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Simsek B, Ozyuksel A, Saygi M, Basaran M. Posterior pericardial window: a simple and reproducible technique in order to prevent pericardial tamponade in paediatric cardiac surgery. Cardiol Young 2024; 34:765-770. [PMID: 37822207 DOI: 10.1017/s1047951123003426] [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] [Indexed: 10/13/2023]
Abstract
OBJECTIVE Pericardial tamponade, which increases postoperative mortality and morbidity, is still not uncommon after paediatric cardiac surgery. We considered that posterior pericardiotomy may be a useful and safe technique in order to reduce the incidence of early and late pericardial tamponade. Herein, we present our experience with creation of posterior pericardial window following congenital cardiac surgical procedures. METHODS This retrospective study evaluated 229 patients who underwent paediatric cardiac surgical procedures between June 2021 and January 2023. A posterior pericardial window was created in all of the patients. In neonates and infants, pericardial window was performed at a size of 2x2 cm, whereas a 3x3 cm connection was established in elder children and young adults. A curved chest tube was placed and positioned at the posterolateral pericardiophrenic sinus. An additional straight anterior mediastinal chest tube was also inserted in every patient. Transthoracic echocardiographic evaluations were performed daily to assess postoperative pericardial effusion. RESULTS A total of 229 (135 male, 94 female) patients were operated. Mean age and body weight were 24.2 ± 26.7 months and 10.2 ± 6.7 kg, respectively. Eight (3.5%) of the patients were neonates where 109 (47.6%) were infants and 112 (48.9%) were in childhood. Fifty-two (22.7%) re-do operations were performed. Six (2.6%) patients underwent postoperative surgical re-exploration due to surgical site bleeding. Any early or late pericardial tamponade was not encountered in the study group. CONCLUSIONS Posterior pericardial window is an effective and safe technique in order to prevent both the early and late pericardial tamponade after congenital cardiac surgery.
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Affiliation(s)
- Baran Simsek
- Department of Cardiovascular Surgery, Kolan Hospital, Istanbul, Turkey
| | - Arda Ozyuksel
- Department of Cardiovascular Surgery, Biruni University School of Medicine, Istanbul, Turkey
| | - Murat Saygi
- Department of Pediatric Cardiology, Medicana International Hospital, Istanbul, Turkey
| | - Murat Basaran
- Department of Cardiovascular Surgery, Kolan Hospital, Istanbul, Turkey
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Moiseiwitsch N, Nellenbach KA, Downey LA, Boorman D, Brown AC, Guzzetta NA. Influence of Fibrinogen Concentrate on Neonatal Clot Structure When Administered Ex Vivo After Cardiopulmonary Bypass. Anesth Analg 2023; 137:682-690. [PMID: 36727748 DOI: 10.1213/ane.0000000000006357] [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: 02/03/2023]
Abstract
BACKGROUND Bleeding is a serious complication of cardiopulmonary bypass (CPB) in neonates. Blood product transfusions are often needed to adequately restore hemostasis, but are associated with significant risks. Thus, neonates would benefit from other effective, and safe, hemostatic therapies. The use of fibrinogen concentrate (FC; RiaSTAP, CSL Behring, Marburg, Germany) is growing in popularity, but has not been adequately studied in neonates. Here, we characterize structural and degradation effects on the neonatal fibrin network when FC is added ex vivo to plasma obtained after CPB. METHODS After approval by the institutional review board and parental consent, blood samples were collected from neonates undergoing cardiac surgery and centrifuged to yield platelet poor plasma. Clots were formed ex vivo from plasma obtained at several time points: (1) baseline, (2) immediately post-CPB, and (3) post-transfusion of cryoprecipitate. In addition, we utilized post-CPB plasma to construct the following conditions: (4) post-CPB +0.5 mg/mL FC, and (5) post-CPB +0.9 mg/mL FC. The resultant fibrin networks were imaged using confocal microscopy to analyze overall structure, fiber density, and alignment. Clots were also analyzed using a microfluidic degradation assay. Fibrinogen content was quantified for all plasma samples. RESULTS The addition of 0.5 or 0.9 mg/mL FC to post-CPB samples significantly enhanced the median fiber density when compared to untreated post-CPB samples (post-CPB = 0.44 [interquartile range {IQR}: 0.36-0.52], post-CPB +0.5 mg/mL FC = 0.69 [0.56-0.77], post-CPB +0.9 mg/mL FC = 0.87 [0.59-0.96]; P = .01 and P = .006, respectively). The addition of 0.9 mg/mL FC to post-CPB samples resulted in a greater fiber density than that observed after the in vivo transfusion of cryoprecipitate (post-transfusion = 0.54 [0.45-0.77], post-CPB +0.9 mg/mL FC = 0.87 [0.59-0.96]; P = .002). Median fiber alignment did not differ significantly between post-CPB samples and samples treated with FC. Degradation rates were not statistically significant from baseline values with either 0.5 or 0.9 mg/mL FC. In addition, we found a significant correlation between the difference in the baseline and post-CPB fibrinogen concentration with patient age ( P = .033) after controlling for weight. CONCLUSIONS Our results show that clots formed ex vivo with clinically relevant doses of FC (0.9 mg/mL) display similar structural and degradation characteristics compared to the in vivo transfusion of cryoprecipitate. These findings suggest that FC is effective in restoring structural fibrin clot properties after CPB. Future studies after the administration of FC in vivo are needed to validate this hypothesis.
