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Wadle M, Landsem L, Latham G, Ross F. The Year in Review: Anesthesia for Congenital Heart Disease 2023. Semin Cardiothorac Vasc Anesth 2024; 28:91-99. [PMID: 38561024 DOI: 10.1177/10892532241244475] [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: 04/04/2024]
Abstract
This review highlights published literature in 2023 that is related to the anesthetic management of patients with congenital heart disease (CHD). Though not inclusive of all topics, 31 articles are discussed and four primary themes emerged: transfusion and hemostasis, outcomes and risk assessment, monitoring, and pharmacology.
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Affiliation(s)
- Michael Wadle
- Department of Anesthesiology, Seattle Children's Hospital, Seattle, WA, USA
| | - Leah Landsem
- Department of Anesthesiology, Seattle Children's Hospital, Seattle, WA, USA
| | - Gregory Latham
- Department of Anesthesiology, Seattle Children's Hospital, Seattle, WA, USA
| | - Faith Ross
- Department of Anesthesiology, Seattle Children's Hospital, Seattle, WA, USA
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2
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Benson MA, Tolich D, Callum JL, Auron M. Plasma: indications, controversies, and opportunities. Postgrad Med 2024; 136:120-130. [PMID: 38362605 DOI: 10.1080/00325481.2024.2320080] [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] [Received: 07/05/2023] [Accepted: 02/13/2024] [Indexed: 02/17/2024]
Abstract
Plasma is overused as a blood product worldwide; however, data supporting appropriate use of plasma is scant. Its most common utilization is for treatment of coagulopathy in actively bleeding patients; it is also used for coagulation optimization prior to procedures with specific coagulation profile targets. A baseline literature review in PUBMED and Google Scholar was done (1 January 2000 to 1 June 2023), utilizing the following search terms: plasma, fresh frozen plasma, lyophilized plasma, indications, massive transfusion protocol, liver disease, warfarin reversal, cardiothoracic surgery, INR < 2. An initial review of the titles and abstracts excluded all articles that were not focused on transfusional medicine. Additional references were obtained from citations within the retrieved articles. This narrative review discusses the main indications for appropriate plasma use, mainly coagulation factor replacement, major hemorrhage protocol, coagulopathy in liver disease, bleeding in the setting of vitamin K antagonists, among others. The correlation between concentration of coagulation factors and INR, as well as the proper plasma dosing with its volume being weight-based, is also discussed. A high value approach to plasma utilization is supported with a review of the clinical situations where plasma is overutilized or unnecessary. Finally, a discussion of novel plasma products is presented for enhanced awareness.
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Affiliation(s)
- Michael A Benson
- Department of General Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
| | - Deborah Tolich
- Blood Management, Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jeannie L Callum
- Department of Laboratory Medicine and Pathobiology, Queens University, Kingston, ON, Canada
| | - Moises Auron
- Department of Hospital Medicine and Department of Pediatric Hospital Medicine, Cleveland Clinic, Outcomes Research Consortium, Cleveland, OH, USA
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Ranucci M, Di Dedda U, Isgrò G, Giamberti A, Cotza M, Cornara N, Baryshnikova E. Plasma-Free Strategy for Cardiac Surgery with Cardiopulmonary Bypass in Infants < 10 kg: A Retrospective, Propensity-Matched Study. J Clin Med 2023; 12:3907. [PMID: 37373602 DOI: 10.3390/jcm12123907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 05/31/2023] [Accepted: 06/06/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Infants < 10 kg undergoing cardiac surgery with cardiopulmonary bypass (CPB) may receive either fresh frozen plasma (FFP) or other solutions in the CPB priming volume. The existing comparative studies are controversial. No study addressed the possibility of total avoidance of FFP throughout the whole perioperative course in this patient population. This retrospective, non-inferiority, propensity-matched study investigates an FFP-free strategy compared to an FFP-based strategy. METHODS Among patients <10 kg with available viscoelastic measurements, 18 patients who received a total FFP-free strategy were compared to 27 patients (1:1.5 propensity matching) receiving an FFP-based strategy. The primary endpoint was chest drain blood loss in the first 24 postoperative hours. The level of non-inferiority was settled at a difference of 5 mL/kg. RESULTS The 24-h chest drain blood loss difference between groups was -7.7 mL (95% confidence interval -20.8 to 5.3) in favor of the FFP-based group, and the non-inferiority hypothesis was rejected. The main difference in coagulation profile was a lower level of fibrinogen concentration and FIBTEM maximum clot firmness in the FFP-free group immediately after protamine, at the admission in the ICU and for 48 postoperative hours. No differences in transfusion of red blood cells or platelet concentrate were observed; patients in the FFP-free group did not receive FFP but required a larger dose of fibrinogen concentrate and prothrombin complex concentrate. CONCLUSIONS An FFP-free strategy in infants < 10 kg operated with CPB is technically feasible but results in an early post-CPB coagulopathy that was not completely compensated with our bleeding management protocol.
