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Zajonz T, Edinger F, Hofmann J, Yoerueker U, Akintürk H, Markmann M, Müller M. Evaluation of Point-of-Care-Directed Coagulation Management in Pediatric Cardiac Surgery. Thorac Cardiovasc Surg 2024. [PMID: 39137896 DOI: 10.1055/s-0044-1788931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2024]
Abstract
BACKGROUND Coagulatory alterations are common after pediatric cardiac surgery and can be addressed with point-of-care (POC) coagulation analysis. The aim of the present study is to evaluate a preventive POC-controlled coagulation algorithm in pediatric cardiac surgery. METHODS This single-center, retrospective data analysis included patients younger than 18 years who underwent cardiac surgery with cardiopulmonary bypass (CPB) and received a coagulation therapy according to a predefined POC-controlled coagulation algorithm. Patients were divided into two groups (<10 and >10 kg body weight) because of different CPB priming strategies. RESULTS In total, 173 surgeries with the use of the POC-guided hemostatic therapy were analyzed. In 71% of cases, target parameters were achieved and only in one case primary sternal closure was not possible. Children with a body weight ≤10 kg underwent surgical re-evaluation in 13.2% (15/113), and respectively 6.7% (4/60) in patients >10 kg. Hemorrhage in children ≤10 kg was associated with cyanotic heart defects, deeper intraoperative hypothermia, longer duration of CPB, more complex procedures (RACHS-1 score), and with more intraoperative platelets, and respectively red blood cell concentrate transfusions (all p-values < 0.05). In children ≤10 kg, fibrinogen levels were significantly lower over the 12-hour postoperative period (without revision: 3.1 [2.9-3.3] vs. with revision 2.8 [2.3-3.4]). Hemorrhage in children >10 kg was associated with a longer duration of CPB (p = 0.042), lower preoperative platelets (p = 0.026), and over the 12-hour postoperative period lower platelets (p = 0.002) and fibrinogen (p = 0.05). CONCLUSION The use of a preventive, algorithm-based coagulation therapy with factor concentrates after CPB followed by POC created intraoperative clinical stable coagulation status with a subsequent executable thorax closure, although the presented algorithm in its current form is not superior in the reduction of the re-exploration rate compared to equivalent collectives. Reduced fibrinogen concentrations 12 hours after surgery may be associated with an increased incidence of surgical revisions.
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Affiliation(s)
- Thomas Zajonz
- Department of Anesthesiology, Operative Intensive Care and Pain Medicine, Justus Liebig Universität Giessen Fachbereich Medizin, Giessen, Hessen, Germany
| | - Fabian Edinger
- Department of Anesthesiology, Operative Intensive Care and Pain Medicine, Justus Liebig Universität Giessen Fachbereich Medizin, Giessen, Hessen, Germany
| | - Johannes Hofmann
- Department of Anesthesiology, Operative Intensive Care and Pain Medicine, Justus Liebig Universität Giessen Fachbereich Medizin, Giessen, Hessen, Germany
| | - Uygar Yoerueker
- Department of Childrens Heart Center and Cardiovascular Surgery, Justus Liebig Universität Giessen Fachbereich Medizin, Giessen, Hessen, Germany
| | - Hakan Akintürk
- Department of Childrens Heart Center and Cardiovascular Surgery, Justus Liebig Universität Giessen Fachbereich Medizin, Giessen, Hessen, Germany
| | - Melanie Markmann
- Department of Anesthesiology, Operative Intensive Care and Pain Medicine, Justus Liebig Universität Giessen Fachbereich Medizin, Giessen, Hessen, Germany
| | - Matthias Müller
- Department of Anesthesiology, Operative Intensive Care and Pain Medicine, Justus Liebig Universität Giessen Fachbereich Medizin, Giessen, Hessen, Germany
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Katsaras G, Gialamprinou D, Kontovazainitis CG, Psaroulaki E, Mitsiakos G. Neonatal hemostasis and the use of thromboelastography/rotational thromboelastometry in the neonatal period. Minerva Pediatr (Torino) 2024; 76:425-438. [PMID: 37166777 DOI: 10.23736/s2724-5276.23.07214-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
Developmental hemostasis refers to age-related alterations related to the progressive maturation of the hemostatic system. Although the conventional coagulation tests, such as prothrombin time (PT) and activated partial thromboplastin time (aPTT), are indeed helpful in coagulation workup, they do not accurately delineate the hemostasis in vivo. The viscoelastic tests, namely thromboelastography (TEG) and rotational thromboelastometry (ROTEM), seem to reflect hemostasis more accurately since they measure various clot parameters without excluding the cellular coagulation components. TEG and ROTEM have shown redaction in blood product administration when used in therapeutic algorithms in older children and adults, but their use in neonates is limited. This review summarizes the current literature regarding using these tests in the neonatal population. Several studies tried to resolve the lack of neonatal reference values of the TEG/ROTEM parameters by publishing neonatal reference ranges for various gestational age groups. Moreover, few studies concerning therapeutic hypothermia, neonates undergoing surgery, and critically ill neonates have shown some predictive value of these tests regarding bleeding events. Even though their results seem promising, larger studies of higher quality are needed to clarify any discrepancies and point out whether these tests have significant predictive value. In conclusion, viscoelastic tests need to be increasingly part of the NICUs' clinical routine and should be used along with conventional coagulation tests in transfusion therapy.