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Affiliation(s)
- Nina Moiseiwitsch
- From the Joint Department of Biomedical Engineering of University of North Carolina - Chapel Hill and North Carolina State University, Raleigh, North Carolina
- Comparative Medicine Institute, North Carolina State University, Raleigh, North Carolina
| | - Kimberly A Nellenbach
- From the Joint Department of Biomedical Engineering of University of North Carolina - Chapel Hill and North Carolina State University, Raleigh, North Carolina
- Comparative Medicine Institute, North Carolina State University, Raleigh, North Carolina
| | - Laura A Downey
- Department of Anesthesiology, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - David Boorman
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia
| | - Ashley C Brown
- From the Joint Department of Biomedical Engineering of University of North Carolina - Chapel Hill and North Carolina State University, Raleigh, North Carolina
- Comparative Medicine Institute, North Carolina State University, Raleigh, North Carolina
- Department of Material Science and Engineering, North Carolina State University, Raleigh, North Carolina
| | - Nina A Guzzetta
- Department of Anesthesiology, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
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Shenker J, Abuelhija H, Karam O, Nellis M. Transfusion Strategies in the 21st Century: A Case-Based Narrative Report. Crit Care Clin 2023; 39:287-298. [PMID: 36898774 DOI: 10.1016/j.ccc.2022.09.005] [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: 11/13/2022]
Abstract
The transfusion of all blood components (red blood cells, plasma, and platelets) has been associated with increased morbidity and mortality in children. It is essential that pediatric providers weigh the risks and benefits before transfusing a critically ill child. A growing body of evidence has demonstrated the safety of restrictive transfusion practices in critically ill children.
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Affiliation(s)
- Jennifer Shenker
- Department of Pediatrics, New York Presbyterian Hospital - Weill Cornell Medicine, 525 East 68th Street, M508, New York, NY 10065, USA
| | - Hiba Abuelhija
- Pediatric Critical Care, Hadassah University Medical Center, Hadassah Ein Kerem, POB 12000, Jerusalem 911200, Israel
| | - Oliver Karam
- Department of Pediatrics, Yale School of Medicine, 333 Cedar Street, New Haven, CT 06520, USA
| | - Marianne Nellis
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Weill Cornell Medicine, 525 East 68th Street, M512, New York, NY 10065, USA.
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Benson JW, Hraska V, Scott JP, Stuth EAE, Yan K, Zhang J, Niebler RA. Comparison of Prothrombin Complex Concentrate with Activated Factor VII Use for Bleeding Following Cardiopulmonary Bypass in Children. World J Pediatr Congenit Heart Surg 2023; 14:282-288. [PMID: 36919404 DOI: 10.1177/21501351231162911] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
OBJECTIVE This study aims to compare the efficacy and safety of activated recombinant factor VII (rFVIIa) and prothrombin complex concentrate (PCC) in the treatment of bleeding complications following surgery requiring cardiopulmonary bypass (CPB) in children. DESIGN/METHODS This is a retrospective chart review of a single institution comprising patients aged 0 to 18 years old with congenital heart disease. Patients must have received either PCC or rFVIIa after coming off CPB. Our primary efficacy endpoint is time in the operating room from off-CPB to pediatric intensive care unit admission. Our primary safety endpoint is thrombosis through 30 days. RESULTS Our primary efficacy outcome was significantly shorter in the PCC group compared with the rFVIIa group (P < .0001). Similarly, secondary efficacy outcomes of packed red blood cell administration, chest tube output, and transfusion exposures all significantly favored PCC administration. However, CPB time was significantly longer, and body temperatures were significantly lower, in the rFVIIa group. Safety outcomes, including our primary safety outcome of thrombosis through 30 days, were similar between the two groups. CONCLUSION This study questions whether PCC could be favored over rFVIIa for hemostasis in children with congenital heart disease following CPB surgery. In addition, this study has found no difference when comparing PCC and rFVIIa in terms of safety outcomes, particularly thrombosis events. There are several limitations to this study due to the retrospective nature of the design and the differences between the two study groups. Despite the limitations, this study suggests that relatively early administration of PCC could be favored over delayed administration of rFVIIa to control recalcitrant post-CPB bleeding in the operating room.
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Affiliation(s)
- John W Benson
- Division of Pediatric Critical Care, Department of Pediatrics, 5506Medical College of Wisconsin, Milwaukee, WI, USA
| | - Viktor Hraska
- Division of Congenital Heart Surgery and Herma Heart Institute, Department of Surgery, 5506Medical College of Wisconsin, Milwaukee, WI, USA
| | - John P Scott
- Division of Pediatric Anesthesiology, Department of Anesthesiology, Children's Wisconsin, 5506Medical College of Wisconsin, Herma Heart Institute, Milwaukee, WI, USA.,Division of Pediatric Critical Care, Department of Pediatrics, Children's Wisconsin, 5506Medical College of Wisconsin, Herma Heart Institute, Milwaukee, WI, USA
| | - Eckehard A E Stuth
- Division of Pediatric Anesthesiology, Department of Anesthesiology, Children's Wisconsin, 5506Medical College of Wisconsin, Herma Heart Institute, Milwaukee, WI, USA
| | - Ke Yan
- Section of Quantitative Health Sciences, Department of Pediatrics, 5506Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jian Zhang
- Section of Quantitative Health Sciences, Department of Pediatrics, 5506Medical College of Wisconsin, Milwaukee, WI, USA
| | - Robert A Niebler
- Division of Pediatric Critical Care, Department of Pediatrics, Children's Wisconsin, 5506Medical College of Wisconsin, Herma Heart Institute, Milwaukee, WI, USA
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Siemens K, Hunt BJ, Parmar K, Taylor D, Salih C, Tibby SM. Factor XIII levels, clot strength, and impact of fibrinogen concentrate in infants undergoing cardiopulmonary bypass: a mechanistic sub-study of the FIBCON trial. Br J Anaesth 2023; 130:175-182. [PMID: 36371257 DOI: 10.1016/j.bja.2022.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 08/31/2022] [Accepted: 09/24/2022] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Acquired factor XIII (FXIII) deficiency after major surgery can increase postoperative bleeding. We evaluated FXIII contribution to clot strength and the effect of fibrinogen concentrate administration on FXIII activity in infants undergoing cardiac surgery using cardiopulmonary bypass. METHODS We conducted a prospectively planned, mechanistic sub-study, nested within the Fibrinogen Concentrate Supplementation in the Management of Bleeding During Paediatric Cardiopulmonary Bypass: A Phase 1B/2A, Open-Label Dose Escalation Study (FIBCON) trial, which investigated fibrinogen concentrate supplementation during cardiopulmonary bypass (ISRCTN: 50553029) in 111 infants (median age 6.4 months). The relationships between platelet number, fibrinogen concentration, and FXIII activity with rotational thromboelastometry clot strength (EXTEM-MCF) in blood taken immediately before cardiopulmonary bypass and after separation from bypass were estimated using multivariable linear regression. Changes in coagulation variables over time were quantified using a generalised linear model comparing three groups: fibrinogen concentrate-supplemented infants, placebo, and a third cohort with lower bleeding risk. RESULTS Overall, 48% of the variability (multivariable R2) in EXTEM-MCF clot strength was explained by three factors: the largest contribution was from FXIII activity (partial R2=0.21), followed by platelet number (partial R2=0.14), and fibrinogen concentration (partial R2=0.095). During cardiopulmonary bypass, mean platelet count fell by a similar amount in the three groups (-36% to -41%; interaction P=0.98). Conversely, fibrinogen concentration increased in all three groups: 132% in the fibrinogen concentrate-supplemented group, 26% in the placebo group, and 51% in the low-risk group. A similar increase was observed for FXIII activity (61%, 23%, and 25%, respectively; interaction P<0.0001). CONCLUSIONS FXIII contribution to clot strength is considerable in infants undergoing cardiac surgery. Fibrinogen concentrate supplementation also increased FXIII activity, and hence clot strength. CLINICAL TRIAL REGISTRATION ISRCTN: 50553029.