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Affiliation(s)
- Marco Ranucci
- Department of Cardiovascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, San Donato Milanese, 20097 Milan, Italy
| | - Umberto Di Dedda
- Department of Cardiovascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, San Donato Milanese, 20097 Milan, Italy
| | - Giuseppe Isgrò
- Department of Cardiovascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, San Donato Milanese, 20097 Milan, Italy
| | - Alessandro Giamberti
- Department of Congenital Heart Surgery, IRCCS Policlinico San Donato, San Donato Milanese, 20097 Milan, Italy
| | - Mauro Cotza
- Department of Cardiovascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, San Donato Milanese, 20097 Milan, Italy
| | - Noemi Cornara
- Department of Cardiovascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, San Donato Milanese, 20097 Milan, Italy
| | - Ekaterina Baryshnikova
- Department of Cardiovascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, San Donato Milanese, 20097 Milan, Italy
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Naguib AN, Carrillo SA, Corridore M, Bigelow AM, Walczak A, Tram NK, Hersey D, Galantowicz M, Tobias JD. A ROTEM-guided algorithm aimed to reduce blood product utilization during neonatal and infant cardiac surgery. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2023; 55:60-69. [PMID: 37378438 DOI: 10.1051/ject/2023017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 04/24/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND Neonates and infants undergoing cardiac surgery tend to receive high volumes of blood products. The use of rotational thromboelastometry (ROTEM®) has been shown to reduce the administration of blood products in adults after cardiac surgery. We sought to develop a targeted administration of blood products based on ROTEM® to reduce blood product utilization during and after neonatal and infant cardiac surgery. METHODS We conducted a retrospective review of data from a single center for neonates and infants undergoing congenital cardiac surgery using cardiopulmonary bypass (CPB) from September 2018-April 2019 (control group). Then, using a ROTEM® algorithm, we collected data prospectively between April-November 2021 (ROTEM group). Data collected included age, weight, gender, procedure, STAT score, CPB time, aortic cross-clamp time, volume, and type of blood products administered in the operating room and cardiothoracic intensive care unit (CTICU). In addition, ROTEM® data, coagulation profile in CTICU, chest tube output at 6 and 24 hours, use of factors concentrate, and thromboembolic complications were recorded. RESULTS The final cohort of patients included 28 patients in the control group and 40 patients in the ROTEM group. The cohort included neonates and infants undergoing the following procedures: arterial switch, aortic arch augmentation, Norwood procedure, and comprehensive stage II procedure. There were no differences in the demographics or procedure complexity between the two groups. Patients in the ROTEM® group received fewer platelets (36 ± 12 vs. 49 ± 27 mL/kg, p 0.028) and cryoprecipitate (8 ± 3 vs. 15 ± 10 mL/kg, p 0.001) intraoperatively when compared to the control group. CONCLUSION The utilization of ROTEM® may have contributed to a significant reduction in some blood product administration during cardiac surgery for infants and neonates. ROTEM® data may play a role in reducing blood product administration in neonatal and infant cardiac surgery.
