. Multivariate logistic regression analysis and propensity score matching analysis were used to adjust for important confounders. RESULTS The presence of preoperative Hb × SpO2 < aaHb was observed in 21.6% of cyanotic children (n = 777). Children with Hb × SpO2 < aaHb had higher in-hospital mortality (12.5% vs. 4.6%, P < 0.001) and composite outcome incidence (69.6% vs. 32.3%, P < 0.001) than those with Hb × SpO2 ≥ aaHb. After propensity score matching, 141 pairs of children were successfully matched. Multivariate analysis showed that preoperative Hb × SpO2 < aaHb was significantly associated with the composite outcome in the entire population (odds ratio = 4.092, 95% confidence interval = 2.748-6.095, P < 0.001) and the matched cohorts (odds ratio = 2.277, 95% confidence interval = 1.366-3.795, P = 0.002). CONCLUSION Our results suggest that a preoperative Hb × SpO2 value below the lower limit of normal hemoglobin is a prognostic factor in cyanotic children undergoing cardiac surgery and is a potential criterion to evaluate preoperative anemia in this population.
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Affiliation(s)
- Dan Zhou
- Pediatric Intensive Care Unit, West China Hospital, Sichuan University, Chengdu, China.,West China School of Nursing, Sichuan University, Chengdu, China
| | - Li-Jing Deng
- Pediatric Intensive Care Unit, West China Hospital, Sichuan University, Chengdu, China
| | - Yun-Fei Ling
- Department of Cardiac Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Meng-Lin Tang
- Pediatric Intensive Care Unit, West China Hospital, Sichuan University, Chengdu, China.,West China School of Nursing, Sichuan University, Chengdu, China
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Corwin HL, Shander A, Speiss B, Muñoz M, Faraoni D, Calcaterra D, Welsby I, Ozawa S, Arnofsky A, Goldweit RS, Tibi P. Management of Perioperative Iron Deficiency in Cardiac Surgery: A Modified RAND Delphi Study. Ann Thorac Surg 2020; 113:316-323. [PMID: 33345781 DOI: 10.1016/j.athoracsur.2020.11.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 10/29/2020] [Accepted: 11/10/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND Over the last decade, preoperative anemia has become recognized as a clinical condition in need of management. Although the etiology of preoperative anemia can be multifactorial, two-thirds of anemic elective surgical patients have iron deficiency anemia. At the same time, one-third of non-anemic elective surgical patients are also iron deficient. METHODS Modified-RAND Delphi methodology was employed to identify areas of consensus among an expert panel regarding the management of iron deficiency in patients undergoing cardiac surgery. A list of statements was sent to panel members to respond to using a five-point Likert Scale. All panel members subsequently attended a face-to-face meeting. The initial survey was presented and discussed, and panel members responded to each statement on the Likert scale again. Based on the second survey, the panel came to a consensus on recommendations. RESULTS The panel recommended all patients undergoing cardiac surgery be evaluated for iron deficiency, whether or not anemia is present. Evaluation should include iron studies and reticulocyte hemoglobin content. If iron deficiency is present, with or without anemia, patients should receive parenteral iron. Erythropoietin stimulating agents may be appropriate for some patients. CONCLUSIONS Consensus of an expert panel resulted in a standardized approach to diagnosing and managing iron deficiency in patients undergoing cardiac surgery.
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Affiliation(s)
- Howard L Corwin
- Critical Care Medicine, Geisinger Health System Danville, PA.
| | - Aryeh Shander
- Department of Anesthesiology and Critical Care Medicine, Englewood Health, TeamHealth, Englewood, NJ
| | - Bruce Speiss
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, FL
| | - Manuel Muñoz
- Department of Surgical Specialties, Biochemistry, and Immunology, University of Malaga School of Medicine, Malaga, Spain
| | - David Faraoni
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada
| | - Domenico Calcaterra
- Department of Cardiothoracic Surgery, Bethesda Heart Hospital, Baptist South Florida, Boynton Beach, FL
| | - Ian Welsby
- Department of Anesthesiology and Critical Care, Duke University School of Medicine, Durham, NC
| | - Sherri Ozawa
- Patient Blood Management, Englewood Hospital and Medical Center, Englewood, NJ
| | - Adam Arnofsky
- Cardiothoracic Surgery, Englewood Hospital and Medical Center, Englewood, NJ
| | - Richard S Goldweit
- Interventional Cardiology, Englewood Hospital and Medical Center, Englewood, NJ
| | - Pierre Tibi
- Department of Cardiothoracic and Vascular Diseases, Yavapai Regional Medical Center, Prescott, AZ
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Ertugay S, Kudsioğlu T, Şen T. Consensus Report on Patient Blood Management in Cardiac Surgery by Turkish Society of Cardiovascular Surgery (TSCVS), Turkish Society of Cardiology (TSC), and Society of Cardio-Vascular-Thoracic Anaesthesia and Intensive Care (SCTAIC). TURK GOGUS KALP DAMAR CERRAHISI DERGISI 2019; 27:429-450. [PMID: 32082905 PMCID: PMC7018143 DOI: 10.5606/tgkdc.dergisi.2019.01902] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 10/10/2019] [Indexed: 01/18/2023]
Abstract
Anemia, transfusion and bleeding independently increase the risk of complications and mortality in cardiac surgery. The main goals of patient blood management are to treat anemia, prevent bleeding, and optimize the use of blood products during the perioperative period. The benefit of this program has been confirmed in many studies and its utilization is strongly recommended by professional organizations. This consensus report has been prepared by the authors who are the task members appointed by the Turkish Society of Cardiovascular Surgery, Turkish Society of Cardiology (TSC), and Society of Cardio-Vascular-Thoracic Anaesthesia and Intensive Care to raise the awareness of patient blood management. This report aims to summarize recommendations for all perioperative blood- conserving strategies in cardiac surgery.