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Affiliation(s)
- Kristina Siemens
- Paediatric Intensive Care Unit, Evelina London Children's Hospital Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Beverley J Hunt
- Thrombosis and Haemophilia Centre and Thrombosis and Vascular Biology Group, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Kiran Parmar
- Thrombosis and Vascular Biology Group, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Dan Taylor
- Department of Anaesthesia, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Caner Salih
- Department of Cardiac Surgery, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Shane M Tibby
- Paediatric Intensive Care Unit, Evelina London Children's Hospital Guy's and St Thomas' NHS Foundation Trust, London, UK.
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Treatment Algorithm for Patients With von Willebrand Syndrome Type 2A and Congenital Heart Disease-A Treatment Algorithm May Reduce Perioperative Blood Loss in Children With Congenital Heart Disease. Pediatr Crit Care Med 2022; 23:812-821. [PMID: 35834676 DOI: 10.1097/pcc.0000000000003026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES In children with congenital heart disease (CHD), excessive perioperative bleeding is associated with increased morbidity and mortality, thus making adequate perioperative hemostasis crucial. We investigate the prevalence of acquired von Willebrand syndrome type 2A (aVWS) in CHD and develop a treatment algorithm for patients with aVWS and CHD (TAPAC) to reduce perioperative blood loss. DESIGN Retrospective cohort study. SETTING Single-center study. PATIENTS A total of 627 patients with CHD, undergoing corrective cardiac surgery between January 2008 and May 2017. INTERVENTIONS The evaluation of perioperative bleeding risk was based on the laboratory parameters von Willebrand factor (VWF) antigen, ristocetin cofactor activity, platelet function analyzer (PFA) closure time adenosine diphosphate, and PFA epinephrine. According to the bleeding risk, treatment was performed with desmopressin or VWF. MEASUREMENTS AND MAIN RESULTS aVWS was confirmed in 63.3 %, with a prevalence of 45.5% in the moderate and 66.3 % in the high-risk group. In addition, prevalence increased with ascending peak velocity above the stenosis (v max ) from 40.0% at less than or equal to 3 m/s to 83.3% at greater than 5 m/s. TAPAC reduced mean blood loss by 36.3% in comparison with a historical control cohort ( p < 0.001), without increasing the number of thrombotic or thromboembolic events during the hospital stay. With ascending v max , there was an increase in perioperative blood loss in the historical cohort ( p < 0.001), which was not evident in the TAPAC cohort ( p = 0.230). CONCLUSIONS The prevalence of aVWS in CHD seems to be higher than assumed and leads to significantly higher perioperative blood loss, especially at high v max . Identifying these patients through appropriate laboratory analytics and adequate treatment could reduce blood loss effectively.
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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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8
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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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Differential sialic acid content in adult and neonatal fibrinogen mediates differences in clot polymerization dynamics. Blood Adv 2021; 5:5202-5214. [PMID: 34555851 PMCID: PMC9153052 DOI: 10.1182/bloodadvances.2021004417] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 07/21/2021] [Indexed: 11/20/2022] Open
Abstract
Increased sialic acid in neonatal fibrinogen influences fibrin knob-hole interactions during polymerization. Neonatal fibrin polymerization involves more B knob– and fewer A knob–mediated interactions compared with adults.
Neonates possess a molecular variant of fibrinogen, known as fetal fibrinogen, characterized by increased sialic acid, a greater negative charge, and decreased activity compared with adults. Despite these differences, adult fibrinogen is used for the treatment of bleeding in neonates, with mixed efficacy. To determine safe and efficacious bleeding protocols for neonates, more information on neonatal fibrin clot formation and the influence of sialic acid on these processes is needed. Here, we examine the influence of sialic acid on neonatal fibrin polymerization. We hypothesized that the increased sialic acid content of neonatal fibrinogen promotes fibrin B:b knob-hole interactions and consequently influences the structure and function of the neonatal fibrin matrix. We explored this hypothesis through analysis of structural properties and knob:hole polymerization dynamics of normal and desialylated neonatal fibrin networks and compared them with those formed with adult fibrinogen. We then characterized normal neonatal fibrin knob:hole interactions by forming neonatal and adult clots with either thrombin or snake-venom thrombin-like enzymes that preferentially cleave fibrinopeptide A or B. Sialic acid content of neonatal fibrinogen was determined to be a key determinant of resulting clot properties. Experiments analyzing knob:hole dynamics indicated that typical neonatal fibrin clots are formed with the release of more fibrinopeptide B and less fibrinopeptide A than adults. After the removal of sialic acid, fibrinopeptide release was roughly equivalent between adults and neonates, indicating the influence of sialic acid on fibrin neonatal fibrin polymerization mechanisms. These results could inform future studies developing neonatal-specific treatments of bleeding.