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Affiliation(s)
- Aymen N Naguib
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Sergio A Carrillo
- Department of Cardiothoracic Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Marco Corridore
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Amee M Bigelow
- The Heart Center, Nationwide Children's Hospital, Department of Pediatrics, The Ohio State University, Columbus, Ohio, USA
| | - Ashley Walczak
- Department of Cardiothoracic Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Nguyen K Tram
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Diane Hersey
- Department of Cardiothoracic Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Mark Galantowicz
- Department of Cardiothoracic Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio, USA
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Abedzadeh M, Kachoueian N, Fazli A, Pazhoha M, Orouji Omid S, Vahid P, Givtaj N. The impact of using fresh frozen plasma in cardiopulmonary bypass preparation on thromboelastometric parameters and receiving blood products among pediatric patients undergoing cardiac surgery. J Cardiovasc Thorac Res 2023; 15:9-13. [PMID: 37342666 PMCID: PMC10278187 DOI: 10.34172/jcvtr.2023.30511] [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: 02/01/2022] [Accepted: 11/20/2022] [Indexed: 06/23/2023] Open
Abstract
Introduction: The aim of this study was to determine the effect of fresh frozen plasma (FFP) for priming of cardiopulmonary bypass (CPB) circuit on rotational thromboelastometry (ROTEM) and transfusion in pediatric cardiac surgery. Methods: Eighty patients younger than seven years old, were divided into case (FFP) (n=40) and control (n=40) groups. In the case group,10-20 mL/kg fresh frozen plasm was used for priming the CPB. The control group received 10-20 mL/kg of hydroxyethyl starch. ROTEM was done before surgical incision and after separation from CPB. The amount of transfusion (platelet and FFP) in the operating room and 24 hours after surgery were recorded. Results: Statistically significant difference was found between the case and control group in terms of changes in the Rotem parameters. The amount of transfusion of platelets in the operating room was significantly higher in the control group than in the case group. Conclusion: It seems that adding FFP to the prime solution is more effective in young patients and infants due to the higher susceptibility of the infant coagulation system to coagulation and hemorrhagic disorders in comparison with other patients.
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Affiliation(s)
- Maryam Abedzadeh
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Naser Kachoueian
- Department of Cardiac Surgery, Imam Hossein Educational Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Azadeh Fazli
- Azad University of Medical Sciences, Tehran, Iran
| | - Maryam Pazhoha
- Mazandaran University of Medical Sciences, Mazandaran, Iran
| | - Samira Orouji Omid
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Parvin Vahid
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Nader Givtaj
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
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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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Jenks CL, Landry LM, Garrison CF, Campbell JG, Weeks MF, Tramel SW, Knudson JD. Pediatric Extracorporeal Membrane Oxygenation Anticoagulation Protocol Associated with a Decrease in Complications. ASAIO J 2022; 68:275-280. [PMID: 33883505 DOI: 10.1097/mat.0000000000001438] [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] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) in pediatrics has rapidly progressed in recent years; however, there continues to be considerable variation in anticoagulation practices. In 2016, we implemented a standardized anticoagulation protocol in effort to reduce clotting and bleeding complications. A single-center retrospective analysis of pediatric patients requiring ECMO between 2014 and 2018 was performed. One hundred one ECMO cases in 94 pediatric patients met eligibility criteria (preprotocol = 64 cases; postprotocol = 37 cases). Demographics, ECMO parameters, complications, laboratories, and blood product requirements were analyzed for differences between the two groups. There was a significant decrease in the incidence of hematologic (p < 0.022), neurologic (p < 0.001), and renal complications (p < 0.001) in the postprotocol era. Incidence of bleeding, cardiac/pulmonary complications, and circuit changes were similar between the groups. The postprotocol group required fewer transfusions of red blood cells and cryoprecipitate. Additionally, platelet counts and fibrinogen levels were maintained higher in the postprotocol era. In conclusion, implementation of a standardized anticoagulation protocol was associated with improved anticoagulation parameters and a decrease in hematologic and neurologic complications, coagulopathy, renal injury, and blood product administration. We attribute these findings to transitioning to anti-Xa as a measure of heparinization and maintaining higher platelet counts.