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Affiliation(s)
- Georgios Katsaras
- Department of Pediatrics, Hospital Unit of Edessa, General Hospital of Pella, Edessa, Greece -
- Second Neonatal Department and Neonatal Intensive Care Unit (NICU), Aristotle University of Thessaloniki, Papageorgiou Hospital, Thessaloniki, Greece -
| | - Dimitra Gialamprinou
- Second Neonatal Department and Neonatal Intensive Care Unit (NICU), Aristotle University of Thessaloniki, Papageorgiou Hospital, Thessaloniki, Greece
| | - Christos-Georgios Kontovazainitis
- Second Neonatal Department and Neonatal Intensive Care Unit (NICU), Aristotle University of Thessaloniki, Papageorgiou Hospital, Thessaloniki, Greece
| | - Evdokia Psaroulaki
- Department of Pediatrics, Hospital Unit of Edessa, General Hospital of Pella, Edessa, Greece
| | - Georgios Mitsiakos
- Second Neonatal Department and Neonatal Intensive Care Unit (NICU), Aristotle University of Thessaloniki, Papageorgiou Hospital, Thessaloniki, Greece
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3
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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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Nishida K, Kojima T, Monteleone MP, Watanabe F. Association Between Plasma Fibrinogen Concentration After Cardiopulmonary Bypass and Postoperative Blood Loss in Children Undergoing Cardiac Surgery: A Retrospective Cohort Study. Cureus 2023; 15:e38245. [PMID: 37252510 PMCID: PMC10225113 DOI: 10.7759/cureus.38245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2023] [Indexed: 05/31/2023] Open
Abstract
Background Intraoperative hypofibrinogenemia is a major factor associated with increased postoperative blood loss in adult cardiac surgery. However, previous pediatric studies on this topic did not sufficiently adjust for potential confounders and variations in surgeons' techniques. Therefore, evidence for the association between hypofibrinogenemia and postoperative blood loss after cardiac surgery in children remains insufficient. In this study, we aimed to evaluate the association between postoperative blood loss and hypofibrinogenemia by adjusting for potential confounders and the effects of differences in surgeons' techniques. Methodology This single-center, retrospective, cohort study included children who underwent cardiac surgery with cardiopulmonary bypass from April 2019 to March 2022. Multilevel logistic regression models with mixed effects were used to evaluate the association of major blood loss in the first six hours postoperatively with fibrinogen concentration at the end of cardiopulmonary bypass. The difference in the surgeon's techniques was adjusted as a random effect for the model. The model included potential confounders identified as risk factors in previous studies. Results A total of 401 patients were included. A fibrinogen concentration ≤150 mg/dL (adjusted odds ratio (aOR) = 2.08; 95% confidence interval (CI) = 1.18-3.67; p = 0.011) and the presence of cyanotic disease (aOR = 2.34; 95% CI = 1.10-4.97; p = 0.027) were associated with major blood loss in the first six postoperative hours. Conclusions A fibrinogen concentration ≤150 mg/dL and the presence of cyanotic disease were associated with postoperative blood loss in pediatric cardiac surgery. Maintaining a fibrinogen concentration >150 mg/dL is recommended, especially for patients with cyanotic diseases.