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Fuller S, Kumar SR, Roy N, Mahle WT, Romano JC, Nelson JS, Hammel JM, Imamura M, Zhang H, Fremes SE, McHugh-Grant S, Nicolson SC. The American Association for Thoracic Surgery Congenital Cardiac Surgery Working Group 2021 consensus document on a comprehensive perioperative approach to enhanced recovery after pediatric cardiac surgery. J Thorac Cardiovasc Surg 2021; 162:931-954. [PMID: 34059337 DOI: 10.1016/j.jtcvs.2021.04.072] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 04/26/2021] [Accepted: 04/26/2021] [Indexed: 12/22/2022]
Affiliation(s)
- Stephanie Fuller
- Division of Cardiothoracic Surgery, Department of Surgery, The Children's Hospital of Philadelphia, and Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pa
| | - S Ram Kumar
- Division of Cardiac Surgery, Department of Surgery, and Department of Pediatrics, Keck School of Medicine of the University of Southern California, Heart Institute, Children's Hospital Los Angeles, Los Angeles, Calif.
| | - Nathalie Roy
- Department of Cardiac Surgery, Boston Children's Hospital, Department of Surgery, Harvard Medical School, Boston, Mass
| | - William T Mahle
- Division of Cardiology, Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Jennifer C Romano
- Departments of Cardiac Surgery and Pediatrics, University of Michigan, CS Mott Children's Hospital, Ann Arbor, Mich
| | - Jennifer S Nelson
- Department of Cardiovascular Services, Nemours Children's Hospital, and Department of Surgery, University of Central Florida College of Medicine, Orlando, Fla
| | - James M Hammel
- Department of Cardiothoracic Surgery, Children's Hospital and Medical Center of Omaha, Omaha, Neb
| | - Michiaki Imamura
- Division of Congenital Heart Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Tex
| | - Haibo Zhang
- Department of Cardiothoracic Surgery, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Stephen E Fremes
- Division of Cardiac Surgery, Department of Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Sara McHugh-Grant
- Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia, Philadelphia, Penn
| | - Susan C Nicolson
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Penn
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11
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Long JB, Engorn BM, Hill KD, Feng L, Chiswell K, Jacobs ML, Jacobs JP, Goswami D. Postoperative Hematocrit and Adverse Outcomes in Pediatric Cardiac Surgery Patients: A Cross-Sectional Study From the Society of Thoracic Surgeons and Congenital Cardiac Anesthesia Society Database Collaboration. Anesth Analg 2021; 133:1077-1088. [PMID: 33721876 DOI: 10.1213/ane.0000000000005416] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND We sought to examine potential associations between pediatric postcardiac surgical hematocrit values and postoperative complications or mortality. METHODS A retrospective, cross-sectional study from the Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD) and Congenital Cardiac Anesthesia Society Database Module (2014-2019) was completed. Multivariable logistic regression models, adjusting for covariates in the STS-CHSD mortality risk model, were used to assess the relationship between postoperative hematocrit and the primary outcomes of operative mortality or any major complication. Hematocrit was assessed as a continuous variable using linear splines to account for nonlinear relationships with outcomes. Operations after which the oxygen saturation is typically observed to be <92% were classified as cyanotic and ≥92% as acyanotic. RESULTS In total, 27,462 index operations were included, with 4909 (17.9%) being cyanotic and 22,553 (82.1%) acyanotic. For cyanotic patients, each 5% incremental increase in hematocrit over 42% was associated with a 1.31-fold (95% confidence interval [CI], 1.10-1.55; P = .003) increase in the odds of operative mortality and a 1.22-fold (95% CI, 1.10-1.36; P < .001) increase in the odds of a major complication. For acyanotic patients, each 5% incremental increase in hematocrit >38% was associated with a 1.45-fold (95% CI, 1.28-1.65; P < .001) increase in the odds of operative mortality and a 1.21-fold (95% CI, 1.14-1.29; P < .001) increase in the odds of a major complication. CONCLUSIONS High hematocrit on arrival to the intensive care unit (ICU) is associated with increased operative mortality and major complications in pediatric patients following cardiac surgery.
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Affiliation(s)
- Justin B Long
- From the Department of Pediatric Anesthesiology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
| | - Branden M Engorn
- Department of Anesthesiology and Critical Care Medicine, Rady Children's Hospital, San Diego, California
| | | | - Liqi Feng
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Karen Chiswell
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Marshall L Jacobs
- Department of Surgery, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jeffrey P Jacobs
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Congenital Heart Center, University of Florida, Gainesville, Florida
| | - Dheeraj Goswami
- Department of Anesthesiology and Critical Care Medicine, Bloomberg Children's Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland
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12
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Harris JM, Sheehan K, Rogers CA, Murphy T, Caputo M, Mumford AD. Prediction of Bleeding in Pediatric Cardiac Surgery Using Clinical Characteristics and Prospective Coagulation Test Results. Semin Thorac Cardiovasc Surg 2021; 34:277-288. [PMID: 33444767 DOI: 10.1053/j.semtcvs.2021.01.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 01/05/2021] [Indexed: 11/11/2022]
Abstract
Bleeding caused by coagulopathy is common in children undergoing cardiac surgery and causes adverse outcomes. Coagulation testing assists selection of treatments to stop bleeding but has an uncertain role for predicting bleeding. We aimed to evaluate how well prospective coagulation testing predicted excessive bleeding during and after cardiac surgery compared to prediction using clinical characteristics alone. The study was a single-center, prospective cohort study in children having a range of cardiac surgery procedures with coagulation testing at anesthetic induction and immediately after cardiopulmonary bypass. The primary outcome was clinical concern about bleeding (CCB), a composite of either administration of prohemostatic treatments in response to bleeding or a high chest drain volume after surgery. In 225 children, CCB occurred in 26 (12%) during surgery and in 68 (30%) after surgery. Multivariable fractional polynomial models using the clinical characteristics of the children alone predicted CCB during surgery (c-statistic 0.64; 95% confidence interval 0.53, 0.76) and after surgery (0.74; 0.67, 0.82). Incorporating coagulation test results into these models improved prediction (c-statistics 0.79; 0.70, 0.87, and 0.80; 0.74, 0.87, respectively). However, this increased the overall proportion of children classified correctly as CCB or not CCB during surgery by only 0.9% and after surgery by only 0.4%. Incorporating coagulation test results into predictive models had no effect on prediction of blood transfusion or postoperative complications. Prospective coagulation testing marginally improves prediction of CCB during and after cardiac surgery but the clinical impact of this is small when compared to prediction using clinical characteristics.