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Affiliation(s)
- Christopher L Jenks
- From the Department of Pediatrics, Division of Pediatric Critical Care, University of Mississippi Medical Center, Jackson, Mississippi
| | - Lily M Landry
- Department of Pediatrics, Division of Pediatric Cardiology, University of Mississippi Medical Center, Jackson, Mississippi
| | - Carrie F Garrison
- Department of Pediatrics, Division of Pediatric Critical Care, Studer Family Children's Hospital at Sacred Heart, Pensacola, Florida
| | - Joshua G Campbell
- School of Medicine, University of Mississippi Medical Center, Jackson, Mississippi
| | - Mary F Weeks
- School of Medicine, University of Mississippi Medical Center, Jackson, Mississippi
| | - Sarah W Tramel
- School of Medicine, University of Mississippi Medical Center, Jackson, Mississippi
| | - Jarrod D Knudson
- From the Department of Pediatrics, Division of Pediatric Critical Care, University of Mississippi Medical Center, Jackson, Mississippi
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Siemens K, Donnelly P, Hunt BJ, Carter MJ, Murdoch IA, Tibby SM. Evaluating the Impact of Cardiopulmonary Bypass Priming Fluids on Bleeding After Pediatric Cardiac Surgery: A Systematic Review and Meta-Analysis. J Cardiothorac Vasc Anesth 2022; 36:1584-1594. [PMID: 35000839 DOI: 10.1053/j.jvca.2021.11.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 11/16/2021] [Accepted: 11/21/2021] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Cardiopulmonary bypass (CPB) predisposes young children to coagulopathy. The authors evaluated possible effects of CPB priming fluids on perioperative bleeding in pediatric cardiac surgery. DESIGN Meta-analysis and systematic review of previously published studies. SETTING Each study was conducted in a surgical center or intensive care unit. PARTICIPANTS Studies investigating patients <18 years without underlying hematologic disorders were included. INTERVENTIONS The authors evaluated randomized controlled trials (RCTs) published between 1980 and 2020 on MEDLINE, EMBASE, PubMed, and CENTRAL databases. The primary outcome was postoperative bleeding; secondary endpoints included blood product transfusion, mortality, and safety. MEASUREMENTS AND MAIN RESULTS Twenty eligible RCTs were analyzed, with a total of 1,550 patients and a median of 66 patients per study (range 20-200). The most frequently assessed intervention was adding fresh frozen plasma (FFP) to the prime (8/20), followed by albumin (5/20), artificial colloids (5/20), and blood-based priming solutions (3/20). Ten studies with 771 patients evaluated blood loss at 24 hours in mL/kg and were included in a meta-analysis. Most of them investigated the addition of FFP to the priming fluid (7/10). No significant difference was found between intervention and control groups, with a mean difference of -0.13 (-2.61 to 2.34), p = 0.92, I2 = 69%. Further study endpoints were described but their reporting was too heterogeneous to be quantitatively analyzed. CONCLUSIONS This systematic review of current evidence did not show an effect of different CPB priming solutions on 24-hour blood loss. The analysis was limited by heterogeneity within the dataset regarding population, type of intervention, dosing, and the chosen comparator, compromising any conclusions.
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Affiliation(s)
- K Siemens
- PICU Evelina London Children's Hospital, St Thomas' Hospital, London, United Kingdom
| | - P Donnelly
- PICU Evelina London Children's Hospital, St Thomas' Hospital, London, United Kingdom
| | - B J Hunt
- Haematology, St Thomas' Hospital, London, United Kingdom; Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - M J Carter
- PICU Evelina London Children's Hospital, St Thomas' Hospital, London, United Kingdom
| | - I A Murdoch
- PICU Evelina London Children's Hospital, St Thomas' Hospital, London, United Kingdom
| | - S M Tibby
- PICU Evelina London Children's Hospital, St Thomas' Hospital, London, United Kingdom; Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK..
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Nellis ME, Remy KE, Lacroix J, Cholette JM, Bembea MM, Russell RT, Steiner ME, Goobie SM, Vogel AM, Crighton G, Valentine SL, Delaney M, Parker RI. Research Priorities for Plasma and Platelet Transfusion Strategies in Critically Ill Children: From the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding. Pediatr Crit Care Med 2022; 23:e63-e73. [PMID: 34989706 PMCID: PMC8769351 DOI: 10.1097/pcc.0000000000002859] [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 a list of high-priority research initiatives for the study of plasma and platelet transfusions in critically ill children 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 pediatric patients at risk of bleeding and receiving plasma and/or platelet transfusions. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A panel of 13 experts developed research priorities for the study of plasma and platelet transfusions in critically ill children which were reviewed and ratified by the 29 Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding experts. The specific priorities focused on the following subpopulations: severe trauma, traumatic brain injury, intracranial hemorrhage, cardiopulmonary bypass surgery, extracorporeal membrane oxygenation, oncologic diagnosis or stem cell transplantation, acute liver failure and/or liver transplantation, noncardiac surgery, invasive procedures outside of the operating room, and sepsis and/or disseminated intravascular coagulation. In addition, tests to guide plasma and platelet transfusion, as well as component selection and processing, were addressed. We developed four general overarching themes and 14 specific research priorities using modified Research and Development/University of California, Los Angeles methodology. CONCLUSIONS Studies are needed to focus on the efficacy/harm, dosing, timing, and outcomes of critically ill children who receive plasma and/or platelet transfusions. The completion of these studies will facilitate the development of evidence-based recommendations.
