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Kiskaddon AL, Goldenberg NA, Fierstein JL, Miller A, Quintessenza JA, Kartha VM. Dosing, Monitoring, Blood Product Utilization, and Thromboembolic Complications of Four-Factor Prothrombin Complex Concentrate as Part of an Institutional Protocol in Pediatric Cardiac Surgery: A Retrospective Cohort Study. Semin Thromb Hemost 2024; 50:873-882. [PMID: 38049114 DOI: 10.1055/s-0043-1777301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/06/2023]
Abstract
Pediatric cardiac surgery patients are predisposed to blood loss. Blood product administration can lead to complications. Prothrombin complex concentrates (PCCs) offer potential advantages of factor composition, small volume, decreased immunogenicity/infectious risks, and accessibility. The objective of this study was to describe dosing, monitoring, blood product utilization, and thromboembolic complications of administering four-factor PCC (4F-PCC) in pediatric cardiac surgery. We performed a retrospective review of patients aged <18 years undergoing cardiac surgery from June 2020 to May 2022 (inclusive) who received 4F-PCC. Outcomes of interest included 4F-PCC dosing (units/kg) and number of doses administered, chest tube output, blood product administration, donor exposure, length of stay, and thromboembolic events. Eighty-six patients met eligibility criteria. The median (range) age and weight were 0.37 (0.01-16.3) years and 5.3 (1.6-98) kg, respectively. Median (range) total 4F-PCC dose per patient was 25 (9.2-50) units/kg, with 6 patients (7%) receiving a total of two doses. Median (range) 24-hour postoperative packed red blood cells, platelet, plasma, and cryoprecipitate administration volumes were 0 (0-2.57) mL/kg/24 h, 0 (0-1.09), 0 (0-2.64), and 0 (0-0.28 mL/kg/24 h), respectively. Median (range) length of stay and 24-hour postoperative chest tube output were 10 (6-26) days and 1.1 (0.1-4.2) mL/kg/h, respectively. Two (2%) patients experienced a thromboembolic event within 30 days of 4F-PCC administration. These retrospective findings suggest no worsening of hemostatic parameters, a mild median improvement in fibrinogen, low blood product utilization, and low thromboembolism rates following 4F-PCC use in pediatric cardiac surgery.
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Affiliation(s)
- Amy L Kiskaddon
- Department of Pharmacy, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
- Division of Cardiology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
- Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
- Heart Institute, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Neil A Goldenberg
- Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
- Division of Hematology, Departments of Medicine and Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
- Cancer and Blood Disorders Institute, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Jamie L Fierstein
- Epidemiology and Biostatistics Shared Resource, Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Alexandra Miller
- Epidemiology and Biostatistics Shared Resource, Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | | | - Vyas M Kartha
- Department of Anesthesiology, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
- Division of Anesthesiology and Critical Care Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
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Alhamdan F, Yuki K. Postoperative Organ Dysfunction Risk Stratification Using Extracellular Vesicle-Derived circRNAs in Pediatric Congenital Heart Surgery. Cells 2024; 13:1417. [PMID: 39272989 PMCID: PMC11394075 DOI: 10.3390/cells13171417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2024] [Revised: 08/15/2024] [Accepted: 08/23/2024] [Indexed: 09/15/2024] Open
Abstract
Breakthroughs in surgical and medical techniques have significantly improved outcomes for children with congenital heart disease (CHD), but research continues to address the ongoing challenge of organ dysfunction after surgery, particularly in neonates and infants. Our study explored circular RNAs (circRNAs) within plasma-derived extracellular vesicles (EVs) in neonates and infants undergoing CHD surgery. Post-surgery EV circRNAs showed dramatic expression changes between organ dysfunction (OD) and control groups. Tissue injury-related pathways were consistent across pre- and post-surgery in OD. The top two significant predicted tissue sources of these circRNAs originated from the respiratory system, aligning with the fact that all patients in the OD arm experienced respiratory dysfunction. Five of these circRNAs, namely circ-CELSR1, circ-PLXNA1, circ-OBSL1, circ-DAB2IP, and circ-KANK1, significantly correlated with PELOD (Pediatric Logistic Organ Dysfunction) score and demonstrated high performance (AUC = 0.95), supporting the potential of circRNAs as prognostic markers. These findings pave the way for EV circRNAs as promising tools for managing post-surgical organ dysfunction and potentially guiding therapeutic strategies in children with CHD.
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Affiliation(s)
- Fahd Alhamdan
- Department of Anesthesiology, Critical Care and Pain Medicine, Cardiac Anesthesia Division, Boston Children's Hospital, Boston, MA 02115, USA
- Departments of Immunology and Anaesthesia, Harvard Medical School, Boston, MA 02115, USA
- Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Koichi Yuki
- Department of Anesthesiology, Critical Care and Pain Medicine, Cardiac Anesthesia Division, Boston Children's Hospital, Boston, MA 02115, USA
- Departments of Immunology and Anaesthesia, Harvard Medical School, Boston, MA 02115, USA
- Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
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Bohuta L, Charette K, Chan T, Joffe D, Koth A, Greene CL, Mauchley D, McMullan DM. Encouraging results of blood conservation in neonatal open-heart surgery. J Thorac Cardiovasc Surg 2024; 167:1154-1163. [PMID: 37517580 DOI: 10.1016/j.jtcvs.2023.07.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 06/23/2023] [Accepted: 07/22/2023] [Indexed: 08/01/2023]
Abstract
OBJECTIVE To report early outcomes of blood conservation in neonatal open-heart surgery. METHODS Ninety-nine patients undergoing neonatal open-heart surgery during the implementation of a blood conservation program between May 2021 and February 2023 were reviewed. Patients either received traditional blood management (blood prime, n = 43) or received blood conservation strategies (clear prime, n = 56). Baseline characteristics and outcomes were compared between groups. RESULTS There was no difference in body weight (median, 3.2 kg vs 3.3 kg; P = .83), age at surgery (median, 5 days vs 5 days; P = .37), distribution of The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Congenital Heart Surgery Mortality Categories categories or duration of cardiopulmonary bypass. Patients in the clear prime group had higher preoperative hematocrit (median, 41% vs 38%; P < .01), shorter postoperative mechanical ventilation time (median, 48 hours vs 92 hours; P = .02) and postoperative intensive care unit length of stay (median, 6 days vs 9 days; P < .01) than patients in the blood prime group. Fourteen patients (25%) in the clear prime group, including 1 Norwood patient, were discharged without any transfusion. Among patients within the clear prime group, hospitalizations without blood exposure were associated with higher preoperative hematocrit (median, 43% vs 40%; P = .02), shorter postoperative mechanical ventilation times (median, 22 hours vs 66 hours; P = .01) and shorter postoperative hospital stays (median, 10 days vs 15 days; P = .02). CONCLUSIONS Bloodless surgery is possible in a significant proportion of neonates undergoing open-heart surgery, including the Norwood operation, even in the early stages of experience. Early clinical results are favorable but long-term follow-up and continued efforts are warranted to prove safety and reproducibility.
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Affiliation(s)
- Lyubomyr Bohuta
- Division of Cardiac Surgery, Seattle Children's Hospital, Seattle, Wash.
| | - Kevin Charette
- Division of Perfusion Services, Seattle Children's Hospital, Seattle, Wash
| | - Titus Chan
- Division of Critical Care, Seattle Children's Hospital, Seattle, Wash
| | - Denise Joffe
- Division of Anesthesia, Seattle Children's Hospital, Seattle, Wash
| | - Andrew Koth
- Division of Critical Care, Seattle Children's Hospital, Seattle, Wash
| | | | - David Mauchley
- Division of Cardiac Surgery, Seattle Children's Hospital, Seattle, Wash
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Kayoum AA, Rivera Flores E, Reyes M, Almasarweh SI, Ojito J, Burke RP, Sasaki J. Safety of bloodless open-heart surgery on cardiopulmonary bypass in selected children: A single center experience with minimal invasive extracorporeal circulation. Perfusion 2024; 39:391-398. [PMID: 36482703 DOI: 10.1177/02676591221145623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
INTRODUCTION Bloodless cardiac surgery refers to open-heart surgery without blood or blood products. The cardiopulmonary bypass (CPB) circuits are primed with crystalloid solely, and there is no intraoperative blood transfusion. METHODS Our program considers bloodless congenital cardiac surgery with a minimal invasive extracorporeal circulation (MiECC) system for patients above 10 kg of weight. We performed a single-center retrospective cohort study of all consecutive patients undergoing bloodless cardiac surgery for congenital heart defects between January 2016 and December 2018. RESULTS A total of 164 patients were reviewed (86 male and 78 female) at a median age of 9.6 years (interquartile range (IQR), 4.5-15), a weight of 32 kg (IQR, 16-55), preoperative hemoglobin 13.7 g/dl (IQR, 12.6-14.9), and preoperative hematocrit of 40.4% (IQR, 37.2-44.3). Median CPB time was 81.5 min (IQR, 58-125), and median hematocrit coming off CPB was 26% (IQR, 23-29.7). The congenital heart surgery risk (STAT) category was distributed in STAT 1 for 70, STAT 2 for 80, STAT 3 for 9, and STAT 4 for 5 patients. Most patients (95%) were extubated in the operating room with a low complication rate during the hospital stay (14.6%). Only 6 (4%) patients needed a blood transfusion during the postoperative period, with a higher incidence of complications during the hospital course (p < 0.001). CONCLUSIONS Bloodless congenital heart surgery with MiECC system is safe in low-surgical-risk patients. Our patients had a low rate of complications and short hospital stays.
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Affiliation(s)
- Anas Abdul Kayoum
- Division of Cardiology, Department of Pediatrics, Duke University Hospital, Durham, NC, USA
| | | | - Marcelle Reyes
- Department of Cardiology, Nicklaus Children's Hospital, Miami, FL, USA
| | - Saleem I Almasarweh
- Division of Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Jorge Ojito
- Department of Cardiology, Nicklaus Children's Hospital, Miami, FL, USA
| | - Redmond P Burke
- Department of Cardiology, Nicklaus Children's Hospital, Miami, FL, USA
| | - Jun Sasaki
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
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Ma Y, Li C, Sun L, Li X. The Ratio of Intraoperative Red Blood Cell Transfusion to Blood Loss Associated with Early Postoperative Complications in Pediatric Liver Transplantation Patients. Transfus Med Hemother 2024; 51:41-47. [PMID: 38314246 PMCID: PMC10836861 DOI: 10.1159/000530290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 03/20/2023] [Indexed: 02/06/2024] Open
Abstract
Introduction Liver transplantation (LT) is an operation purposed to save the lives of children with acute or chronic liver diseases, hepatic tumors, and some genetic and metabolic diseases. However, patients who underwent LT have a significant risk of intraoperative blood loss and red blood cell (RBC) transfusion, especially in pediatric patients. Methods In this study, 569 pediatric patients (<18 years old) who underwent LT at a tertiary university hospital between 2013 and 2020 were included. Multiple logistic regression was used to analyze the association between the ratio of intraoperative RBC transfusion to blood loss (IRTBL) and the complications after LT in pediatric patients. IRTBL was divided into quartiles in the adjusted model. Odds ratios, 95% confidence intervals, and p values for trends were calculated. Restricted cubic spline (RCS) regression was used to evaluate the nonlinear association between IRTBL and complications. Results Compared with the lowest level and the highest level of IRTBL, Q2 and Q3 quartiles of IRTBL showed significantly positive association with early complications. A significantly nonlinear association was observed between the IRTBL and early complications in the RCS model with the multiple adjustments of potential covariates (P overall<0.01, P nonlinear<0.01). However, no significant association was observed between late complications and IRTBL. Conclusion In this study, we found there was a nonlinear relationship between the ratio of IRTBL and early postoperative complications in pediatric LT patients, which provides a theoretical basis for RBC transfusion in pediatric LT patients.