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Affiliation(s)
- Jessica M Harris
- Bristol Trials Centre, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Karen Sheehan
- Department of Paediatric Cardiac Surgery, Bristol Royal Hospital for Children, University Hospitals Bristol, Bristol, UK
| | - Chris A Rogers
- Bristol Trials Centre, Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Tim Murphy
- Department of Paediatric Cardiac Surgery, Bristol Royal Hospital for Children, University Hospitals Bristol, Bristol, UK
| | - Massimo Caputo
- Department of Paediatric Cardiac Surgery, Bristol Royal Hospital for Children, University Hospitals Bristol, Bristol, UK; Bristol Heart Institute, University Hospitals Bristol, Bristol, UK; Department of Paediatric Cardiac Surgery, School of Translational Sciences, University of Bristol, Bristol, UK
| | - Andrew D Mumford
- Department of Haematology, School of Cellular and Molecular Medicine, University of Bristol, Bristol, UK.
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13
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Aran AA, Karam O, Nellis ME. Bleeding in Critically Ill Children-Review of Literature, Knowledge Gaps, and Suggestions for Future Investigation. Front Pediatr 2021; 9:611680. [PMID: 33585373 PMCID: PMC7873638 DOI: 10.3389/fped.2021.611680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 01/04/2021] [Indexed: 11/13/2022] Open
Abstract
Clinically significant bleeding complicates up to 20% of admissions to the intensive care unit in adults and is associated with severe physiologic derangements, requirement for significant interventions and worse outcome. There is a paucity of published data on bleeding in critically ill children. In this manuscript, we will provide an overview of the epidemiology and characteristics of bleeding in critically ill children, address the association between bleeding and clinical outcomes, describe the current definitions of bleeding and their respective limitations, and finally provide an overview of current knowledge gaps and suggested areas for future research.
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Affiliation(s)
- Adi Avniel Aran
- Pediatric Cardiac Critical Care Division, Hadassah University Medical Center, Jerusalem, Israel
| | - Oliver Karam
- Division of Pediatric Critical Care Medicine, Children's Hospital of Richmond at VCU, Richmond, VA, United States
| | - Marianne E Nellis
- Pediatric Critical Care Medicine, NY Presbyterian Hospital-Weill Cornell Medicine, New York, NY, United States
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14
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Dennhardt N, Sümpelmann R, Horke A, Keil O, Nickel K, Heiderich S, Boethig D, Beck CE. Prevention of postoperative bleeding after complex pediatric cardiac surgery by early administration of fibrinogen, prothrombin complex and platelets: a prospective observational study. BMC Anesthesiol 2020; 20:302. [PMID: 33339495 PMCID: PMC7747387 DOI: 10.1186/s12871-020-01217-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 12/07/2020] [Indexed: 12/28/2022] Open
Abstract
Background Postoperative bleeding is a major problem in children undergoing complex pediatric cardiac surgery. The primary aim of this prospective observational study was to evaluate the effect of an institutional approach consisting of early preventive fibrinogen, prothrombin complex and platelets administration on coagulation parameters and postoperative bleeding in children. The secondary aim was to study the rate of re-intervention and postoperative transfusion, the occurrence of thrombosis, length of mechanical ventilation, ICU stay and mortality. Methods In fifty children (age 0–6 years) with one or more predefined risk factors for bleeding after cardiopulmonary bypass (CPB), thrombelastography (TEG) and standard coagulation parameters were measured at baseline (T1), after CPB and reversal of heparin (T2), at sternal closure (T3) and after 12 h in the ICU (T4). Clinical bleeding was evaluated by the surgeon at T2 and T3 using a numeric rating scale (NRS, 0–10). Results After CPB and early administration of fibrinogen, prothrombin complex and platelets, the clinical bleeding evaluation score decreased from a mean value of 6.2 ± 1.9 (NRS) at T2 to a mean value of 2.1 ± 0.8 at T3 (NRS; P < 0.001). Reaction time (R), kinetic time (K), maximum amplitude (MA) and maximum amplitude of fibrinogen (MA-fib) improved significantly (P < 0.001 for all), and MA-fib correlated significantly with the clinical bleeding evaluation (r = 0.70, P < 0.001). The administered total amount of fibrinogen (mg kg− 1) correlated significantly with weight (r = − 0.42, P = 0.002), priming volume as percentage of estimated blood volume (r = 0.30, P = 0.034), minimum CPB temperature (r = − 0.30, P = 0.033) and the change in clinical bleeding evaluation from T2 to T3 (r = 0.71, P < 0.001). The incidence of postoperative bleeding (> 10% of estimated blood volume) was 8%. No child required a surgical re-intervention, and no cases of thrombosis were observed. Hospital mortality was 0%. Conclusion In this observational study of children with an increased risk of bleeding after CPB, an early preventive therapy with fibrinogen, prothrombin complex and platelets guided by clinical bleeding evaluation and TEG reduced bleeding and improved TEG and standard coagulation parameters significantly, with no occurrence of thrombosis or need for re-operation. Trial registration German Clinical Trials Register DRKS00018109 (retrospectively registered 27th August 2019).