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Affiliation(s)
- Serkan Ertugay
- Department of Cardiovascular Surgery, Ege University School of Medicine, İzmir, Turkey
| | - Türkan Kudsioğlu
- Anesthesiology and Reanimation, University of Health Sciences, Siyami Ersek Thoracic and Cardiovascular Surgery Center, İstanbul, Turkey
| | - Taner Şen
- Department of Cardiology, University of Health Sciences, Kütahya
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Cholette JM, Faraoni D, Goobie SM, Ferraris V, Hassan N. Patient Blood Management in Pediatric Cardiac Surgery: A Review. Anesth Analg 2019; 127:1002-1016. [PMID: 28991109 DOI: 10.1213/ane.0000000000002504] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Efforts to reduce blood product transfusions and adopt blood conservation strategies for infants and children undergoing cardiac surgical procedures are ongoing. Children typically receive red blood cell and coagulant blood products perioperatively for many reasons, including developmental alterations of their hemostatic system, and hemodilution and hypothermia with cardiopulmonary bypass that incites inflammation and coagulopathy and requires systemic anticoagulation. The complexity of their surgical procedures, complex cardiopulmonary interactions, and risk for inadequate oxygen delivery and postoperative bleeding further contribute to blood product utilization in this vulnerable population. Despite these challenges, safe conservative blood management practices spanning the pre-, intra-, and postoperative periods are being developed and are associated with reduced blood product transfusions. This review summarizes the available evidence regarding anemia management and blood transfusion practices in the perioperative care of these critically ill children. The evidence suggests that adoption of a comprehensive blood management approach decreases blood transfusions, but the impact on clinical outcomes is less well studied and represents an area that deserves further investigation.
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Affiliation(s)
- Jill M Cholette
- From the Department of Pediatrics, Golisano Children's Hospital, University of Rochester, Rochester, New York
| | - David Faraoni
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Susan M Goobie
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston, Massachusetts.,Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Victor Ferraris
- Department of Surgery, University of Kentucky Chandler Medical Center & Lexington Veterans Affairs Medical Center, Lexington, Kentucky
| | - Nabil Hassan
- Division of Pediatric Critical Care, Children's Hospital of Illinois At OSF St Frances, University of Illinois at Peoria, Peoria, Illinois
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Deng X, Wang Y, Huang P, Luo J, Xiao Y, Qiu J, Yang G. Red blood cell transfusion threshold after pediatric cardiac surgery: A systematic review and meta-analysis. Medicine (Baltimore) 2019; 98:e14884. [PMID: 30882699 PMCID: PMC6426484 DOI: 10.1097/md.0000000000014884] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Restrictive red blood cell transfusion strategy is implemented to minimize risk following allogeneic blood transfusion in adult cardiac surgery. However, it is still unclear if it can be applied to pediatric cardiac patients. The purpose of this systematic review and meta-analysis was to determine the effect of postoperative restrictive transfusion thresholds on clinical outcomes based on up-to-date results of randomized controlled trials (RCTs) and observational studies in pediatric cardiac surgery. METHOD We searched for RCTs and observational studies in the following databases: the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and ClinicalTrials.gov from their inception to October 26, 2017. We also searched reference lists of published guidelines, reviews, and relevant articles, as well as conference proceedings. No language restrictions were applied and no observational study met the inclusion criteria. RESULTS Four RCTs on cardiac surgery involving 454 patients were included. There were no differences in the pooled fixed effects of intensive care unit (ICU) stay between the liberal and restrictive transfusion thresholds (standardized mean difference SMD, 0.007; 95% confidence interval CI, -0.18-0.19; P = .94). There were also no differences in the length of hospital stay (SMD, -0.062; 95% CI, -0.28-0.15; P = .57), ventilation duration (SMD, -0.015; 95% CI, -0.25-0.22; P = .90), mean arterial lactate level (SMD, 0.071; 95% CI, -0.22-0.36; P = .63), and mortality (risk ratio, 0.49; 95% CI, 0.13-1.94; P = .31). There was no inter-trial heterogeneity for any pooled analysis. Publication bias was tested using Egger, Begg, or the trim-and-fill test, and the results indicated no significant publication bias. CONCLUSION Evidence from RCTs in pediatric cardiac surgery, though limited, showed non-inferiority of restrictive thresholds over liberal thresholds in length of ICU stay and other outcomes following red blood cell transfusion. Further high-quality RCTs are necessary to confirm the findings.