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Affiliation(s)
- Yiming Ma
- Department of Blood Transfusion, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Cheng Li
- Department of Clinical Nutrition, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Liying Sun
- Department of Critical Liver Diseases, Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
- Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
- Clinical Center for Pediatric Liver Transplantation, Capital Medical University, Beijing, China
| | - Xiaofei Li
- Department of Blood Transfusion, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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Fite EL, Rivera BK, McNabb R, Smith CV, Hill KD, Katheria A, Maitre N, Backes CH. Umbilical cord clamping among infants with a prenatal diagnosis of congenital heart disease. Semin Perinatol 2023; 47:151747. [PMID: 37002126 DOI: 10.1016/j.semperi.2023.151747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- Elliott L Fite
- Ohio Perinatal Research Network (OPRN), The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA; Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Brian K Rivera
- Ohio Perinatal Research Network (OPRN), The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA; Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Riley McNabb
- Ohio Perinatal Research Network (OPRN), The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA; Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Charles V Smith
- Center for Integrated Brain Research, Seattle Children's Research Institute, University of Washington School of Medicine, Seattle, WA, USA
| | - Kevin D Hill
- Duke University Pediatric and Congenital Heart Center, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA
| | - Anup Katheria
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women & Newborns, San Diego, CA, USA
| | - Nathalie Maitre
- Emory University School of Medicine, Atlanta, GA, USA; Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Carl H Backes
- Ohio Perinatal Research Network (OPRN), The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA; Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, OH, USA; Departments of Pediatrics and Obstetrics & Gynecology, The Ohio State University, Columbus, OH, USA.
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Acker SN, Nolan MM, Prendergast C, Lyttle B, Fares S, Bensard DD, Partrick DA. Blood Transfusion is Associated With Adverse Outcomes in Pediatric Solid Tumor Oncology Patients Following Tumor Resection. J Pediatr Hematol Oncol 2023; 45:137-142. [PMID: 36031190 DOI: 10.1097/mph.0000000000002530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 07/10/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Packed red blood cell (PRBC) transfusion is a lifesaving intervention that also has proinflammatory and immunosuppressive effects. Adults with a malignancy who receive PRBC transfusion have increased rates of infection, tumor recurrence, and decreased survival. The effect of PRBC transfusion among children with solid tumors is unknown. METHODS We performed a retrospective review of all children who underwent operative resection of a solid tumor malignancy. Data collected included demographic information, location of operation, nadir hemoglobin, and any PRBC transfusion within 30 days of tumor resection. RESULTS Three hundred sixty children underwent tumor resection at our institution between 2002 and 2013; 194 (54%) received a perioperative blood transfusion. After adjusting for stage at diagnosis, tumor location, preoperative chemotherapy and nadir hemoglobin, blood transfusion was associated with a higher rate of postoperative infectious complications, shorter disease-free interval, and a higher rate of tumor recurrence. Each additional transfused unit increased the risk of postoperative infection (odds ratio 3.83; 95% confidence interval 1.21, 14.22, P =0.031). CONCLUSIONS Among children with solid tumor malignancies, PRBC transfusion within 30 days of operation is associated with higher rates of postoperative infection. If transfusion becomes necessary, single unit increments should be transfused. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Shannon N Acker
- Division of Pediatric Surgery, Children's Hospital Colorado
- The Surgical Oncology Program at Children's Hospital Colorado
| | - Margo M Nolan
- Division of Pediatric Surgery, Children's Hospital Colorado
| | | | - Bailey Lyttle
- Division of Pediatric Surgery, Children's Hospital Colorado
| | - Souha Fares
- Biostatistics and Informatics, Colorado School of Public Health, University of Colorado School of Medicine, Aurora
| | - Denis D Bensard
- Biostatistics and Informatics, Colorado School of Public Health, University of Colorado School of Medicine, Aurora
- Department of Surgery, Denver Health Medical Center, Denver, CO
| | - David A Partrick
- Division of Pediatric Surgery, Children's Hospital Colorado
- The Surgical Oncology Program at Children's Hospital Colorado
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Yin MW, Chen BH, Chen XJ, Zhang T, Jin J, Xu J. The characteristics of blood transfusion and analysis of preoperative factors associated with intraoperative blood transfusion in congenital heart surgery: a case-control study. J Cardiothorac Surg 2022; 17:337. [PMID: 36566199 PMCID: PMC9789642 DOI: 10.1186/s13019-022-02068-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 12/09/2022] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Blood transfusion is a common and life-saving procedure in congenital heart surgery (CHS), and it is critical for patients to identify risk factors prior to surgery. Our objective is to conduct an analysis of the preoperative factors that influence blood use during CHS and to offer guidance on preoperative blood preparation. METHODS A total of 1550 cases were retrospectively analyzed in our institution between May 2019 and June 2020. We determined whether to employ red blood cells (RBCs), platelets, and plasma as dependent variables; we treated the data from characteristics and laboratory tests as binary data, except for the Risk Adjustment for Congenital Heart Surgery (RACHS) methods as multinomial data, and finally taken into binary logistic regression analysis. RESULTS The total amounts of transfused RBCs, platelets, and plasma were 850.5 U (N = 713, 46%), 159 U (N = 21, 1.4%), and 1374.2 U (N = 953, 61.5%), respectively. Multivariate analysis found age (OR 0.142, 95% CI 0.099-0.203, P < 0.001), weight (0.170, 0.111-0.262, P < 0.001) RACHS method (RACHS2 vs. RACHS1, 3.444, 2.521-4.704, P < 0.001; RACHS3 vs. RACHS1, 9.333, 4.731-18.412, P < 0.001; RACHS4 vs. RACHS1, 31.327, 2.916-336.546, P = 0.004), and hemoglobin (0.524, 0.315-0.871, P = 0.013) to be independent risk predictors of RBC transfused volume; age (9.911, 1.008-97.417, P = 0.049), weight (0.029, 0.003-0.300, P = 0.029), RACHS method (RACHS3 vs. RACHS1, 13.001, 2.482-68.112, P = 0.002; RACHS4 vs. RACHS1, 59.748, 6.351-562.115, P < 0.001) to be platelets; and age (0.488, 0.352-0.676, P < 0.001), weight (0.252, 0.164-0.386, P < 0.001), RACHS method (RACHS2 vs. RACHS1, 2.931, 2.283-3.764, P < 0.001; RACHS3 vs. RACHS1, 10.754, 4.751-24.342, P < 0.001), APTT (1.628, 1.058-2.503, P = 0.027), and PT (2.174, 1.065-4.435, P = 0.033) to be plasma. CONCLUSION Although patients' age, weight, routine blood test, coagulation function, and protein levels should all be considered for preparing blood before CHS, the RACHS method is the most important factor influencing intraoperative blood transfused volume and should be considered first in clinical blood preparation.
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Affiliation(s)
- Ming-wei Yin
- grid.13402.340000 0004 1759 700XBlood Transfusion Department, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, No. 3333, Binsheng Rd, Binjiang District, Hangzhou, 310052 Zhejiang Province People’s Republic of China
| | - Bao-hai Chen
- grid.13402.340000 0004 1759 700XInformation Center, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, Zhejiang Province People’s Republic of China
| | - Xue-jun Chen
- grid.13402.340000 0004 1759 700XBlood Transfusion Department, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, No. 3333, Binsheng Rd, Binjiang District, Hangzhou, 310052 Zhejiang Province People’s Republic of China
| | - Tao Zhang
- grid.511341.30000 0004 1772 8591Blood Transfusion Department, Tai’an City Central Hospital, Taian, Shandong Province People’s Republic of China
| | - Jie Jin
- grid.13402.340000 0004 1759 700XCardiac Surgery, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, Zhejiang Province People’s Republic of China
| | - Jun Xu
- grid.13402.340000 0004 1759 700XBlood Transfusion Department, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, No. 3333, Binsheng Rd, Binjiang District, Hangzhou, 310052 Zhejiang Province People’s Republic of China
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Karimi M. A Surgeon's Perspective on Blood Conservation Practice in Pediatric Cardiac Surgery. World J Pediatr Congenit Heart Surg 2022; 13:782-787. [DOI: 10.1177/21501351221114846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Blood conservation practice in pediatric cardiac surgery has not been consistently adopted as quality improvement in many centers despite known risks associated with allogeneic blood products, shortage of donors, and costs. There are many blood conservation strategies available which collectively minimize exposure to allogeneic transfusion by maximizing the use of autologous red cells. These strategies are safe, reproducible, and have been implemented in clinical practice collectively with great efficacy for all patient ages and complexity levels. Institutional commitment to a set guideline will improve their blood conservation practice and quality outcome. The purpose of this article is to provide early career and practicing congenital cardiac surgeons with practical information concerning blood conservation strategies which can be considered for implementation in any pediatric cardiac surgery program, and which may be of particular value in resource-limited programs.
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Affiliation(s)
- Mohsen Karimi
- Department of Cardiothoracic Surgery, Stead Family Children’s Hospital, University of Iowa Healthcare, Iowa City, IA, USA
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Valentine SL, Cholette JM, Goobie SM. Transfusion Strategies for Hemostatic Blood Products in Critically Ill Children: A Narrative Review and Update on Expert Consensus Guidelines. Anesth Analg 2022; 135:545-557. [PMID: 35977364 DOI: 10.1213/ane.0000000000006149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Critically ill children commonly receive coagulant products (plasma and/or platelet transfusions) to prevent or treat hemorrhage or correct coagulopathy. Unique aspects of pediatric developmental physiology, and the complex pathophysiology of critical illness must be considered and balanced against known transfusion risks. Transfusion practices vary greatly within and across institutions, and high-quality evidence is needed to support transfusion decision-making. We present recent recommendations and expert consensus statements to direct clinicians in the decision to transfuse or not to transfuse hemostatic blood products, including plasma, platelets, cryoprecipitate, and recombinant products to critically ill children.
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Affiliation(s)
- Stacey L Valentine
- From the Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Jill M Cholette
- Department of Pediatrics, Divisions of Critical Care Medicine and Cardiology, University of Rochester Golisano Children's Hospital, Rochester, New York
| | - Susan M Goobie
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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Atasever AG, Eerens M, Van den Eynde R, Faraoni D, Rex S. Efficacy and safety of aprotinin in paediatric cardiac surgery: A systematic review and meta-analysis. Eur J Anaesthesiol 2022; 39:352-367. [PMID: 34783684 DOI: 10.1097/eja.0000000000001632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The relicensing of aprotinin in Europe and Canada has stimulated discussions on its usefulness in paediatric cardiac surgery. OBJECTIVE To systematically evaluate the available evidence on the efficacy and safety of aprotinin in paediatric cardiac surgery. DESIGN Systematic review of all randomised and observational studies comparing aprotinin with tranexamic acid, epsilon aminocaproic acid, placebo or no drug in paediatric cardiac surgery. Meta-analyses were performed on efficacy and safety outcomes. DATA SOURCES PubMed, Cochrane Central Register of Controlled Trials, Web of Science and Embase were searched from January 2000 to March 2021. ELIGIBILITY CRITERIA Studies that enrolled children under 18 years undergoing cardiac surgery with cardiopulmonary bypass. RESULTS Thirty-two studies enrolling a total of 63 894 paediatric cardiac procedures were included. Aprotinin significantly reduced total blood loss [mean difference -4.70 ml kg-1, 95% confidence interval (CI), -7.88 to -1.53; P = 0.004], postoperative transfusion requirements and the incidence of surgical re-exploration for bleeding [odds ratio (OR) 0.74, 95% CI, 0.56 to 0.97; P = 0.03]. Aprotinin had no effects on 30-day mortality (OR 1.02, 95% CI, 0.93 to 1.11; P = 0.73) and on other safety outcomes, except for the incidence of renal replacement therapy (RRT), which was significantly increased in patients given aprotinin (OR 1.29, 95% CI, 1.08 to 1.54; P = 0.006). Findings from observational and randomised controlled trials did not largely differ. A sub-group analysis in neonates showed that aprotinin significantly reduced packed red blood cell transfusions and the incidence of postoperative surgical re-exploration for bleeding and/or tamponade. When compared with lysine analogues, aprotinin was more effective at reducing bleeding and transfusion without increasing the risk of side effects. CONCLUSION This meta-analysis suggests that aprotinin is effective and well tolerated in paediatric cardiac surgery. Given the large heterogeneity of the results and the risk of selection bias in observational studies, large randomised controlled trials are warranted.