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Affiliation(s)
- Marianne E Nellis
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, NY Presbyterian Hospital - Weill Cornell Medicine, New York, NY
| | - Kenneth E Remy
- Division of Pediatric Critical Care Medicine and Pulmonary/Critical Care Medicine, Departments of Pediatrics and Internal Medicine, Washington University of St. Louis, St. Louis, MO
| | - Jacques Lacroix
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Jill M Cholette
- Division of Pediatric Critical Care Medicine, University of Rochester Golisano Children's Hospital, Rochester, NY
| | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Robert T Russell
- Department of Surgery, University of Alabama Birmingham, Birmingham, AL
| | - Marie E Steiner
- Divisions of Critical Care and Hematology, Department of Pediatrics, University of Minnesota, Minneapolis, MN
| | - Susan M Goobie
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Adam M Vogel
- Division of Pediatric Surgery Texas Children's Hospital, Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Gemma Crighton
- Department of Haematology, Royal Children's Hospital, Melbourne, Australia
| | - Stacey L Valentine
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA
| | - Meghan Delaney
- Division of Pathology and Laboratory Medicine, Children's National Hospital; Department of Pathology and Pediatrics, The George Washington University Health Sciences, Washington, DC
| | - Robert I Parker
- Department of Pediatric Hematology/Oncology, Renaissance School of Medicine, State University of New York at Stony Brook, Stony Brook, NY
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Willems A, De Groote F, Schmartz D, Fils JF, Van der Linden P. Does a balanced colloid decrease perioperative blood loss in paediatric cardiac surgery: A double-blinded randomized controlled trial? Eur J Anaesthesiol 2021; 38:923-931. [PMID: 33966019 DOI: 10.1097/eja.0000000000001526] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Unbalanced fluid solutions cause metabolic acidosis and could be associated with impaired coagulation and increased blood loss. OBJECTIVE To investigate whether the use of a balanced colloid compared with a saline colloid for peri-operative fluid therapy in children undergoing cardiac surgery is associated with decreased blood loss and exposure to blood products. DESIGN Double-blinded randomised controlled trial. SETTING Tertiary children's hospital from 2013 to 2016. PATIENTS Children older than 29 days and younger than 3 years admitted for cardiac surgery with cardiopulmonary bypass (CPB). Exclusion criteria were emergency cardiac surgery, moribund (American Society of Anesthesiologists 5), Jehovah's witnesses, coagulopathy, renal failure, liver injury, intracranial haemorrhage and electrolyte disturbances. From the 128 patients eligible, 88 were included in the study. INTERVENTION Random assignment of patients to either a saline colloid (6% hydroxyethyl starch 130/0.4 in 0.9% NaCl) or a balanced-electrolyte colloid (6% hydroxyethyl starch 130/0.4 in an isotonic solution) for CPB priming and intra- and postoperative fluid therapy during the first postoperative 48 h. MAIN OUTCOME MEASURE The primary outcome measure was calculated blood loss until the third postoperative day (POD3). RESULTS A total of 44 patients were included in each study arm. Calculated blood loss at POD3 was not significantly different between the groups (saline colloid 19.9 [IQR 13.8 to 26.1] ml kg-1 versus balanced colloid 15.9 [IQR 9.0 to 25.3 ml kg-1], P = 0.409). Secondary outcomes related to bleeding, exposure to blood products and coagulation were not different between groups. There was also no difference in length of mechanical ventilation, intensive care and hospital length of stay between groups. CONCLUSION The use of a balanced colloid for peri-operative fluid therapy compared with a saline one is not associated with decreased blood loss or exposure to blood products. TRIAL REGISTRATION EudraCT identifier: 2012-006034-17 and ClinicalTrial.gov identifier: NCT02584868.