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Affiliation(s)
- Nils Dennhardt
- Clinic for Anaesthesiology and Intensive Care Medicine, Hannover Medical School, OE 8050, Carl-Neuberg-Str. 1, D-30625, Hannover, Germany.
| | - Robert Sümpelmann
- Clinic for Anaesthesiology and Intensive Care Medicine, Hannover Medical School, OE 8050, Carl-Neuberg-Str. 1, D-30625, Hannover, Germany
| | - Alexander Horke
- Clinic for Cardiac, Thoracic, Transplant and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, D-30625, Hannover, Germany
| | - Oliver Keil
- Clinic for Anaesthesiology and Intensive Care Medicine, Hannover Medical School, OE 8050, Carl-Neuberg-Str. 1, D-30625, Hannover, Germany
| | - Katja Nickel
- Clinic for Anaesthesiology and Intensive Care Medicine, Hannover Medical School, OE 8050, Carl-Neuberg-Str. 1, D-30625, Hannover, Germany
| | - Sebastian Heiderich
- Clinic for Anaesthesiology and Intensive Care Medicine, Hannover Medical School, OE 8050, Carl-Neuberg-Str. 1, D-30625, Hannover, Germany
| | - Dietmar Boethig
- Clinic for Cardiac, Thoracic, Transplant and Vascular Surgery, Hannover Medical School, Carl-Neuberg-Str. 1, D-30625, Hannover, Germany
| | - Christiane E Beck
- Clinic for Anaesthesiology and Intensive Care Medicine, Hannover Medical School, OE 8050, Carl-Neuberg-Str. 1, D-30625, Hannover, Germany
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15
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Walker SC, Andrews J. Novel Blood Component Therapies in the Pediatric Setting. Clin Lab Med 2020; 41:153-171. [PMID: 33494883 DOI: 10.1016/j.cll.2020.10.010] [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: 11/28/2022]
Abstract
There have been recent advances in safer blood component preparation and use of adjuvant blood derivatives, which have limited safety and efficacy data on use in children. This article reviews the literature on use of whole blood, solvent/detergent-treated plasma, pathogen-reduced platelets, and fibrinogen concentrate in pediatric patients. Many countries have adopted pathogen-reduced blood product technology, and hospitals in the United States are slowly adopting these products. The pediatric transfusion medicine community needs to appraise the evidence for their use and continue to advocate the inclusion of children in the most robust randomized clinical trials for novel blood components.
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Affiliation(s)
- Shannon C Walker
- Department of Pediatrics, Division of Hematology/Oncology, Vanderbilt University Medical Center, Preston Research Building #397, 2220 Pierce Avenue, Nashville, TN 37232, USA
| | - Jennifer Andrews
- Department of Pathology, Microbiology and Immunology, Division of Transfusion Medicine, Vanderbilt University Medical Center, 1301 Medical Center Drive, Suite 4605, Nashville, TN 37232, USA; Department of Pediatrics, Division of Hematology/Oncology, Vanderbilt University Medical Center, 1301 Medical Center Drive, Suite 4605, Nashville, TN 37232, USA.
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16
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17
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Downey LA, Andrews J, Hedlin H, Kamra K, McKenzie ED, Hanley FL, Williams GD, Guzzetta NA. Fibrinogen Concentrate as an Alternative to Cryoprecipitate in a Postcardiopulmonary Transfusion Algorithm in Infants Undergoing Cardiac Surgery. Anesth Analg 2020; 130:740-751. [DOI: 10.1213/ane.0000000000004384] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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18
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Rudasill SE, Liu J, Kamath AF. Revisiting the International Normalized Ratio Threshold for Bleeding Risk and Mortality in Primary Total Hip Arthroplasty: A National Surgical Quality Improvement Program Analysis of 17,567 Patients. J Bone Joint Surg Am 2020; 102:52-59. [PMID: 31609891 DOI: 10.2106/jbjs.19.00160] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Efforts to identify preoperative risk factors for primary total hip arthroplasty have amplified with its increasing incidence. The international normalized ratio (INR) is 1 measure that may influence postoperative outcomes. This study of a national database assessed whether there exists an association between preoperative INR and postoperative bleeding and mortality among patients who underwent primary total hip arthroplasty. METHODS We retrospectively analyzed 17,567 adult patients who underwent primary total hip arthroplasty in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) between 2005 and 2016. Patients were stratified by preoperative INR into 4 groups: INR <1.0, 1.0 to <1.25, 1.25 to <1.5, and ≥1.5. Bleeding necessitating transfusion was the primary outcome, and secondary outcomes included mortality, infection, and readmission. Multivariable logistic regressions controlled for baseline differences. RESULTS Among the patients who underwent total hip arthroplasty, 20.5% had INR <1.0, 73.6% had INR 1.0 to <1.25, 4.2% had INR 1.25 to <1.5, and 1.8% had INR ≥1.5. Mortality increased incrementally from 0.3% for INR <1.0 to 4.9% for INR ≥1.5 (p < 0.001), and bleeding risk increased from 13.2% for INR <1.0 to 29.3% for INR ≥1.5 (p < 0.001). After adjustment, bleeding risk was increased for INR 1.25 to <1.5 (odds ratio [OR], 1.55 [95% confidence interval (CI), 1.26 to 1.92]) and INR ≥1.5 (OR, 1.55 [95% CI, 1.15 to 2.08]) compared with INR <1.0. The only group associated with increased mortality was INR ≥1.5 (OR, 2.69 [95% CI, 1.07 to 6.76]). The length of stay significantly increased with increasing INR, from 3.6 to 6.3 days (p < 0.001). CONCLUSIONS This study found a significant, independent effect between increased preoperative INR and increased bleeding and mortality. Bleeding risk becomes evident at INR ≥1.25, and those patients with INR ≥1.5 are at significantly increased risk of mortality. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Sarah E Rudasill
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Jiabin Liu
- Department of Anesthesiology, Hospital for Special Surgery, New York, NY
| | - Atul F Kamath
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
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19
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Butt W. Bleeding after cardiac surgery: multiple strategies and teamwork are essential! Perfusion 2019; 34:637-639. [PMID: 31394968 DOI: 10.1177/0267659119867196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Warwick Butt