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Affiliation(s)
- Ayse Gulsah Atasever
- From the Department of Anaesthesiology, University Hospitals of the KU Leuven, Herestraat, Leuven, Belgium (AGA, ME, RVdE, SR). Arthur S. Keats Division of Paediatric Cardiovascular Anesthesia. Department of Anesthesiology, Peri-operative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, TX, USA (DF). And Department of Cardiovascular Sciences, KU Leuven, Herestraat, Leuven, Belgium (SR)
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Levy JH, Faraoni D, Almond CS, Baumann-Kreuziger L, Bembea MM, Connors JM, Dalton HJ, Davies R, Dumont LJ, Griselli M, Karkouti K, Massicotte MP, Teruya J, Thiagarajan RR, Spinella PC, Steiner ME. Consensus Statement: Hemostasis Trial Outcomes in Cardiac Surgery and Mechanical Support. Ann Thorac Surg 2022; 113:1026-1035. [PMID: 34826386 DOI: 10.1016/j.athoracsur.2021.09.080] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 08/08/2021] [Accepted: 09/27/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Research evaluating hemostatic agents for the treatment of clinically significant bleeding has been hampered by inconsistency and lack of standardized primary clinical trial outcomes. Clinical trials of hemostatic agents in both cardiac surgery and mechanical circulatory support, such as extracorporeal membrane oxygenation and ventricular assist devices, are examples of studies that lack implementation of universally accepted outcomes. METHODS A subgroup of experts convened by the National Heart, Lung, and Blood Institute and the US Department of Defense developed consensus recommendations for primary outcomes in cardiac surgery and mechanical circulatory support. RESULTS For cardiac surgery the primary efficacy endpoint of total allogeneic blood products (units vs mL/kg for pediatric patients) administered intraoperatively and postoperatively through day 5 or hospital discharge is recommended. For mechanical circulatory support outside the perioperative period the recommended primary outcome for extracorporeal membrane oxygenation is a 5-point ordinal score of thrombosis and bleeding severity adapted from the Common Terminology Criteria for Adverse Events version 5.0. The recommended primary endpoint for ventricular assist device is freedom from disabling stroke (Common Terminology Criteria for Adverse Events AE ≥ grade 3) through day 180. CONCLUSIONS The proposed composite risk scores could impact the design of upcoming clinical trials and enable comparability of future investigations. Harmonizing and disseminating global consensus definitions and management guidelines can also reduce patient heterogeneity that would confound standardized primary outcomes in future research.
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Affiliation(s)
- Jerrold H Levy
- Division Cardiothoracic Anesthesiology and Critical Care, Departments of Anesthesiology and Surgery (Cardiothoracic), Duke University School of Medicine, Durham, North Carolina.
| | - David Faraoni
- Division of Cardiac Anesthesia, Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Christopher S Almond
- Heart Failure Service, Cardiac Anticoagulation Service, Lucile Packard Children's Hospital Stanford, Stanford University School of Medicine, Palo Alto, California
| | | | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jean M Connors
- Hematology Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Heidi J Dalton
- INOVA Heart and Vascular Institute; Department of Pediatrics, INOVA Fairfax Medical Center, Falls Church, Virginia
| | - Ryan Davies
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center and Children's Health, Dallas, Texas
| | - Larry J Dumont
- Vitalant Research Institute, Denver, Colorado; Department of Pathology, University of Colorado Medical School, Denver, Colorado; Department of Pathology and Laboratory Medicine, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Massimo Griselli
- Division of Pediatric Cardiovascular Surgery, University of Minnesota, Minneapolis, Minnesota
| | - Keyvan Karkouti
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - M Patricia Massicotte
- Division of Cardiology, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Jun Teruya
- Division of Transfusion Medicine and Coagulation, Department of Pathology and Immunology, Pediatrics and Medicine, Texan Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Ravi R Thiagarajan
- Cardiac Intensive Care Unit, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Philip C Spinella
- Division of Critical Care, Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri
| | - Marie E Steiner
- Divisions of Hematology and Critical Care, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
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The Acute Effect of Packed Red Blood Cell Transfusion in Mechanically Ventilated Children after the Norwood Operation. Pediatr Cardiol 2022; 43:401-406. [PMID: 34546398 DOI: 10.1007/s00246-021-02735-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 09/10/2021] [Indexed: 10/20/2022]
Abstract
Packed red blood cell (PRBC) transfusions are commonly administered in pediatric patients following the Norwood operation. This study was conducted to determine the effect of PRBC transfusions on hemodynamic parameters in pediatric patients with single-ventricle physiology and parallel circulation. A single-center, retrospective chart review was conducted. Pediatric patients admitted to the cardiac intensive care unit after Norwood operation between 2017 and 2018 were identified. Hemodynamic parameters were collected within a four-hour period before and after a PRBC transfusion. Univariate analyses using paired t tests were conducted to compare blood gas values before and after PRBC transfusion. Next, multivariate regression analyses were conducted to model the impact of transfusion volume, change in hemoglobin levels, and change in FiO2 on the change in PaO2 and PaCO2. These analyses included data from 33 eligible patients who received a PRBC transfusion following a Norwood operation. The hemoglobin levels (p < 0.01) and the PaO2/FiO2 ratio (p = 0.04) were significantly increased, while arterial lactate levels (p = 0.03) were significantly decreased following the transfusion. Transfusion for a pre-transfusion hemoglobin of 12.4 g/dL appears to provide greatest reduction in lactate, used as a surrogate marker for systemic oxygen delivery. No significant changes were found in arterial pH, PaO2, and PaCO2. PRBC transfusions following the Norwood operation may be a useful intervention to increase systemic oxygen delivery, improving PaO2/FiO2 ratio and improving serum lactate. The benefits of PRBC transfusions must be weighed against previously identified risks on a patient-specific basis. Further studies are warranted to further delineate the effects of such transfusions in this population.
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No Difference in the Incidence of Complications in Pediatric Patients with Moderate Anemia 30 Days after Pediatric Hip Surgery with and without Blood Transfusion. CHILDREN 2022; 9:children9020161. [PMID: 35204882 PMCID: PMC8869937 DOI: 10.3390/children9020161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 01/13/2022] [Accepted: 01/19/2022] [Indexed: 01/28/2023]
Abstract
This study investigated the association between postoperative blood transfusion and the incidence of postoperative complications 30 days after pediatric hip surgery as well as factors significantly associated with 30-day postoperative complications. Patients were divided into two groups: those with postoperative complications and those with no complications. Postoperative hematocrit (Hct) was categorized as <25%, 25–30%, and >30%. Comparison was made between all postoperative complications at the 30-day follow-up that were influenced by anemia in patients who received transfusion and those who did not. A multivariate logistic regression model was used to identify factors independently associated with postoperative complications. The overall 30-day postoperative complication rate for all patients was 17% (24/138). No significant difference between the transfusion and the non-transfusion patients was found. Preoperative hematocrit (Hct) was significantly lower in the complications group (p = 0.030), and both length of stay and 30-day readmission were significantly higher in patients with complications (p = 0.011 and p < 0.001, respectively). Multivariate analysis revealed female gender (OR: 3.50, 95% CI: 1.18–10.36; p = 0.026) and length of hospital stay (OR: 1.23, 95% CI: 1.08–1.41; p = 0.004) to be factors independently associated with 30-day postoperative complications. However, no statistically significant difference in the incidence of complications at 30 days following pediatric hip dysplasia surgery was found between patients who received blood transfusion to maintain a Hct level ≥25% and those not receiving transfusion.
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15
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Cholette JM, Muszynski JA, Ibla JC, Emani S, Steiner ME, Vogel AM, Parker RI, Nellis ME, Bembea MM. Plasma and Platelet Transfusions Strategies in Neonates and Children Undergoing Cardiac Surgery With Cardiopulmonary Bypass or Neonates and Children Supported by Extracorporeal Membrane Oxygenation: From the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding. Pediatr Crit Care Med 2022; 23:e25-e36. [PMID: 34989703 PMCID: PMC8769357 DOI: 10.1097/pcc.0000000000002856] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To present the recommendations and consensus statements with supporting literature for plasma and platelet transfusions in critically ill neonates and children undergoing cardiac surgery with cardiopulmonary bypass or supported by extracorporeal membrane oxygenation from the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding. DESIGN Systematic review and consensus conference of international, multidisciplinary experts in platelet and plasma transfusion management of critically ill children. SETTING Not applicable. PATIENTS Critically ill neonates and children following cardiopulmonary bypass or supported by extracorporeal membrane oxygenation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A panel of nine experts developed evidence-based and, when evidence was insufficient, expert-based statements for plasma and platelet transfusions in critically ill neonates and children following cardiopulmonary bypass or supported by extracorporeal membrane oxygenation. These statements were reviewed and ratified by the 29 Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding experts. A systematic review was conducted using MEDLINE, EMBASE, and Cochrane Library databases, from inception to December 2020. Consensus was obtained using the Research and Development/University of California, Los Angeles Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. We developed one good practice statement, two recommendations, and three expert consensus statements. CONCLUSIONS Whereas viscoelastic testing and transfusion algorithms may be considered, in general, evidence informing indications for plasma and platelet transfusions in neonatal and pediatric patients undergoing cardiac surgery with cardiopulmonary bypass or those requiring extracorporeal membrane oxygenation support is lacking.
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Affiliation(s)
- Jill M Cholette
- Department of Pediatrics, University of Rochester Golisano Children's Hospital, Rochester, NY
| | - Jennifer A Muszynski
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Juan C Ibla
- Division of Cardiac Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Sitaram Emani
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA
| | - Marie E Steiner
- Divisions of Critical Care and Hematology, Department of Pediatrics, University of Minnesota Masonic Children's Hospital, Minneapolis, MN
| | - Adam M Vogel
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Robert I Parker
- Professor Emeritus, Department of Pediatrics, Hematology/Oncology, Renaissance School of Medicine, SUNY at Stony Brook, Stony Brook, NY
| | - Marianne E Nellis
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, NY Presbyterian Hospital - Weill Cornell Medicine, New York, NY
| | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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Abstract
ABSTRACT Disparities in access to care for surgical intervention in craniosynostosis have been suggested as a cause in discrepancies between the surgical approach and consequently perioperative outcomes following surgery. This work aimed to investigate the influence of race, insurance status, and the presence of craniosynostosis-related conditions on the short-term outcomes after the surgical management of craniosynostosis. Using the National Inpatient Sample database for the years 2010 to 2012, sociodemographic predictors for 30-day postoperative complication rates and requirements for blood transfusion in craniosynostosis surgeries were identified. Medicaid patients were significantly more likely to experience complications (P = 0.013) and higher rates of blood transfusions (P = 0.011). Compared to those without any complications, patients who experienced postoperative complications and blood transfusions were older (191.5 versus 181.7 days old, P < 0.001), had a greater number of chronic diseases (P < 0.001), and had a longer average length of stay (P < 0.001). On multivariable regression, Medicaid patients were 1.7 times more likely to experience any postoperative complication compared to privately insured patients. White patients also experienced a 0.741 times lower likelihood of requiring a blood transfusion. At the hospital level, receiving surgery at government-operated hospitals was found to be a protective factor for postoperative complications compared to for-profit private (P = 0.016) and nonprofit private (P = 0.028). Healthcare providers and policy makers should be cognizant of these sociodemographic disparities and their potential causes to ensure equitable treatment for all patients regardless of insurance status and racial/ethnic background.