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Affiliation(s)
- Ariane Willems
- From the Paediatric Intensive Care Unit, Department of Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands (AW), Department of Anaesthesiology, University Hospital Brugmann and Queen Fabiola University Children's Hospital, Brussels, Belgium (F-DG, DS, P-VdL) and Ars Statistica, Nivelles, Belgium (JF-F)
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11
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Hanley C, Callum J, Karkouti K, Bartoszko J. Albumin in adult cardiac surgery: a narrative review. Can J Anaesth 2021; 68:1197-1213. [PMID: 33884561 DOI: 10.1007/s12630-021-01991-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 03/03/2021] [Accepted: 03/04/2021] [Indexed: 02/06/2023] Open
Abstract
PURPOSE Intravascular fluids are a necessary and universal component of cardiac surgical patient care. Both crystalloids and colloids are used to maintain or restore circulating plasma volume and ensure adequate organ perfusion. In Canada, human albumin solution (5% or 25% concentration) is a colloid commonly used for this purpose. In this narrative review, we discuss albumin supply in Canada, explore the perceived advantages of albumin, and describe the clinical literature supporting and refuting albumin use over other fluids in the adult cardiac surgical population. SOURCE We conducted a targeted search of PubMed, Embase, Medline, Web of Science, ProQuest Dissertations and Theses Global, the Cochrane Central Register of Controlled trials, and the Cochrane Database of Systematic Reviews. Search terms included albumin, colloid, cardiac surgery, bleeding, hemorrhage, transfusion, and cardiopulmonary bypass. PRINCIPAL FINDINGS Albumin is produced from fractionated human plasma and imported into Canada from international suppliers at a cost of approximately $21 million CAD per annum. While it is widely used in cardiac surgical patients across the country, it is approximately 30-times more expensive than equivalent doses of balanced crystalloid solutions, with wide inter-institutional variability in use and no clear association with improved outcomes. There is a general lack of high-quality evidence for the superiority of albumin over crystalloids in this patient population, and conflicting evidence regarding safety. CONCLUSIONS In cardiac surgical patients, albumin is widely utilized despite a lack of high- quality evidence supporting its efficacy or safety. A well-designed randomized controlled trial is needed to clarify the role of albumin in cardiac surgical patients.
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Affiliation(s)
- Ciara Hanley
- Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Jeannie Callum
- Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre, Toronto, ON, Canada
- Department of Pathology and Molecular Medicine, Queen's University, Kingston, ON, Canada
| | - Keyvan Karkouti
- Department of Anesthesia and Pain Management, Sinai Health System, Women's College Hospital, University Health Network, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, 200 Elizabeth Street 3EN-464, Toronto, ON, M5G 2C4, Canada
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Justyna Bartoszko
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, 200 Elizabeth Street 3EN-464, Toronto, ON, M5G 2C4, Canada.
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12
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Bhatia M, Kumar PA. Con: Routine Use of Fresh Frozen Plasma Should Not Be Used to Prime Cardiopulmonary Bypass Circuits During Cardiac Surgery. J Cardiothorac Vasc Anesth 2021; 35:3122-3124. [PMID: 34119415 DOI: 10.1053/j.jvca.2021.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 05/08/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Meena Bhatia
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Priya A Kumar
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC; Outcomes Research Consortium, Cleveland, OH
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Roberts J, Tolpin D. Pro: Priming the Cardiopulmonary Bypass Circuit With Fresh Frozen Plasma Reduces Bleeding in Complex Cardiac Surgery. J Cardiothorac Vasc Anesth 2021; 35:3118-3121. [PMID: 34144874 DOI: 10.1053/j.jvca.2021.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 05/08/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Jared Roberts
- Division of Cardiovascular Anesthesiology at the Texas Heart Institute at Baylor St. Luke's Medical Center, and Department of Anesthesiology, Baylor College of Medicine, Houston, TX.