- Director Intensive Care, The Royal Children's Hospital, Melbourne, VIC, Australia.,Department of Paediatrics, The University of Melbourne, Melbourne, VIC, Australia.,ICU Research Clinical Sciences Theme, Murdoch Children's Research Center, Melbourne, VIC, Australia.,Department of Medicine, Central Medical School, Monash University, Melbourne, VIC, Australia.,Intensive Care, Cabrini Malvern, Malvern, VIC, Australia
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20
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Nellenbach K, Guzzetta NA, Brown AC. Analysis of the structural and mechanical effects of procoagulant agents on neonatal fibrin networks following cardiopulmonary bypass. J Thromb Haemost 2018; 16:2159-2167. [PMID: 30182421 DOI: 10.1111/jth.14280] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Indexed: 12/18/2022]
Abstract
Essentials The standard of care (SOC) for treating neonatal bleeding is transfusion of adult blood products. We compared neonatal clots formed with cryoprecipitate (SOC) to two procoagulant therapies. The current SOC resulted in clots with increased stiffness and decreased fibrinolytic properties. Procoagulant therapies may be a viable alternative to SOC treatment for neonatal bleeding. SUMMARY: Background Bleeding is a serious complication of neonates undergoing cardiopulmonary bypass (CPB) and associated with substantial morbidity and mortality. Bleeding is addressed through the transfusion of adult blood products, including platelets and cryoprecipitate. However, significant differences exist between neonatal and adult clotting components, specifically fibrinogen. Our recent ex vivo studies have shown that neonatal fibrinogen does not fully integrate with adult fibrinogen, leading to decreased susceptibility to fibrinolysis. These differences may contribute to ineffective clot formation and/or an increased risk of thrombosis. A need exists to identify more effective and safer methods to promote clotting in neonates. Objectives Procoagulant agents, such as prothrombin complex concentrates (PCCs) and recombinant activated factor VII (rFVIIa), are being used off-label to treat excessive bleeding in neonates after CPB. Because these agents stimulate endogenous fibrin formation, we hypothesize that their addition to post-CPB neonatal plasma will better recapitulate native clot properties than cryoprecipitate. Methods We analyze the structural, mechanical and degradation properties of fibrin matrices formed by neonatal plasma collected after CPB in the presence of an activated four-factor (F) PCC (FEIBA), rFVIIa, or cryoprecipitate using confocal microscopy, atomic force microscopy and a fluidics-based degradation assay. Results The ex vivo addition of FEIBA and rFVIIa to post-CPB neonatal plasma resulted in enhanced clot networks with differences in fibrin alignment, mechanics and degradation properties. Conclusions Our results suggest that these procoagulant agents could be used as an alternative to the transfusion of adult fibrinogen for the treatment of bleeding after CPB in neonates.
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Affiliation(s)
- K Nellenbach
- Joint Department of Biomedical Engineering, North Carolina State University and The University of North Carolina at Chapel Hill, Raleigh, NC, USA
- Comparative Medicine Institute, North Carolina State University, Raleigh, NC, USA
| | - N A Guzzetta
- Department of Anesthesiology, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - A C Brown
- Joint Department of Biomedical Engineering, North Carolina State University and The University of North Carolina at Chapel Hill, Raleigh, NC, USA
- Comparative Medicine Institute, North Carolina State University, Raleigh, NC, USA
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21
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Kaiser A, Miller K, Tian G, Moore RH, Guzzetta NA. Feasibility of autologous intraoperative blood collection and retransfusion in small children with complex congenital heart defects undergoing cardiopulmonary bypass. Paediatr Anaesth 2018; 28:795-802. [PMID: 30079485 DOI: 10.1111/pan.13449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/18/2018] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Allogeneic blood product transfusion is common in pediatric patients undergoing cardiopulmonary bypass although it is associated with an increased risk for adverse events. Furthermore, numerous donor exposures may affect future blood transfusion needs and human leukocyte antigen matching for patients who may ultimately require cardiac transplantation. Autologous intraoperative blood collection and retransfusion is a known method of blood preservation, but has not been extensively practiced in pediatric patients. In this study we assess the feasibility of this blood conservation technique in small children with complex congenital heart defects undergoing cardiopulmonary bypass. METHODS After Institutional Review Board approval, we retrospectively reviewed the medical records of children weighing <10 kg who underwent cardiopulmonary bypass over a 2-year period. Eighteen patients underwent autologous intraoperative blood collection and retransfusion and comprised the study group. Eighteen control patients were chosen by a 1:1 matched design using preoperative hematocrit, surgical procedure, and body weight. Multiple corresponding demographic and surgical variables, transfusion data, and clinical outcomes were compared. RESULTS Patient demographics, operative parameters and preoperative laboratory, and coagulation values were similar between the two groups. Despite the removal of autologous blood, study patients did not require more inotropic support prior to cardiopulmonary bypass. They also did not experience a significant increase in bleeding as measured by 24-hour postoperative chest tube output. Study patients were exposed to significantly fewer donor units intraoperatively and within the first 24 hours postoperatively. DISCUSSION The use of autologous intraoperative blood collection and retransfusion is a feasible option for small children with complex congenital heart defects undergoing cardiopulmonary bypass. Study patients received significantly fewer donor exposures without an increase in postoperative bleeding. Children who require multiple cardiac surgeries or eventually transplantation could benefit from this blood conservation technique.