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Efficacy and Safety of Antifibrinolytic Drugs in Pediatric Surgery: A Systematic Review. Semin Thromb Hemost 2021; 47:538-568. [PMID: 34192794 DOI: 10.1055/s-0040-1721736] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Antifibrinolytic drugs are used to reduce blood loss and subsequent transfusions during surgery and following trauma, but the optimal dosing regimen in the pediatric population is still unresolved. The aim of this systematic review was to evaluate efficacy and safety of antifibrinolytic drugs in pediatric surgery and trauma to determine the optimal dosing regimen. A literature search was performed in PubMed, Embase, Cochrane, and Web of Science on May 3, 2020. We included randomized controlled studies investigating the effect of tranexamic acid (TXA), aprotinin, and epsilon-aminocaproic acid, in terms of reducing blood loss, blood transfusions, reoperations, and rebleeds in pediatric patients aged 0 to 18 years undergoing cardiac surgery, noncardiac surgery, or trauma. Fifty randomized controlled trials (RCTs) were included; 28 RCTs investigated cardiac surgery and 22 investigated noncardiac surgery. No RCTs regarding trauma met the inclusion criteria. All antifibrinolytic drugs reduced postoperative blood loss and transfusions when used in pediatric surgery. The dosing regimen varied between studies, but similar effect sizes were found in terms of reduced blood loss regardless of the cumulative dose used. Few studies found adverse events, and no difference in incidence or type of adverse events was seen between the antifibrinolytic and the placebo group. In conclusion, use of antifibrinolytics is efficient and safe in children undergoing surgery. We propose TXA as the drug of choice based on its level of evidence and safety profile; we recommend a dosing regimen composed of a loading dose of 10 to 15 mg/kg prior to surgery followed by 1 to 5 mg/kg/h as continuous infusion throughout surgery.
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Wittenmeier E, Katharina A, Schmidtmann I, Griemert EV, Kriege M, König T, Nina P. Intraoperative transfusion practice in burned children in a university hospital over four years: a retrospective analysis. BMC Anesthesiol 2021; 21:118. [PMID: 33858338 PMCID: PMC8048155 DOI: 10.1186/s12871-021-01336-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 04/09/2021] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Patient blood management programs should be applied to the pediatric population, but little is known about the current transfusion practice of pediatric burn injury patients. This retrospective study was performed to evaluate the practice of red blood cell (RBC) transfusion in children with burn injury, their predictive factors, and adherence to the German transfusion guideline. METHODS We reviewed the RBC transfusion practice of all children younger than 8 years with burn injury who were operated during a four-year period in a German university medical center. We analyzed the data associated with transfusion and guideline conformity of transfusion triggers for RBCs from the beginning to the end of hospital stay using logistic regression. RESULTS During the four-year period, 138 children (median age 21 months, minimum-maximum 9-101 months) with burn injury needed surgery, 31 children were transfused with RBCs. During their hospital stay, the median hemoglobin concentrations (Hb) of transfused and non-transfused children were 8 g/dL (6.3-11.3 g/dL) and 10.7 (7-13.8 g/dL), respectively. Total body surface area burned (TBSA) (OR = 1.17 per % TBSA, 95% CI = [1.05; 1.30], p = 0.0056), length of surgery (OR = 1.016 per minute, 95% CI = [1.003; 1.028], p = 0.0150), and Hb (OR = 0.48 per 1 g/dl in Hb, 95% CI = [0.24; 0.95], p = 0.0343) were associated with transfusion while other factors (age, gender, ASA, and catecholamines) did not show notable association. Length of stay was mainly influenced by TSBA (+ 1.38 days per %, p < 0.0001), age (+ 0.21 days per month, p = 0.0206), and administering of catecholamines (+ 14.3 days, p = 0.0118), but not by RBC transfusion. The decision to transfuse was in 23% too restrictive and in 74% too liberal according to the German guidelines. CONCLUSIONS Amount of TBSA, length of surgery, and Hb influenced the RBC transfusion rate in burned children. However, age and length of stay were not affected by transfusion of RBCs. In clinical practice of burned children, physicians follow a more liberal transfusion strategy than the proposed in guidelines.
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Affiliation(s)
- Eva Wittenmeier
- Department of Anesthesiology, University Medical Centre of Johannes Gutenberg University, Langenbeckstraße 1, 55131, Mainz, Germany.
| | - Astor Katharina
- Department of Anesthesiology and Intensive Care, Catholic Clinical Centre, Mainz, Germany
| | - Irene Schmidtmann
- Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Centre of Johannes Gutenberg University, Mainz, Germany
| | - Eva-Verena Griemert
- Department of Anesthesiology, University Medical Centre of Johannes Gutenberg University, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Marc Kriege
- Department of Anesthesiology, University Medical Centre of Johannes Gutenberg University, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Tatjana König
- Department of Pediatric Surgery, University Medical Centre of Johannes Gutenberg University, Mainz, Germany
| | - Pirlich Nina
- Department of Anesthesiology, University Medical Centre of Johannes Gutenberg University, Langenbeckstraße 1, 55131, Mainz, Germany
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19
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Harris WM, Treggiari MM, LeBlanc A, Giacomuzzi C, You JJ, Muralidaran A, Shen I. Randomized Pilot Trial of Acute Normovolemic Hemodilution in Pediatric Cardiac Surgery Patients. World J Pediatr Congenit Heart Surg 2020; 11:452-458. [PMID: 32645767 DOI: 10.1177/2150135120923627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Due to the substantial improvement in survival among pediatric patients undergoing congenital heart surgery, reducing early and long-term morbidity is becoming the major focus of care. Blood transfusion is associated with worse postoperative outcomes after cardiac surgery. Acute normovolemic hemodilution (ANH) is a blood conservation strategy that aims to reduce allogenic blood transfusion during cardiac surgery. However, there are scant data regarding its efficacy for pediatric cardiac surgery patients. METHODS We designed a single-center, controlled, randomized, pilot trial in patients between 6 and 36 months old undergoing pediatric heart surgery. Patients were equally assigned to undergo ANH prior to initiation of cardiopulmonary bypass or to be managed per usual care. The primary end point was the amount of blood product transfused perioperatively. Secondary end points were markers of morbidity: postoperative bleeding, hematocrit, inotropic agents use, intensive care unit, and hospital stay. The analysis was by intention-to-treat. Estimates of differences between groups are presented with 95% CIs. RESULTS Twelve pediatric heart surgery patients were randomized to each group, ANH and usual care. Baseline characteristics were similar between groups. Acute normovolemic hemodilution implementation did not result in a reduction in the administration of blood product transfused (difference between ANH and usual care among patients transfused = -1.4 mL [-29.4 to 26.6], P = .92). Secondary end points were not different between groups. CONCLUSIONS In this small trial of pediatric cardiac surgery patients, ANH as a strategy to reduce blood component therapy was safe; however, the study failed to show a reduction in perioperative transfusion or other postoperative outcomes.
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Affiliation(s)
- Weronika M Harris
- Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Miriam M Treggiari
- Department of Anesthesiology and Perioperative Medicine, Oregon Health & Science University, Portland, OR, USA.,Department of Anesthesiology, Yale University, New Haven, CT, USA
| | - Ashleigh LeBlanc
- Department of Pediatric Perfusion and ECMO Services, Oregon Health & Science University, Portland, OR, USA
| | - Carmen Giacomuzzi
- Department of Pediatric Perfusion and ECMO Services, Oregon Health & Science University, Portland, OR, USA
| | - Jayme J You
- Department of Pediatric Perfusion and ECMO Services, Oregon Health & Science University, Portland, OR, USA
| | - Ashok Muralidaran
- Department of Cardiothoracic Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Irving Shen
- Department of Cardiothoracic Surgery, Oregon Health & Science University, Portland, OR, USA
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Bianchi P, Beccaris C, Norbert M, Dunlop B, Ranucci M. Use of Coagulation Point-of-Care Tests in the Management of Anticoagulation and Bleeding in Pediatric Cardiac Surgery: A Systematic Review. Anesth Analg 2020; 130:1594-1604. [PMID: 32224832 DOI: 10.1213/ane.0000000000004563] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Bleeding and coagulation management are essential aspects in the management of neonates and children undergoing cardiac surgery. The use of point-of-care tests (POCTs) in a pediatric setting is not as widely used as in the adult setting. This systematic review aims to summarize the evidence showed by the literature regarding the use of POCTs in children undergoing cardiac surgery. We included all studies examining the pediatric population (<18 years old) undergoing cardiac surgery in which the coagulation profile was assessed with POCTs. Three electronic databases (PubMed, Embase, and the Cochrane Controlled Clinical Trials register) were searched. Tests involved were heparin effect tests, viscoelastic tests, and platelet function tests. Due to the wide heterogeneity of the patients and tests studied, a formal meta-analysis was impossible, and the results are therefore presented through a systematic review. Eighty articles were found, of which 47 are presented in this review. At present, literature data are too weak to define POCTs as a "gold standard" for the treatment of perioperative bleeding in pediatric cardiac surgery. Nevertheless, introduction of POCTs into postoperative algorithms has shown to improve bleeding management, patient outcome, and cost efficiency.
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Affiliation(s)
- Paolo Bianchi
- From the Department of Anesthesia and Intensive Care, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
| | - Camilla Beccaris
- Great Ormond Street Hospital NHS Foundation Trust, Cardiac Intensive Care Unit, London, United Kingdom
| | | | | | - Marco Ranucci
- Department of Cardiothoracic, Vascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, Milan, Italy
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21
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Kato H, Chasovskyi K, Gandhi SK. Are Blood Products Routinely Required in Pediatric Heart Surgery? Pediatr Cardiol 2020; 41:932-938. [PMID: 32170329 DOI: 10.1007/s00246-020-02338-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 03/05/2020] [Indexed: 11/24/2022]
Abstract
A restrictive blood transfusion strategy has emerged in adult cardiac surgery. However, the feasibility in children is poorly investigated. 352 consecutive patients undergoing open-heart surgery were retrospectively reviewed, excluding patients requiring extracorporeal membrane oxygenation. Patient demographics, perioperative blood product usage, and clinical outcome parameters were investigated. Variables predicting the need for blood products were delineated. Of the 352 study patients, 148 patients (42%) underwent bloodless surgery and 204 (58%) were transfused. Of the 204 transfused patients, 170 (83.4%) patients received one blood transfusion and 34 (16.6%) received two or more blood transfusions. Patient's weight and preoperative hematocrit (Hct) were statistically significant in predicting the need for blood priming the CPB circuit (AUC 0.99, p < 0.001, sensitivity 96.6%, specificity 95.2%). A body weight of 8.5 kg carried a sensitivity of 100% and specificity of 94.5% (p < 0.001) for a blood prime. Among patients with a weight less than 8.5 kg (n = 171), only 27 patients (15.8%, p < 0.001) required additional transfusion of PRBCs. Factors impacting the need for a blood transfusion during CPB included redo surgery [odds ratio (OR) 4.61, p = 0.001] and the highest lactate level on CPB (OR 1.65, p = 0.006). Redo surgery had the highest impact (OR 7.27, p = 0.012) for requiring a postoperative PRBC transfusion. A restrictive transfusion strategy can be safely implemented in pediatric cardiac surgery. The majority of children with a BW > 8.5 kg required no blood products and those with a BW ≤ 8.5 kg required only 1 unit of blood, to prime the cardiopulmonary bypass circuit.