| | - Daniel Tolpin
- Division of Cardiovascular Anesthesiology at the Texas Heart Institute at Baylor St. Luke's Medical Center, and Department of Anesthesiology, Baylor College of Medicine, Houston, TX
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Welch TP, Trivedi PM, Fang ZA, Ing RJ, Mittnacht AJC, Mossad EB. Selected 2020 Highlights in Congenital Cardiac Anesthesia. J Cardiothorac Vasc Anesth 2021; 35:2848-2854. [PMID: 33934987 DOI: 10.1053/j.jvca.2021.03.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 03/24/2021] [Indexed: 11/11/2022]
Abstract
This article is a review of the highlights of pertinent literature published during the 12 months of 2020 that are of interest to the congenital cardiac anesthesiologist. After a search of the US National Library of Medicine's PubMed database, several topics emerged for which significant contributions were made in 2020. The authors of the present article considered the following topics noteworthy to be included in this review: pediatric cardiac care in the coronavirus disease 2019 era, the use of mechanical circulatory support in coronavirus disease 2019-related multisystem inflammatory syndrome in children, transfusion and coagulation management in children undergoing congenital heart surgery, and pulmonary vein stenosis.
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Affiliation(s)
- Timothy P Welch
- Division of Pediatric Cardiovascular Anesthesia, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Premal M Trivedi
- Division of Pediatric Cardiovascular Anesthesia, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Zhe A Fang
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children Toronto, Ontario, Canada
| | - Richard J Ing
- Department of Anesthesiology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Alexander J C Mittnacht
- Department of Anesthesiology, Westchester Medical Center, New York Medical College, Valhalla, NY.
| | - Emad B Mossad
- Division of Pediatric Cardiovascular Anesthesia, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
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Dieu A, Van Regemorter V, Detaille T, Houtekie L, Eeckhoudt S, Khalifa C, Kahn D, Clement De Clety S, Poncelet A, Momeni M. Combined Use of Rotational Thromboelastometry (Rotem) and Platelet Impedance Aggregometry (Multiplate Analyzer) in Cyanotic and Acyanotic Infants and Children Undergoing Cardiac Surgery With Cardiopulmonary Bypass: Subgroup Analysis of a Randomized Clinical Trial. J Cardiothorac Vasc Anesth 2020; 35:2115-2123. [PMID: 33127287 DOI: 10.1053/j.jvca.2020.09.133] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 09/27/2020] [Accepted: 09/27/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Few studies have investigated the Multiplate platelet function analyzer in pediatrics. The authors evaluated Multiplate combined with Rotem in terms of guiding platelet transfusion after pediatric cardiac surgery with cardiopulmonary bypass (CPB). The authors further compared coagulation parameters between cyanotic and acyanotic patients. DESIGN Subgroup analysis of a randomized clinical trial. SETTING Tertiary hospital. PARTICIPANTS Patients weighing between seven and 15 kg. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Rotem and Multiplate tests were performed (1) after anesthesia induction, (2) upon CPB separation, and (3) upon intensive care unit arrival. Among a total of 59 subjects, 9 patients required platelet transfusion. In multivariate linear regression, analysis EXTEM maximum clot firmness upon CPB separation was associated with the volume of transfused platelets (regression coefficient = -0.348 [95% confidence interval -1.006 to -0.028]; p = 0.039). No such association was found for the Multiplate test. Acyanotic and cyanotic heart disease were present in 32 and 27 children, respectively. There were no significant differences between these two groups in terms of platelet count and function. Postoperative blood loss was significantly higher in the cyanotic group compared with the acyanotic arm (p = 0.015; difference [95% confidence interval -2.40 {-4.20 to -0.60}]). There were no differences between groups regarding transfusion of allogeneic blood products. CONCLUSIONS This study showed that Rotem, but not Multiplate results, were associated with platelet transfusion in pediatric cardiac surgery with no intake of platelet inhibitors. The usefulness of combining these tests in platelet transfusion decision-making needs to be evaluated in larger populations.
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Affiliation(s)
- Audrey Dieu
- Department of Anesthesiology, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Victoria Van Regemorter
- Department of Anesthesiology, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Thierry Detaille
- Department of Pediatric Intensive Care Unit, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Laurent Houtekie
- Department of Pediatric Intensive Care Unit, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Stéphane Eeckhoudt
- Department of Hematology, Laboratoires des Hôpitaux Universitaires de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Céline Khalifa
- Department of Anesthesiology, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - David Kahn
- Department of Anesthesiology, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Stéphan Clement De Clety
- Department of Pediatric Intensive Care Unit, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Alain Poncelet
- Department of Cardiac Surgery, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Mona Momeni
- Department of Anesthesiology, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium.