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Affiliation(s)
- Ania Kaiser
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia.,Division of Pediatric Anesthesiology, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Kati Miller
- Department of Clinical Research, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Ganzhong Tian
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Reneé H Moore
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Nina A Guzzetta
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia.,Division of Pediatric Anesthesiology, Children's Healthcare of Atlanta, Atlanta, Georgia
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22
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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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23
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Patregnani JT, Sochet AA, Zurakowski D, Klugman D, Diab Y, Berger JT, Sinha P. Cardiopulmonary Bypass Reduces Early Thrombosis of Systemic-to-Pulmonary Artery Shunts. World J Pediatr Congenit Heart Surg 2018; 9:276-282. [PMID: 29692234 DOI: 10.1177/2150135118755985] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Shunt thrombosis is a significant cause of morbidity and mortality after systemic-to-pulmonary artery shunt (SPS) placement. Concurrent procedures with placement of SPS may require cardiopulmonary bypass (CPB). Cardiopulmonary bypass is known to cause bleeding and platelet dysfunction in infants, which may protect from early shunt thrombosis. We hypothesized that infants undergoing SPS placement on CPB have a lower incidence of early shunt thrombosis. METHODS Retrospective cohort study of infants undergoing SPS placement from January 2008 to December 2014 was performed. Patients with and without early shunt thrombosis and on or off CPB were compared using the Mann-Whitney U test or Fisher exact test. Multivariable regression analysis was performed to identify independent predictors of early shunt thrombosis and to assess effect of CPB independent of other factors. RESULTS Seventy-five infants underwent SPS placement during the study period (on CPB, n = 25; off CPB, n = 50). Operative mortality was 11% (8/75). Nine (12%) patients developed early shunt thrombosis, all of whom had shunt placement off CPB. Independent risk factors for early shunt thrombosis were identified to be SPS placement off CPB ( P = .011), prematurity ( P = .034), and competitive antegrade pulmonary blood flow ( P = .038). CONCLUSION Prematurity, competitive antegrade pulmonary blood flow, and shunt placement off CPB lead to higher risk of early shunt thrombosis. We speculate that the protection offered by use of CPB may be accounted for by the associated complex coagulopathy and platelet dysfunction associated with CPB.
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Affiliation(s)
- Jason T Patregnani
- 1 Division of Cardiac Intensive Care Medicine, Children's National Health System, The George Washington School of Medicine, Washington, DC, USA
| | - Anthony A Sochet
- 2 Division of Critical Care Medicine, Johns Hopkins All Children's Hospital, Johns Hopkins University, St Petersburg, FL, USA
| | - David Zurakowski
- 3 Department of Anesthesia, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,4 Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Darren Klugman
- 1 Division of Cardiac Intensive Care Medicine, Children's National Health System, The George Washington School of Medicine, Washington, DC, USA
| | - Yaser Diab
- 5 Division of Hematology/Oncology, Children's National Health System, The George Washington School of Medicine, Washington, DC, USA
| | - John T Berger
- 1 Division of Cardiac Intensive Care Medicine, Children's National Health System, The George Washington School of Medicine, Washington, DC, USA
| | - Pranava Sinha
- 6 Division of Cardiovascular Surgery, Children's National Health System, The George Washington School of Medicine, Washington, DC, USA
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24
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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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25
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Validation of a definition of excessive postoperative bleeding in infants undergoing cardiac surgery with cardiopulmonary bypass. J Thorac Cardiovasc Surg 2017; 155:2112-2124.e2. [PMID: 29338867 DOI: 10.1016/j.jtcvs.2017.12.038] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 11/16/2017] [Accepted: 12/05/2017] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To derive and validate an objective definition of postoperative bleeding in neonates and infants undergoing cardiac surgery with cardiopulmonary bypass. METHODS Using a retrospective cohort of 124 infants and neonates, we included published bleeding definitions and cumulative chest tube output over different postoperative periods (eg, 2, 12, or 24 hours after intensive care unit admission) in a classification and regression tree model to determine chest tube output volumes that were associated with red blood cell transfusions and surgical re-exploration for bleeding in the first 24 hours after intensive care unit admission. After the definition of excessive bleeding was determined, it was validated via a prospective cohort of 77 infants and neonates. RESULTS Excessive bleeding was defined as ≥7 mL/kg/h for ≥2 consecutive hours in the first 12 postoperative hours and/or ≥84 mL/kg total for the first 24 postoperative hours and/or surgical re-exploration for bleeding or cardiac tamponade physiology in the first 24 postoperative hours. Excessive bleeding was associated with longer length of hospital stay, increased 30-day readmission rate, and increased transfusions in the postoperative period. CONCLUSIONS The proposed standard definition of excessive bleeding is based on readily obtained objective data and relates to important early clinical outcomes. Application and validation by other institutions will help determine the extent to which our specialty should consider this definition for both clinical investigation and quality improvement initiatives.
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Abstract
OBJECTIVES The objective of this article is to review the particular tendencies as well as specific concerns of bleeding and clotting in children with critical cardiac disease. DATA SOURCE MEDLINE and PubMed. CONCLUSION Children with critical heart disease are at particular risk for bleeding and clotting secondary to intrinsic as well as extrinsic factors. We hope that this review will aid the clinician in managing the unique challenges of bleeding and clotting in this patient population, and serve as a springboard for much needed research in this area.
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Abstract
There has been extraordinary progress over the last half-century in the field of medical transplantation in which tissue, organs, or body parts from one human are placed into another. Solid organ transplants have allowed thousands of children with otherwise devastating inherited or acquired disorders to survive. Depending upon the clinical situation, there are many specific peri-transplant issues that must be carefully addressed to optimize outcomes. Although surgical, immunologic, and infectious concerns are usually in the forefront, important aspects regarding hemostasis frequently arise. The number of solid organs that can be successfully transplanted in children has expanded over the last decades and includes kidney, liver, heart, lung, intestine, pancreas, and thymus. Bleeding complications may occur in the setting of organ failure prior to transplantation, during the surgical procedure, or in the post-transplant setting, and can results in significant morbidity. This report will focus on preventing and managing non-surgical-related bleeding complications in children undergoing liver, heart, kidney transplantation, in whom there are often unique aspects of coagulation to be considered.
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Affiliation(s)
- L Raffini
- Division of Hematology, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - C Witmer
- Division of Hematology, Department of Pediatrics, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Williams GD, Ramamoorthy C. Editorial comment on paper by Naguib, et al. 'A single-center strategy to minimize blood transfusion in neonates and children undergoing cardiac surgery'. Paediatr Anaesth 2015; 25:442-4. [PMID: 25851520 DOI: 10.1111/pan.12653] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Glyn D Williams
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford Children's Hospital, Stanford University Medical Center, Stanford, CA, USA.
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