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Affiliation(s)
- Hideyuki Kato
- Division of Cardiovascular and Thoracic Surgery, BC Children's Hospital, 4480 Oak Street, Vancouver, BC, Canada
| | - Kyrylo Chasovskyi
- Division of Cardiovascular and Thoracic Surgery, BC Children's Hospital, 4480 Oak Street, Vancouver, BC, Canada. .,Division of Cardiovascular and Thoracic Surgery, Perfusion Services, BC Children's Hospital, 4480 Oak Street, Suite AB307, Vancouver, BC, V6H 3V4, Canada.
| | - Sanjiv K Gandhi
- Division of Cardiovascular and Thoracic Surgery, BC Children's Hospital, 4480 Oak Street, Vancouver, BC, Canada
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22
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Sisti DJ, Williams GD, Ding V, Long J, Maeda K, Chen S, Navaratnam M. The use of prothrombin complex concentrate as a warfarin reversal agent in pediatric patients undergoing orthotopic heart transplantation. Paediatr Anaesth 2020; 30:564-570. [PMID: 32037665 DOI: 10.1111/pan.13839] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 02/04/2020] [Accepted: 02/06/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Patients supported with a ventricular assist device are predisposed to severe bleeding at the time of orthotopic heart transplant due to several risk factors including anticoagulation with vitamin K antagonists. Kcentra, a four-factor prothrombin complex concentrate, has been approved by the FDA for warfarin reversal in adults prior to urgent surgery. There is a lack of published data on the preoperative use of four-factor prothrombin complex concentrates in pediatric patients undergoing cardiacsurgery. METHODS This is a single-center retrospective analysis of pediatric patients with a continuous-flow ventricular assist device who underwent heart transplant, comparing patients who received Kcentra for anticoagulation reversal with a historical patient cohort who did not. Consecutive patients from January 2013 to December 2017 were analyzed. The primary outcome was volume of blood product transfusion prior to cardiopulmonary bypass initiation. Secondary outcomes include blood product transfusion after cardiopulmonary bypass intraoperatively and up to 24 hours postoperatively, chest tube output within 24 hours of surgery, time to extubation, incidence of thromboembolism, and post-transplant length ofstay. RESULTS From 2013 to 2017, 31 patients with continuous-flow ventricular assist devices underwent heart transplant, with 27 patients included in the analysis. Fifteen patients received Kcentra compared with 12 patients who received fresh-frozen plasma for anticoagulation reversal. Compared with the control group, patients who received Kcentra had less packed red blood cells, fresh-frozen plasma, and platelets transfused prior to cardiopulmonary bypass initiation. The Kcentra group also received less packed red blood cells on bypass and less packed red blood cells after cardiopulmonary bypass termination. There were no differences in chest tube output, time to extubation, intensive care unit length of stay, or overall hospital length of stay. Neither group had thromboembolic complications detected during the first seven postoperative days. CONCLUSION This small retrospective study indicates that preoperative warfarin reversal with Kcentra reduces blood product exposure in pediatric patients with ventricular assist devices undergoing heart transplant.
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Affiliation(s)
- Daniel J Sisti
- Department of Anesthesiology, UCSF Benioff Children's Hospital Oakland, Oakland, CA, USA
| | - Glyn D Williams
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford Children's Health, Palo Alto, CA, USA
| | - Victoria Ding
- Quantitative Sciences Unit, Stanford School of Medicine, Palo Alto, CA, USA
| | - Jin Long
- Quantitative Sciences Unit, Stanford School of Medicine, Palo Alto, CA, USA
| | - Katsuhide Maeda
- Department of Cardiothoracic Surgery, Pediatric Cardiac Surgery Stanford Children's Health, Palo Alto, CA, USA
| | - Sharon Chen
- Department of Pediatrics, Cardiology, Stanford Children's Health, Palo Alto, CA, USA
| | - Manchula Navaratnam
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford Children's Health, Palo Alto, CA, USA
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Premont RT, Reynolds JD, Zhang R, Stamler JS. Role of Nitric Oxide Carried by Hemoglobin in Cardiovascular Physiology: Developments on a Three-Gas Respiratory Cycle. Circ Res 2019; 126:129-158. [PMID: 31590598 DOI: 10.1161/circresaha.119.315626] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
A continuous supply of oxygen is essential for the survival of multicellular organisms. The understanding of how this supply is regulated in the microvasculature has evolved from viewing erythrocytes (red blood cells [RBCs]) as passive carriers of oxygen to recognizing the complex interplay between Hb (hemoglobin) and oxygen, carbon dioxide, and nitric oxide-the three-gas respiratory cycle-that insures adequate oxygen and nutrient delivery to meet local metabolic demand. In this context, it is blood flow and not blood oxygen content that is the main driver of tissue oxygenation by RBCs. Herein, we review the lines of experimentation that led to this understanding of RBC function; from the foundational understanding of allosteric regulation of oxygen binding in Hb in the stereochemical model of Perutz, to blood flow autoregulation (hypoxic vasodilation governing oxygen delivery) observed by Guyton, to current understanding that centers on S-nitrosylation of Hb (ie, S-nitrosohemoglobin; SNO-Hb) as a purveyor of oxygen-dependent vasodilatory activity. Notably, hypoxic vasodilation is recapitulated by native S-nitrosothiol (SNO)-replete RBCs and by SNO-Hb itself, whereby SNO is released from Hb and RBCs during deoxygenation, in proportion to the degree of Hb deoxygenation, to regulate vessels directly. In addition, we discuss how dysregulation of this system through genetic mutation in Hb or through disease is a common factor in oxygenation pathologies resulting from microcirculatory impairment, including sickle cell disease, ischemic heart disease, and heart failure. We then conclude by identifying potential therapeutic interventions to correct deficits in RBC-mediated vasodilation to improve oxygen delivery-steps toward effective microvasculature-targeted therapies. To the extent that diseases of the heart, lungs, and blood are associated with impaired tissue oxygenation, the development of new therapies based on the three-gas respiratory system have the potential to improve the well-being of millions of patients.
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Affiliation(s)
- Richard T Premont
- From the Institute for Transformative Molecular Medicine (R.T.P., J.D.R., R.Z., J.S.S.), Case Western Reserve University School of Medicine, OH.,Harrington Discovery Institute (R.T.P., J.D.R., J.S.S.), University Hospitals Cleveland Medical Center, OH
| | - James D Reynolds
- From the Institute for Transformative Molecular Medicine (R.T.P., J.D.R., R.Z., J.S.S.), Case Western Reserve University School of Medicine, OH.,Department of Anesthesiology and Perioperative Medicine (J.D.R.), Case Western Reserve University School of Medicine, OH.,Harrington Discovery Institute (R.T.P., J.D.R., J.S.S.), University Hospitals Cleveland Medical Center, OH
| | - Rongli Zhang
- From the Institute for Transformative Molecular Medicine (R.T.P., J.D.R., R.Z., J.S.S.), Case Western Reserve University School of Medicine, OH.,Department of Medicine, Cardiovascular Research Institute (R.Z., J.S.S.), Case Western Reserve University School of Medicine, OH
| | - Jonathan S Stamler
- From the Institute for Transformative Molecular Medicine (R.T.P., J.D.R., R.Z., J.S.S.), Case Western Reserve University School of Medicine, OH.,Department of Medicine, Cardiovascular Research Institute (R.Z., J.S.S.), Case Western Reserve University School of Medicine, OH.,Harrington Discovery Institute (R.T.P., J.D.R., J.S.S.), University Hospitals Cleveland Medical Center, OH
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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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Fulkerson DH, Weyhenmeyer J, Archer JB, Shaikh KA, Walsh M. Thromboelastography-Guided Therapy of Hemorrhagic Complications after Craniopharyngioma Resection: Case-Based Update. Pediatr Neurosurg 2019; 54:293-300. [PMID: 31390646 DOI: 10.1159/000501117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 05/05/2019] [Indexed: 11/19/2022]
Abstract
PURPOSE Thromboelastography (TEG) is a point-of-care test that evaluates the entire hemostatic process. The use of TEG is expanding in multiple pediatric surgical disciplines. However, there is very little literature regarding its application in pediatric neurosurgical patients. METHODS The authors provide a case-based update and literature review regarding potential applications of TEG to pediatric neurosurgical patients. RESULTS The authors describe a 12-year-old female who experienced a number of complications after a craniopharyngioma resection. The patient suffered multiple new intraventricular hemorrhages with removal of external ventricular drains. Standard coagulopathy tests did not reveal any abnormalities. However, an abnormal TEG value suggested primary hyperfibrinolysis, which led to a change in medical management. The patient did not suffer any further bleeding episodes after the change in treatment. CONCLUSIONS The authors discuss a case where TEG influenced patient management and identified a problem despite normal values of standard laboratory tests. Neurosurgeons should be aware of the potential benefits for TEG testing in pediatric patients.
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Affiliation(s)
- Daniel H Fulkerson
- Beacon Children's Hospital, North Central Neurosurgery, Beacon Medical Group, South Bend, Indiana, USA,
| | - Jonathan Weyhenmeyer
- Department of Neurosurgery, Indiana University School of Medicine, Goodman Campbell Brain and Spine, Indianapolis, Indiana, USA
| | - Jacob B Archer
- Department of Neurosurgery, Indiana University School of Medicine, Goodman Campbell Brain and Spine, Indianapolis, Indiana, USA
| | - Kashif A Shaikh
- Beacon Children's Hospital, North Central Neurosurgery, Beacon Medical Group, South Bend, Indiana, USA
| | - Mark Walsh
- South Bend Memorial Hospital, South Bend, Indiana, USA
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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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Recommendations on RBC Transfusions in Critically Ill Children With Acute Respiratory Failure From the Pediatric Critical Care Transfusion and Anemia Expertise Initiative. Pediatr Crit Care Med 2018; 19:S114-S120. [PMID: 30161065 PMCID: PMC6126368 DOI: 10.1097/pcc.0000000000001619] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To present the recommendations and supporting literature for RBC transfusions in critically ill children with bleeding developed by the Pediatric Critical Care Transfusion and Anemia Expertise Initiative. DESIGN Consensus conference series of international, multidisciplinary experts in RBC transfusion management of critically ill children. METHODS The panel of 38 experts developed evidence-based and, when evidence was lacking, expert-based clinical recommendations as well as research priorities for RBC transfusions in critically ill children. The respiratory subgroup included six 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 Transfusion and Anemia Expertise Initiative experts developed seven recommendations focused on children with acute respiratory failure. All recommendations reached agreement (> 80%). Transfusion of RBCs in children with respiratory failure with an hemoglobin level less than 5 g/dL was strongly recommended. It was strongly recommended that RBCs not be systematically administered to children with respiratory failure who are hemodynamically stable and who have a hemoglobin level greater than or equal to 7 g/dL. Experts could not make a recommendation for children with hemodynamic instability, with severe hypoxemia and/or with an hemoglobin level between 5 and 7 g/dL. Specific RBC transfusion strategies using physiologic-based metrics and biomarkers could not be elaborated. CONCLUSIONS The Transfusion and Anemia Expertise Initiative Consensus Conference developed specific recommendations regarding RBC transfusion management in critically ill children with respiratory failure, as well as recommendations to guide future research. Clinical recommendations emphasize relevant hemoglobin thresholds. Research recommendations emphasize the need to identify appropriate physiologic thresholds, suggest a better understanding of alternatives to RBC transfusion, and identify the need for better evidence on hemoglobin thresholds that might be used in specific subpopulations of critically ill children.
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Crescini WM, Muralidaran A, Shen I, LeBlanc A, You J, Giacomuzzi C, Treggiari MM. The use of acute normovolemic hemodilution in paediatric cardiac surgery. Acta Anaesthesiol Scand 2018; 62:756-764. [PMID: 29504128 DOI: 10.1111/aas.13095] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 12/06/2017] [Accepted: 02/04/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Acute normovolemic hemodilution (ANH) is considered safe and effective in decreasing perioperative transfusion in paediatric populations undergoing high blood-loss surgeries. We determined the association between ANH and the intraoperative use of allogeneic blood products in paediatric cardiac surgery patients. METHODS This is a single-centre retrospective cohort study including paediatric patients between 0 and 36 months of age undergoing surgical repair or palliation of their cardiac defect with the use of cardiopulmonary bypass between November 2013 and November 2014. Our primary endpoint was the volume per kilogram of body weight of any blood product administered. Secondary endpoints were postoperative bleeding, coagulation profile, creatinine, vasoactive support, duration of mechanical ventilation, and hospital stay. RESULTS In all, 50 patients met eligibility criteria and were included. Of those, seven were exposed to ANH and while 43 patients were treated according to usual care. Baseline characteristics were similar in both groups. After adjustment for baseline characteristics including age, American Society of Anaesthesiologists (ASA) classification, and Risk Adjusted Congenital Heart Surgery score, ANH was associated with reduced administration of allogenic blood products, with the mean difference between groups of 57.5 ml/kg (95% CI: 34.8, 80.2). The ANH group had lower blood losses at 6 and 24 h postoperatively. There were no differences in the duration of ICU or hospital stay. CONCLUSION We found a reduction in the administration of blood products and lower postoperative blood losses associated with the use of ANH in paediatric cardiac surgery patients. The data suggest that ANH might be beneficial in reducing perioperative morbidity in this patient population.