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Affiliation(s)
| | | | | | | | | | - Jun Qiu
- Department of Emergency Center, Hunan Children's Hospital, Changsha, China
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Recommendations on RBC Transfusion in Infants and Children With Acquired and Congenital Heart Disease From the Pediatric Critical Care Transfusion and Anemia Expertise Initiative. Pediatr Crit Care Med 2018; 19:S137-S148. [PMID: 30161069 PMCID: PMC6126364 DOI: 10.1097/pcc.0000000000001603] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To present the recommendations and supporting literature for RBC transfusions in critically ill children with acquired and congenital heart disease developed by the Pediatric Critical Care Transfusion and Anemia Expertise Initiative. DESIGN Consensus conference series of 38 international, multidisciplinary experts in RBC transfusion management of critically ill children. METHODS Experts developed evidence-based and, when evidence was lacking, expert-based clinical recommendations and research priorities for RBC transfusions in critically ill children. The cardiac disease subgroup included three experts. Electronic searches were conducted using PubMed, EMBASE, and Cochrane Library databases from 1980 to May 2017. Agreement was obtained using the Research and Development/UCLA appropriateness method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. RESULTS Twenty-one recommendations were developed and reached agreement. For children with myocardial dysfunction and/or pulmonary hypertension, there is no evidence that transfusion greater than hemoglobin of 10 g/dL is beneficial. For children with uncorrected heart disease, we recommended maintaining hemoglobin greater than 7-9.0 g/dL depending upon their cardiopulmonary reserve. For stable children undergoing biventricular repairs, we recommend not transfusing if the hemoglobin is greater than 7.0 g/dL. For infants undergoing staged palliative procedures with stable hemodynamics, we recommend avoiding transfusions solely based upon hemoglobin, if hemoglobin is greater than 9.0 g/dL. We recommend intraoperative and postoperative blood conservation measures. There are insufficient data supporting shorter storage duration RBCs. The risks and benefits of RBC transfusions in children with cardiac disease requires further study. CONCLUSIONS We present RBC transfusion management recommendations for the critically ill child with cardiac disease. Clinical recommendations emphasize relevant hemoglobin thresholds, and research recommendations emphasize need for further understanding of physiologic and hemoglobin thresholds and alternatives to RBC transfusion in subpopulations lacking pediatric literature.
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Association of haematocrit and red blood cell transfusion with outcomes in infants with shunt-dependent pulmonary blood flow and univentricular physiology. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2014; 13:417-22. [PMID: 25545877 DOI: 10.2450/2014.0128-14] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Accepted: 10/28/2014] [Indexed: 12/20/2022]
Abstract
BACKGROUND The aim of this study was to investigate the association between red blood cell (RBC) transfusion and haematocrit values with outcomes in infants with univentricular physiology undergoing surgery for a modified Blalock-Taussig shunt. MATERIAL AND METHODS This study included infants ≤ 2 months of age who underwent modified Blalock-Taussig shunt surgery at the Arkansas Children's Hospital (2006-2012). Infants undergoing a Norwood operation or Damus-Kaye-Stansel operation with modified Blalock-Taussig shunt were excluded. Demographics, pre-operative, operative, daily laboratory data, and post-operative variables were collected. We studied the association between haematocrit and blood transfusion with a composite clinical outcome. Multivariable logistic regression models were fitted to study the probability of study outcomes as a function of haematocrit values and RBC transfusions after operation. RESULTS Seventy-three patients qualified for inclusion. All study patients received blood transfusion within the first 48 hours after heart surgery. The median haematocrit was 44.3 (interquartile range [IQR] 42.5-46.2), and the median volume of RBC transfused was 28 mL/kg (IQR, 10-125) in the first 14 days after surgery. The overall in-hospital mortality rate was 13.6% (10 patients). A multivariable analysis adjusted for risk factors, including weight, prematurity, cardiopulmonary bypass and postoperative need for nitric oxide and dialysis, revealed no association between haematocrit values and RBC transfusion with the composite clinical outcome. DISCUSSION We did not find an association between higher haematocrit values and increasing RBC transfusions with improved outcomes in infants with shunt-dependent pulmonary blood flow and univentricular physiology. The power of our study was small, which prevents any strong statement on this lack of association. Future multi-centre, randomised controlled trials are needed to investigate this topic in further detail.
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