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Faraoni D, Caplan LA, DiNardo JA, Guzzetta NA, Miller-Hance WC, Latham G, Momeni M, Nicolson SC, Spaeth JP, Taylor K, Twite M, Vener DF, Zabala L, Nasr VG. Considerations for Pediatric Heart Programs During COVID-19: Recommendations From the Congenital Cardiac Anesthesia Society. Anesth Analg 2020; 131:403-409. [PMID: 32459667 PMCID: PMC7273948 DOI: 10.1213/ane.0000000000005015] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2020] [Indexed: 12/15/2022]
MESH Headings
- Betacoronavirus/pathogenicity
- COVID-19
- COVID-19 Testing
- Cardiology/standards
- Clinical Laboratory Techniques/standards
- Consensus
- Coronavirus Infections/diagnosis
- Coronavirus Infections/therapy
- Coronavirus Infections/transmission
- Coronavirus Infections/virology
- Delivery of Health Care, Integrated/standards
- Health Services Accessibility/standards
- Health Services Needs and Demand/standards
- Heart Defects, Congenital/diagnosis
- Heart Defects, Congenital/physiopathology
- Heart Defects, Congenital/therapy
- Host-Pathogen Interactions
- Humans
- Infant, Newborn
- Infection Control/standards
- Infectious Disease Transmission, Patient-to-Professional/prevention & control
- Infectious Disease Transmission, Vertical/prevention & control
- Needs Assessment/standards
- Pandemics
- Pediatrics/standards
- Personal Protective Equipment/standards
- Pneumonia, Viral/diagnosis
- Pneumonia, Viral/therapy
- Pneumonia, Viral/transmission
- Pneumonia, Viral/virology
- Risk Assessment
- Risk Factors
- SARS-CoV-2
- Time-to-Treatment/standards
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Affiliation(s)
- David Faraoni
- From the Division of Cardiac Anesthesia, Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Lisa A. Caplan
- Arthur S. Keats Division of Pediatric Cardiovascular Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas
| | - James A. DiNardo
- Division of Cardiac Anesthesia, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Nina A. Guzzetta
- Department of Anesthesiology, Emory University School of Medicine, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Wanda C. Miller-Hance
- Arthur S. Keats Division of Pediatric Cardiovascular Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas
- Section of Cardiology, Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston, Texas
| | - Gregory Latham
- Division of Pediatric Cardiac Anesthesia, Department of Anesthesiology and Pain Medicine, Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, Washington
| | - Mona Momeni
- Division of Cardiac Anesthesia, Department of Acute Medicine, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Institut de Recherche Expérimentale et Clinique, Brussels, Belgium
| | - Susan C. Nicolson
- Division of Cardiothoracic Anesthesia, The Cardiac Center at The Children’s Hospital of Philadelphia, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania
| | - James P. Spaeth
- Division of Cardiac Anesthesia, Department of Anesthesia, Cincinnati Children’s Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Katherine Taylor
- From the Division of Cardiac Anesthesia, Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Mark Twite
- Section of Pediatric Anesthesiology, Department of Anesthesiology, Children’s Hospital Colorado, University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - David F. Vener
- Arthur S. Keats Division of Pediatric Cardiovascular Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children’s Hospital, Baylor College of Medicine, Houston, Texas
| | - Luis Zabala
- Division of Pediatric Cardiac Anesthesia, Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Children’s Health, Dallas, Texas
| | - Viviane G. Nasr
- Division of Cardiac Anesthesia, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
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18
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Priming Cardiopulmonary Bypass in Pediatric Surgery: Reply. Anesthesiology 2020; 133:239-241. [PMID: 32412936 DOI: 10.1097/aln.0000000000003352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Fresh Frozen Plasma versus Crystalloid Priming of Cardiopulmonary Bypass Circuit in Pediatric Surgery: A Randomized Clinical Trial: Erratum. Anesthesiology 2020; 132:937. [PMID: 32168016 DOI: 10.1097/aln.0000000000003142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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