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Affiliation(s)
- W. M. Crescini
- Department of Anesthesiology and Perioperative Medicine; Oregon Health & Science University; Portland OR USA
| | - A. Muralidaran
- Department of Surgery; Division of Cardiothoracic Surgery; Oregon Health & Science University; Portland OR USA
| | - I. Shen
- Department of Surgery; Division of Cardiothoracic Surgery; Oregon Health & Science University; Portland OR USA
| | - A. LeBlanc
- Department of Pediatric Perfusion and ECMO Services; Oregon Health & Science University; Portland OR USA
| | - J. You
- Department of Pediatric Perfusion and ECMO Services; Oregon Health & Science University; Portland OR USA
| | - C. Giacomuzzi
- Department of Pediatric Perfusion and ECMO Services; Oregon Health & Science University; Portland OR USA
| | - M. M. Treggiari
- Department of Anesthesiology and Perioperative Medicine; Oregon Health & Science University; Portland OR USA
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Abstract
Red cell transfusions are amongst the most common therapeutic procedures in seriously ill children, particularly in the inpatient setting. This is despite the fact that there is no evidence base for most clinical settings, with the exception of patients with hemoglobinopathies, particularly thalassemia and sickle cell anemia. Obviously exsanguinating hemorrhage and life threatening anemia are urgent indications for which no other therapeutic approach is currently available. Most transfusions are, however, given prophylactically to prevent the complications of hypoxia or hemodynamic stability, based upon expert opinion and a faith in the oxygen carrying capacity and beneficial hemodynamic properties of transfused red cells. The question confronting current day pediatric practice is to what extent transfused red cells prevent adverse events, other than in thalassemia and sickle cell anemia, as opposed to causing them. Do transfusions of red cells prevent organ failure, stroke, etc. or not? There is epidemiologic evidence in the adult randomized trial literature that liberal red cell transfusion likely causes more such adverse events than it prevents. The relevance of such studies to children, particularly neonates, is uncertain. Randomized trials in critically ill neonates have yielded little to no evidence that liberal red cell transfusion is beneficial, but the data are not definitive. In critically ill older children the data suggest there is no benefit to liberal red cell transfusion, but the indications for red cell transfusion are uncertain. Most practitioners would agree that combining laboratory data such hemoglobin/hematocrit with clinical indications for transfusions (evidence of end organ hypoxia such as tachycardia, shortness of breath, etc.) is the only viable strategy at present, until more definitive randomized trial data are available.
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Wittenmeier E, Troeber C, Zier U, Schmidtmann I, Pirlich N, Becke K, Piepho T. Red blood cell transfusion in perioperative pediatric anesthesia: a survey of current practice in Germany. Transfusion 2018; 58:1597-1605. [DOI: 10.1111/trf.14581] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 01/19/2018] [Accepted: 02/06/2018] [Indexed: 12/23/2022]
Affiliation(s)
| | | | - Ulrike Zier
- Institute of Occupational, Social and Environmental HealthMainz Germany
| | - Irene Schmidtmann
- Institute of Medical Biostatistics, Epidemiology and InformaticsMedical Centre of the Johannes Gutenberg‐UniversityMainz Germany
| | | | - Karin Becke
- Cnopf Childrens Hospital/Hospital HallerwieseNürnberg Germany
| | - Tim Piepho
- Krankenhaus der Barmherzigen Brüder Trier, Department of Anesthesiology and Intensive CareBrothers of Mercy HospitalTrier Germany
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Boettcher W, Redlin M, Dehmel F, Graefe K, Cho MY, Habazettl H, Kukucka M. Asanguineous priming of miniaturized paediatric cardiopulmonary bypass circuits for congenital heart surgery: independent predictors associated with transfusion requirements and effects on postoperative morbidity. Eur J Cardiothorac Surg 2018; 53:1075-1081. [DOI: 10.1093/ejcts/ezx479] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 11/28/2017] [Indexed: 11/14/2022] Open
Affiliation(s)
- Wolfgang Boettcher
- Department of Congenital and Pediatric Heart Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Matthias Redlin
- Department of Anesthesiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Frank Dehmel
- Department of Congenital and Pediatric Heart Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Katharina Graefe
- Department of Anesthesiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Mi-Young Cho
- Department of Congenital and Pediatric Heart Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Helmut Habazettl
- Department of Anesthesiology, Deutsches Herzzentrum Berlin, Berlin, Germany
- Institute of Physiology, Charité—Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Marian Kukucka
- Department of Anesthesiology, Deutsches Herzzentrum Berlin, Berlin, Germany
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Siemens K, Sangaran DP, Hunt BJ, Murdoch IA, Tibby SM. Strategies for Prevention and Management of Bleeding Following Pediatric Cardiac Surgery on Cardiopulmonary Bypass: A Scoping Review. Pediatr Crit Care Med 2018; 19:40-47. [PMID: 29189637 DOI: 10.1097/pcc.0000000000001387] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE We aimed to systematically describe, via a scoping review, the literature reporting strategies for prevention and management of mediastinal bleeding post pediatric cardiopulmonary bypass surgery. DATA SOURCES MEDLINE, EMBASE, PubMed, and Cochrane CENTRAL Register. STUDY SELECTION Two authors independently screened publications from 1980 to 2016 reporting the effect of therapeutic interventions on bleeding-related postoperative outcomes, including mediastinal drain loss, transfusion, chest re-exploration rate, and coagulation variables. Inclusions: less than 18 years, cardiac surgery on cardiopulmonary bypass. DATA EXTRACTION Data from eligible studies were extracted using a standard data collection sheet. DATA SYNTHESIS Overall, 299 of 7,434 screened articles were included, with observational studies being almost twice as common (n = 187, 63%) than controlled trials (n = 112, 38%). The most frequently evaluated interventions were antifibrinolytic drugs (75 studies, 25%), blood products (59 studies, 20%), point-of-care testing (47 studies, 16%), and cardiopulmonary bypass circuit modifications (46 studies, 15%). The publication rate for controlled trials remained constant over time (4-6/yr); however, trials were small (median participants, 51; interquartile range, 57) and overwhelmingly single center (98%). Controlled trials originated from 22 countries, with the United States, India, and Germany accounting for 50%. The commonest outcomes were mediastinal blood loss and transfusion requirements; however, these were defined inconsistently (blood loss being reported over nine different time periods). The majority of trials were aimed at bleeding prevention (98%) rather than treatment (10%), nine studies assessed both. CONCLUSIONS Overall, this review demonstrates small trial sizes, low level of evidence, and marked heterogeneity of reported endpoints in the included studies. The need for more, higher quality studies reporting clinically relevant, comparable outcomes is highlighted. Emerging fields such as the use of coagulation factor concentrates, goal-directed guidelines, and anti-inflammatory therapies appear to be of particular interest. This scoping review can potentially guide future trial design and form the basis for therapy-specific systematic reviews.
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Affiliation(s)
- Kristina Siemens
- PICU, Evelina London Children's Hospital, St Thomas' Hospital, Westminster Bridge Road, London, United Kingdom
| | - Dilanee P Sangaran
- PICU, Evelina London Children's Hospital, St Thomas' Hospital, Westminster Bridge Road, London, United Kingdom
| | - Beverley J Hunt
- Department of Haematology, St Thomas' Hospital, London, United Kingdom
| | - Ian A Murdoch
- PICU, Evelina London Children's Hospital, St Thomas' Hospital, Westminster Bridge Road, London, United Kingdom
| | - Shane M Tibby
- PICU, Evelina London Children's Hospital, St Thomas' Hospital, Westminster Bridge Road, London, United Kingdom
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Redlin M, Boettcher W, Dehmel F, Cho MY, Kukucka M, Habazettl H. Accuracy of predicted haemoglobin concentration on cardiopulmonary bypass in paediatric cardiac surgery: effect of different formulae for estimating patient blood volume. Perfusion 2017; 32:639-644. [DOI: 10.1177/0267659117714861] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction: When applying a blood-conserving approach in paediatric cardiac surgery with the aim of reducing the transfusion of homologous blood products, the decision to use blood or blood-free priming of the cardiopulmonary bypass (CPB) circuit is often based on the predicted haemoglobin concentration (Hb) as derived from the pre-CPB Hb, the prime volume and the estimated blood volume. We assessed the accuracy of this approach and whether it may be improved by using more sophisticated methods of estimating the blood volume. Patients and Methods: Data from 522 paediatric cardiac surgery patients treated with CPB with blood-free priming in a 2-year period from May 2013 to May 2015 were collected. Inclusion criteria were body weight <15 kg and available Hb data immediately prior to and after the onset of CPB. The Hb on CPB was predicted according to Fick’s principle from the pre-CPB Hb, the prime volume and the patient blood volume. Linear regression analyses and Bland-Altman plots were used to assess the accuracy of the Hb prediction. Different methods to estimate the blood volume were assessed and compared. Results: The initial Hb on CPB correlated well with the predicted Hb (R2=0.87, p<0.001). A Bland-Altman plot revealed little bias at 0.07 g/dL and an area of agreement from -1.35 to 1.48 g/dL. More sophisticated methods of estimating blood volume from lean body mass did not improve the Hb prediction, but rather increased bias. Conclusion: Hb prediction is reasonably accurate, with the best result obtained with the simplest method of estimating the blood volume at 80 mL/kg body weight. When deciding for or against blood-free priming, caution is necessary when the predicted Hb lies in a range of ± 2 g/dL around the transfusion trigger.
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Affiliation(s)
- Matthias Redlin
- Department of Anesthesiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Wolfgang Boettcher
- Department of Congenital and Pediatric Heart Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Frank Dehmel
- Department of Congenital and Pediatric Heart Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Mi-Young Cho
- Department of Congenital and Pediatric Heart Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Marian Kukucka
- Department of Anesthesiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Helmut Habazettl
- Department of Anesthesiology, Deutsches Herzzentrum Berlin, Berlin, Germany
- Institute of Physiology, Charité, University Medicine Berlin, Berlin, Germany
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Huebner M, Wolkewitz M, Enriquez-Sarano M, Schumacher M. Competing risks need to be considered in survival analysis models for cardiovascular outcomes. J Thorac Cardiovasc Surg 2017; 153:1427-1431. [DOI: 10.1016/j.jtcvs.2016.12.039] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 12/19/2016] [Accepted: 12/22/2016] [Indexed: 10/20/2022]
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Karimi M, Sullivan JM, Linthicum C, Mathew A. Blood conservation pediatric cardiac surgery in all ages and complexity levels. World J Cardiol 2017; 9:332-338. [PMID: 28515851 PMCID: PMC5411967 DOI: 10.4330/wjc.v9.i4.332] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 12/21/2016] [Accepted: 01/14/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To demonstrate the feasibility of blood conservation methods and practice across all ages and risk categories in congenital cardiac surgery.
METHODS We retrospectively analyzed a collected database of 356 patients who underwent cardiac surgery using cardiopulmonary bypass (CPB) from 2010-2015. The patients were grouped into blood conservation (n = 138) and non-conservation (n = 218) groups and sub-grouped based on their ages and procedural complexity scores.
RESULTS There were no statistical differences in gender, weight, pre-operative and pre-CPB hematocrit levels in both groups. Despite equivalent hematocrit levels during and after CPB for both groups, there was significantly less operative homologous blood utilized in blood conservation group across all ages and complexity levels.
CONCLUSION Blood conservation surgery can be performed in congenital patients needing cardiac surgery in all age groups and complexity categories. The above findings in addition to attendant risks and side effects of blood transfusion and the rising cost of safer blood products justify blood conservation in congenital cardiac surgery.
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Karimi M, Sullivan JM, Lerer T, Hronek C. National trends and variability in blood utilization in paediatric cardiac surgery. Interact Cardiovasc Thorac Surg 2017; 24:938-943. [DOI: 10.1093/icvts/ivw439] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 11/17/2016] [Indexed: 12/12/2022] Open
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Choi ES, Cho S, Jang WS, Kim WH. Cardiopulmonary Bypass Priming Using Autologous Cord Blood in Neonatal Congenital Cardiac Surgery. Korean Circ J 2016; 46:714-718. [PMID: 27721864 PMCID: PMC5054185 DOI: 10.4070/kcj.2016.46.5.714] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 02/12/2016] [Accepted: 03/08/2016] [Indexed: 12/05/2022] Open
Abstract
Background and Objectives A blood transfusion is almost inevitable in neonatal cardiac surgery. This study aimed to assess the feasibility of using autologous cord blood for a cardiopulmonary bypass (CPB) priming as an alternative to an allo-transfusion in neonatal cardiac surgery. Subjects and Methods From January 2012 to December 2014, cord blood had been collected during delivery after informed consent and was stored immediately into a blood bank. Eight neonatal patients had their own cord blood used for CPB priming during cardiac surgery. Results All patients underwent surgery for their complex congenital heart disease. The median age and body weight at surgery was 11 days (from 0 to 21 days) and 3.2 kg (from 2.2 to 3.7 kg). The median amount and hematocrit of collected cord blood was 72.5 mL (from 43 to 105 mL) and 48.7% (from 32.0 to 51.2%). The median preoperative hematocrit of neonates was 36.5% (from 31.0 to 45.0%); the median volume of CPB priming was 130 mL (From 120 to 140 mL). Seven out of eight patients did not need an allo-transfusion in CPB priming and only one neonate used 20 mL of packed red blood cells in CPB priming to obtain the target hematocrit. Conclusion Autologous cord blood can be used for CPB priming as alternative to packed red blood cells in neonatal congenital cardiac surgery in order to reduce allo-transfusion.
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Affiliation(s)
- Eun Seok Choi
- Department of Thoracic and Cardiovascular Surgery, Sejong General Hospital, Bucheon, Korea
| | - Sungkyu Cho
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Woo Sung Jang
- Department of Thoracic and Cardiovascular Surgery, Kyungpook National University Hospital, Kyungpook National University College of Medicine, Daegu, Korea
| | - Woong-Han Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Children's Hospital, Seoul National University College of Medicine, Seoul, Korea
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DiNardo JA, Faraoni D. Red Blood Cell Transfusion and Massive Bleeding in Children Undergoing Heart Transplant. Anesth Analg 2016; 122:1245-6. [PMID: 27101483 DOI: 10.1213/ane.0000000000001235] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- James A DiNardo
- From the Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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Intraoperative Red Blood Cell Transfusion in Infant Heart Transplant Patients Is Not Associated with Worsened Outcomes. Anesth Analg 2016; 122:1567-77. [DOI: 10.1213/ane.0000000000001241] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Exploring the Role of Polycythemia in Patients With Cyanosis After Palliative Congenital Heart Surgery. Pediatr Crit Care Med 2016; 17:216-22. [PMID: 26825044 DOI: 10.1097/pcc.0000000000000654] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES To understand the relationship between polycythemia and clinical outcome in patients with hypoplastic left heart syndrome following the Norwood operation. DESIGN A retrospective, single-center cohort study. SETTING Pediatric cardiovascular ICU, university-affiliated children's hospital. PATIENTS Infants with hypoplastic left heart syndrome admitted to our medical center from September 2009 to December 2012 undergoing stage 1/Norwood operation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Baseline demographic and clinical information including first recorded postoperative hematocrit and subsequent mean, median, and nadir hematocrits during the first 72 hours postoperatively were recorded. The primary outcomes were in-hospital mortality and length of hospitalization. Thirty-two patients were included in the analysis. Patients did not differ by operative factors (cardiopulmonary bypass time and cross-clamp time) or traditional markers of severity of illness (vasoactive inotrope score, lactate, saturation, and PaO2/FIO2 ratio). Early polycythemia (hematocrit value > 49%) was associated with longer cardiovascular ICU stay (51.0 [± 38.6] vs 21.4 [± 16.2] d; p < 0.01) and total hospital length of stay (65.0 [± 46.5] vs 36.1 [± 20.0] d; p = 0.03). In a multivariable analysis, polycythemia remained independently associated with the length of hospitalization after controlling for the amount of RBC transfusion (weight, 4.36 [95% CI, 1.35-7.37]; p < 0.01). No difference in in-hospital mortality rates was detected between the two groups (17.6% vs 20%). CONCLUSIONS Early polycythemia following the Norwood operation is associated with longer length of hospitalization even after controlling for blood cell transfusion practices. We hypothesize that polycythemia may be caused by hemoconcentration and used as an early marker of capillary leak syndrome.
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van Walraven C, McAlister FA. Competing risk bias was common in Kaplan–Meier risk estimates published in prominent medical journals. J Clin Epidemiol 2016; 69:170-3.e8. [DOI: 10.1016/j.jclinepi.2015.07.006] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 06/26/2015] [Accepted: 07/20/2015] [Indexed: 02/07/2023]
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Wang H, Brewer MP, Lai WW, Krishnamurthy G, Chai PJ. Bloodless Repair of Isolated Pulmonary Artery in a Neonate. World J Pediatr Congenit Heart Surg 2015; 7:112-5. [PMID: 26715005 DOI: 10.1177/2150135115582071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Pediatric cardiac surgery, especially for small neonates, typically requires blood products to counter hemodilution during cardiopulmonary bypass. Children with congenital heart defects whose families adhere to faith-based proscriptions against blood transfusion therefore represent a challenging surgical population. Here, we report the case of a ten-day-old, 3.6-kg patient of Jehovah's Witness faith, who was diagnosed with unilateral pulmonary artery discontinuity, bilateral patent ductus arteriosus, and an otherwise structurally normal heart. Pulmonary artery reimplantation was successfully performed without giving blood products. This case adds to previous reports of successful bloodless cardiac surgery in neonates and describes the specific strategies that contributed to successful pulmonary artery reimplantation.
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Affiliation(s)
- Hanjay Wang
- College of Physicians and Surgeons, Columbia University Medical Center, New York, NY, USA
| | - Michael P Brewer
- Department of Clinical Perfusion, Columbia University Medical Center, New York, NY, USA
| | - Wyman W Lai
- Department of Pediatrics, Columbia University Medical Center, New York, NY, USA
| | - Ganga Krishnamurthy
- Department of Pediatrics, Columbia University Medical Center, New York, NY, USA
| | - Paul J Chai
- Department of Surgery, Columbia University Medical Center, New York, NY, USA
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Nguyen TT, Hill S, Austin TM, Whitney GM, Wellons JC, Lam HV. Use of blood-sparing surgical techniques and transfusion algorithms: association with decreased blood administration in children undergoing primary open craniosynostosis repair. J Neurosurg Pediatr 2015; 16:556-563. [PMID: 26230459 PMCID: PMC4733600 DOI: 10.3171/2015.3.peds14663] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECT Craniofacial reconstruction surgery (CFR) is often associated with significant blood loss, coagulopathy, and perioperative blood transfusion. Due to transfusion risks, many different approaches have been used to decrease allogeneic blood transfusion for these patients during the perioperative period. Protocols have decreased blood administration during the perioperative period for many types of surgeries. The object of this study was to determine if a protocol involving blood-sparing surgical techniques and a transfusion algorithm decreased intraoperative blood transfusion and blood loss. METHODS A protocol using transfusion algorithms and implementation of blood-sparing surgical techniques for CFR was implemented at Vanderbilt University on January 1, 2013. Following Institutional Review Board approval, blood loss and transfusion data were gathered retrospectively on all children undergoing primary open CFR, using the protocol, for the calendar year 2013. This postprotocol cohort was compared with a preprotocol cohort, which consisted of all children undergoing primary open CFR during the previous calendar year, 2012. RESULTS There were 41 patients in the preprotocol and 39 in the postprotocol cohort. There was no statistical difference between the demographics of the 2 groups. When compared with the preprotocol cohort, intraoperative packed red blood cell transfusion volume decreased from 36.9 ± 21.2 ml/kg to 19.2 ± 10.9 ml/kg (p = 0.0001), whereas fresh-frozen plasma transfusion decreased from 26.8 ± 25.4 ml/kg to 1.5 ± 5.7 ml/kg (p < 0.0001) following implementation of the protocol. Furthermore, estimated blood loss decreased from 64.2 ± 32.4 ml/kg to 52.3 ± 33.3 ml/kg (p = 0.015). Use of fresh-frozen plasma in the postoperative period also decreased when compared with the period before implementation of the protocol. There was no significant difference in morbidity and mortality between the 2 groups. CONCLUSIONS The results of this study suggested that using a multidisciplinary protocol consisting of transfusion algorithms and implementation of blood-sparing surgical techniques during major CFR in pediatric patients is associated with reduced intraoperative administration of blood product, without shifting the transfusion burden to the postoperative period.
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Affiliation(s)
- Thanh T. Nguyen
- Department of Anesthesiology, Vanderbilt University, Nashville, Tennessee
| | - Sarah Hill
- Department of Nursing, Vanderbilt University, Nashville, Tennessee
| | - Thomas M. Austin
- Department of Anesthesiology, Vanderbilt University, Nashville, Tennessee
| | - Gina M. Whitney
- Department of Anesthesiology, University of Colorado, Aurora, Colorado
| | - John c. Wellons
- Department of Neurosurgery and Pediatrics, Vanderbilt University, Nashville, Tennessee
| | - Humphrey V. Lam
- Department of Anesthesiology, Vanderbilt University, Nashville, Tennessee
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Abstract
In pediatric cardiac surgery, there is a substantial gap between published recommendations or guidelines for blood product use and clinical practice. The drawbacks of blood transfusion are well acknowledged though. The aim of this paper is to present the rationale for packed red blood cells, fresh frozen plasma (FFP), and platelets used in pediatric patients. Blood hemoglobin level is the current trigger used for packed red blood cells transfusion, though commonly admitted to be suboptimal. An increase in hemoglobin level is likely to be associated with an increase in blood oxygen content and blood oxygen delivery. However, above a critical level of hemoglobin, normovolemic anemia is well tolerated, and any increase in hemoglobin will fail to increase oxygen consumption and therefore to improve end-organ oxygen supply. FFP is one way to address the coagulation factors deficiency induced by hemodilution, consumption, or hepatic insufficiency. The volume needed to increase these factors is not negligible. To avoid dilution and/or fluid overload, the use of clotting factor concentrate is recommended. The same remark can be made regarding the treatment of antithrombin III deficiency. Platelets infusion should be restricted to bleeding patients with thrombocytopenia and without surgical bleeding. In clinical studies, the prevention of bleeding through prophylactic infusion of platelets proved to be useless. Optimizing the use of blood products (avoiding overuse, underuse, and inappropriate use) is a challenging task in pediatric cardiac surgery. Data or guidelines cannot replace clinical judgment and the decision to transfuse is left to individual discretion, but the medical community needs to optimize its transfusion practice, otherwise policy-makers without similar expertise may step in to regulate the use of blood products.
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Affiliation(s)
- Yves Durandy
- Intensive Care Department, Pediatric Cardiac Surgery, CCML, Le Plessis-Robinson, France; Perfusion Department, Pediatric Cardiac Surgery, CCML, Le Plessis-Robinson, France
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Mazine A, Rached-D'Astous S, Ducruet T, Lacroix J, Poirier N. Blood Transfusions After Pediatric Cardiac Operations: A North American Multicenter Prospective Study. Ann Thorac Surg 2015; 100:671-7. [PMID: 26141778 DOI: 10.1016/j.athoracsur.2015.04.033] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Revised: 04/04/2015] [Accepted: 04/07/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND Red blood cell transfusion is an important supportive measure after pediatric cardiac operations. However, no clear hemoglobin threshold has been established. This study characterized anemia development and red blood cell transfusions in the pediatric intensive care unit (PICU) after cardiac operations. METHODS A prospective, multicenter, 6-month cohort study on the management of anemia in critically ill pediatric patients was conducted in 30 North American PICUs. This observational study enrolled 977 consecutive children (aged <18 years) who stayed in the PICU for 48 hours or more. We analyzed a subgroup of postcardiac surgical patients from this study. RESULTS Included were 175 cardiac patients, 56% of whom had cyanotic heart disease. The mean Pediatric Risk of Mortality (PRISM III) score was 6.4 ± 5.4. Fifty-four percent of children were anemic in the PICU (20% on admission, 34% during PICU stay). Most patients (79%) received at least one red blood cell transfusion in the PICU. Patients who received a transfusion had a significantly longer PICU stay (9.3 ± 6.3 vs 6.1 ± 5.4 days, p = 0.01). Pretransfusion hemoglobin was different in acyanotic and cyanotic patients (mean ± standard deviation: 11.1 ± 2.2 g/dL and 11.8 ± 2.1 g/dL, respectively). According to the attending physician, a low hemoglobin level was the primary indication for transfusion in only 17% of cases. CONCLUSIONS Pediatric cardiac surgical patients are at high risk of receiving red blood cell transfusions. This study, which showed great variability in transfusion practices across North American PICUs, highlights the need for clearer transfusion guidelines in this specific population.
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Affiliation(s)
- Amine Mazine
- Department of Cardiac Surgery, Centre hospitalier universitaire (CHU) Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
| | - Soha Rached-D'Astous
- Department of Pediatrics, Centre hospitalier universitaire (CHU) Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
| | - Thierry Ducruet
- Department of Biostatistics, Centre hospitalier universitaire (CHU) Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
| | - Jacques Lacroix
- Department of Pediatrics, Centre hospitalier universitaire (CHU) Sainte-Justine, Université de Montréal, Montréal, Québec, Canada.
| | - Nancy Poirier
- Department of Cardiac Surgery, Centre hospitalier universitaire (CHU) Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
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Nguyen TT, Lam HV, Phillips M, Edwards C, Austin TM. Intraoperative optimization to decrease postoperative PRBC transfusion in children undergoing craniofacial reconstruction. Paediatr Anaesth 2015; 25:294-300. [PMID: 25495602 PMCID: PMC4308555 DOI: 10.1111/pan.12600] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/17/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND Craniofacial reconstructive surgery for craniosynostosis is associated with large blood loss and intraoperative transfusion. This blood loss may continue through the initial postoperative period, potentially resulting in transfusion postoperatively. The purpose of this study is to determine if there is an association between any modifiable intraoperative factors and postoperative blood transfusion in this patient population. METHODS A cohort of 55 pediatric patients who underwent primary craniofacial reconstruction at Vanderbilt Children's Hospital from January 1, 2013 to April 31, 2014 was analyzed. The authors analyzed 20 different demographic and perioperative variables for statistical associations with postoperative PRBC transfusion using multiple logistic regression with optimal models being selected by Bayesian model averaging. RESULTS The optimal regression model only included initial PACU Hct as a predictor and showed a significant association between this variable and postoperative PRBC transfusion (odds ratio 0.69, 95% CI 0.55-0.87, P = 0.0016). Based on the average decrease in postoperative hematocrit (Hct) and the postoperative transfusion trigger, an initial PACU Hct threshold of 30 was calculated. In our patient sample, an initial PACU Hct above 30 was associated with a 50% decrease in the absolute risk of receiving a PRBC transfusion postoperatively. CONCLUSIONS Based on this retrospective analysis, it may be justifiable to transfuse residual volume from previously exposed intraoperative PRBCs to a Hct above 30 to decrease the likelihood of subsequent blood transfusions from different donors in the postoperative period.
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Affiliation(s)
- Thanh T. Nguyen
- Department of Anesthesiology, Division of Pediatric Anesthesiology, Vanderbilt University School of Medicine, Nashville, USA
| | - Humphrey V. Lam
- Department of Anesthesiology, Division of Pediatric Anesthesiology, Vanderbilt University School of Medicine, Nashville, USA
| | - Maxie Phillips
- Lincoln Memorial University, DeBusk College of Osteopathic Medicine, Harrogate, USA
| | | | - Thomas M. Austin
- Department of Anesthesiology, Division of Pediatric Anesthesiology, Vanderbilt University School of Medicine, Nashville, USA
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Association of blood products administration during cardiopulmonary bypass and excessive post-operative bleeding in pediatric cardiac surgery. Pediatr Cardiol 2015; 36:459-67. [PMID: 25293425 DOI: 10.1007/s00246-014-1034-z] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Accepted: 09/26/2014] [Indexed: 10/24/2022]
Abstract
Our objectives were to study risk factors and post-operative outcomes associated with excessive post-operative bleeding in pediatric cardiac surgeries performed using cardiopulmonary bypass (CPB) support. A retrospective observational study was undertaken, and all consecutive pediatric heart surgeries over 1 year period were studied. Excessive post-operative bleeding was defined as 10 ml/kg/h of chest tube output for 1 h or 5 ml/kg/h for three consecutive hours in the first 12 h of pediatric cardiac intensive care unit (PCICU) stay. Risk factors including demographics, complexity of cardiac defect, CPB parameters, hematological studies, and post-operative morbidity and mortality were evaluated for excessive bleeding. 253 patients were studied, and 107 (42 %) met the criteria for excessive bleeding. Bayesian model averaging revealed that greater volume of blood products transfusion during CPB was significantly associated with excessive bleeding. Multiple logistic regression analysis of blood products transfusion revealed that increased volume of packed red blood cells (PRBCs) administration for CPB prime and during CPB was significantly associated with excessive bleeding (p = 0.028 and p = 0.0012, respectively). Proportional odds logistic regression revealed that excessive bleeding was associated with greater time to achieve negative fluid balance, prolonged mechanical ventilation, and duration of PCICU stay (p < 0.001) after adjusting for multiple parameters. A greater volume of blood products administration, especially PRBCs transfusion for CPB prime, and during the CPB period is associated with excessive post-operative bleeding. Excessive bleeding is associated with worse post-operative outcomes.
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Longer RBC storage duration is associated with increased postoperative infections in pediatric cardiac surgery. Pediatr Crit Care Med 2015; 16:227-35. [PMID: 25607740 PMCID: PMC4351137 DOI: 10.1097/pcc.0000000000000320] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVES Infants and children undergoing open heart surgery routinely require multiple RBC transfusions. Children receiving greater numbers of RBC transfusions have increased postoperative complications and mortality. Longer RBC storage age is also associated with increased morbidity and mortality in critically ill children. Whether the association of increased transfusions and worse outcomes can be ameliorated by use of fresh RBCs in pediatric cardiac surgery for congenital heart disease is unknown. INTERVENTIONS One hundred and twenty-eight consecutively transfused children undergoing repair or palliation of congenital heart disease with cardiopulmonary bypass who were participating in a randomized trial of washed versus standard RBC transfusions were evaluated for an association of RBC storage age and clinical outcomes. To avoid confounding with dose of transfusions and timing of infection versus timing of transfusion, a subgroup analysis of patients only transfused 1-2 units on the day of surgery was performed. MEASUREMENTS AND MAIN RESULTS Mortality was low (4.9%) with no association between RBC storage duration and survival. The postoperative infection rate was significantly higher in children receiving the oldest blood (25-38 d) compared with those receiving the freshest RBCs (7-15 d) (34% vs 7%; p = 0.004). Subgroup analysis of subjects receiving only 1-2 RBC transfusions on the day of surgery (n = 74) also demonstrates a greater prevalence of infections in subjects receiving the oldest RBC units (0/33 [0%] with 7- to 15-day storage; 1/21 [5%] with 16- to 24-day storage; and 4/20 [20%] with 25- to 38-day storage; p = 0.01). In multivariate analysis, RBC storage age and corticosteroid administration were the only predictors of postoperative infection. Washing the oldest RBCs (> 27 d) was associated with a higher infection rate and increased morbidity compared with unwashed RBCs. DISCUSSION Longer RBC storage duration was associated with increased postoperative nosocomial infections. This association may be secondary in part, to the large doses of stored RBCs transfused, from single-donor units. Washing the oldest RBCs was associated with increased morbidity, possibly from increased destruction of older, more fragile erythrocytes incurred by washing procedures. Additional studies examining the effect of RBC storage age on postoperative infection rate in pediatric cardiac surgery are warranted.
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Hoashi T, Yazaki S, Kagisaki K, Kitano M, Kubota SM, Shiraishi I, Ichikawa H. Management of ostium secundum atrial septal defect in the era of percutaneous trans-catheter device closure: 7-Year experience at a single institution. J Cardiol 2014; 65:418-22. [PMID: 25113951 DOI: 10.1016/j.jjcc.2014.07.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Revised: 06/19/2014] [Accepted: 07/11/2014] [Indexed: 01/25/2023]
Abstract
OBJECTIVES This study aimed to review the single institutional experience of the repair of secundum atrial septal defect (ASD) after the initiation of percutaneous trans-catheter device closure, to confirm the current management strategy and outcomes. METHODS From August 2005 to December 2012, a total of 1026 (659 females, age 27±21 years) consecutive patients underwent the repair of ASD. Including eight patients who converted to surgical repair, 317 patients (31%) underwent surgical repair and 709 (69%) underwent trans-catheter device closure. RESULTS An embolized device into the left atrium was surgically retrieved in one patient soon after trans-catheter device closure without any postoperative complications. The other patient developed left atrium to aorta fistula due to late erosion, and required the removal of implanted device and patch closure of fistula and ASD 3 months after trans-catheter device closure. Whereas serious central nerve system complications occurred in three patients after the surgical repair including a 75-year-old patient with postoperative transient atrial fibrillation who subsequently developed aspiration pneumonia and died; there were no mortalities and no morbidities associated with cranial nerve function after trans-catheter device closure. A number of patients approached through partial sternotomy with limited skin incision have increased per year, and the length of skin incision was 5.1±1.2cm in pediatric patients weighing less than 15kg (n=40), 6.9±1.9cm in the remaining pediatric patients (n=91), and 10.0±2.5cm in young adult females (n=10). CONCLUSION Percutaneous trans-catheter ASD closure was safely performed under the support of a surgical team. The cosmetic outcome of surgical closure is improving after initiation of partial sternotomy via limited skin incision for the pediatric population and young adult females. Prior to the treatment, the physicians must thoroughly inform patients and families of the advantages and disadvantages of both treatment options.
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Affiliation(s)
- Takaya Hoashi
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan.
| | - Satoshi Yazaki
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Koji Kagisaki
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Masataka Kitano
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Sayaka Miura Kubota
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Isao Shiraishi
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Hajime Ichikawa
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
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Mainwaring RD, Reddy VM, Hanley FL. Completion of the Three-Stage Fontan Pathway Without Cardiopulmonary Bypass. World J Pediatr Congenit Heart Surg 2014; 5:427-33. [DOI: 10.1177/2150135114536908] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Accepted: 04/17/2014] [Indexed: 11/15/2022]
Abstract
Background: The three-stage surgical approach is now accepted as the standard for management of children born with functional single ventricle. However, there is little consensus on the cardiopulmonary bypass strategies employed for these procedures. We have attempted to avoid cardiopulmonary bypass in patients with single ventricle whenever possible to eliminate the adverse effects that are induced by this process. The purpose of this study was to review our experience in patients who underwent all three stages of the Fontan pathway without ever being exposed to bypass. Methods: A total of 52 patients with single ventricle underwent “off-pump” treatment at all three stages of their surgical management. The time period of the study was from 2002 to 2013. There were 31 males and 21 females. Anatomic diagnoses included double inlet left ventricle (n = 11), pulmonary atresia with intact ventricular septum (n = 11), tricuspid atresia (n = 10), double outlet right ventricle (n = 9), and other (n = 11). Results: There was no operative mortality in the 52 patients undergoing Fontan completion. The patients have been followed for an average of 5.1 ± 2.5 years, with one late mortality. The median length of hospital stay for the three stages was 17, 5, and 9 days, respectively. Of the 52 patients, 42 were able to undergo all three stages without the need for a blood transfusion. Conclusions: This series demonstrates the feasibility of achieving a Fontan circulation without patients exposed to cardiopulmonary bypass. There was no operative mortality and low mid-term mortality. It is notable that 80% of patients never required a blood transfusion with this approach. The elimination of cardiopulmonary bypass provides several potential clinical benefits in this highly select subset of patients with single ventricle.
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Affiliation(s)
- Richard D. Mainwaring
- Division of Pediatric Cardiac Surgery, Lucile Packard Children’s Hospital/Stanford University, Stanford, CA, USA
| | - V. Mohan Reddy
- Division of Pediatric Cardiac Surgery, Lucile Packard Children’s Hospital/Stanford University, Stanford, CA, USA
| | - Frank L. Hanley
- Division of Pediatric Cardiac Surgery, Lucile Packard Children’s Hospital/Stanford University, Stanford, CA, USA
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