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Affiliation(s)
- Keisuke Nishida
- Department of Anesthesiology, Aichi Children's Health and Medical Center, Obu, JPN
| | - Taiki Kojima
- Department of Anesthesiology, Aichi Children's Health and Medical Center, Obu, JPN
- Division of Comprehensive Pediatric Medicine, Nagoya University Graduate School of Medicine, Nagoya, JPN
| | - Matthew P Monteleone
- Division of Cardiac Anesthesia, Cincinnati Children's Hospital Medical Center, Ohio, USA
| | - Fumio Watanabe
- Department of Anesthesiology, Aichi Children's Health and Medical Center, Obu, JPN
- Division of Comprehensive Pediatric Medicine, Nagoya University Graduate School of Medicine, Nagoya, JPN
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5
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Viscoelastic Testing and Factor Concentrate Therapy to Reduce Bleeding and Transfusions in the Surgical Separation of Ischiophagus Twins: A Case Report. A A Pract 2022; 16:e01594. [DOI: 10.1213/xaa.0000000000001594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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6
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George S, Wake E, Jansen M, Roy J, Maconachie S, Paasilahti A, Wiseman G, Gibbons K, Winearls J. Fibrinogen Early In Severe paediatric Trauma studY (FEISTY junior): protocol for a randomised controlled trial. BMJ Open 2022; 12:e057780. [PMID: 35508351 PMCID: PMC9073392 DOI: 10.1136/bmjopen-2021-057780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Trauma causes 40% of child deaths in high-income countries, with haemorrhage being a leading contributor to death in this population. There is a growing recognition that fibrinogen and platelets play a major role in trauma-induced coagulopathy (TIC) but the exact physiological mechanisms are poorly understood. METHODS AND ANALYSIS This is a prospective multicentre, open-label, randomised, two-arm parallel feasibility study conducted in the emergency departments, intensive care units and operating theatres of participating hospitals. Severely injured children, aged between 3 months and 18 years, presenting with traumatic haemorrhage requiring transfusion of blood products will be screened for inclusion.Sixty-eight patients will be recruited and will be allocated to fibrinogen replacement using fibrinogen concentrate (FC) or cryoprecipitate in a 1:1 ratio. Fibrinogen replacement will be administered to patients with a FIBTEM A5 of ≤10. All other aspects of the currently used rotational thromboelastometry-guided treatment algorithm and damage-control approach to trauma remain the same in both groups.The primary outcome is time to administration of fibrinogen replacement from time of identification of hypofibrinogenaemia. Clinical secondary outcomes and feasibility outcomes will also be analysed. ETHICS AND DISSEMINATION This study has received ethical clearance from the Children's Health Queensland Human Research Ethics Committee (HREC/17/QRCH/78). Equipment and consumables for sample testing have been provided to the study by Haemoview Diagnostics, Werfen Australia and Haemonetics Australia. FC has been provided by CSL Behring, Australia. The funding bodies and industry partners have had no input into the design of the study, and will not be involved in the preparation or submission of the manuscript for publication.The use of viscoelastic haemostatic assays and early fibrinogen replacement has the potential to improve outcomes in paediatric trauma through earlier recognition of TIC. This in turn may reduce transfusion volumes and downstream complications and reduce the reliance on donor blood products such as cryoprecipitate.The use of FC has implications for regional and remote centres who would not routinely have access to cryoprecipitate but could store FC easily. Access to early fibrinogen replacement in these centres could make a significant impact and assist in closing the gap in trauma care available to residents of these communities.Outcomes of this study will be submitted for publication in peer-reviewed journals and submitted for presentation at national and international scientific fora. TRIAL REGISTRATION NUMBER NCT03508141.
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Affiliation(s)
- Shane George
- Departments of Emergency Medicine and Children's Critical Care, Gold Coast University Hospital, Southport, Queensland, Australia
- School of Medicine and Menzies Health Institute Queensland, Griffith University, Southport, Queensland, Australia
- Child Health Research Centre, The University of Queensland, South Brisbane, Queensland, Australia
| | - Elizabeth Wake
- Trauma Service, Gold Coast University Hospital, Southport, Queensland, Australia
- School of Medical Sciences, Griffith University, Southport, Queensland, Australia
| | - Melanie Jansen
- Paedatiatric Intensive Care Unit, Children's Hospital at Westmead, Westmead, New South Wales, Australia
- Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
| | - John Roy
- Department of Haematology, Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Sharon Maconachie
- Department of Anaesthesia, Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Anni Paasilahti
- Department of Intensive Care, Mackay Base Hospital, Mackay, Queensland, Australia
| | - Greg Wiseman
- Paediatric Intensive Care Unit, Townsville Hospital and Health Service, Townsville, Queensland, Australia
| | - Kristen Gibbons
- Child Health Research Centre, The University of Queensland, South Brisbane, Queensland, Australia
| | - James Winearls
- School of Medical Sciences, Griffith University, Southport, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Herston, Queensland, Australia
- Department of Intensive Care Medicine, Gold Coast University Hospital, Southport, Queensland, Australia
- Department of Intensive Care Medicine, St Andrews War Memorial Hospital, Brisbane, Queensland, Australia
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7
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Cholette JM, Muszynski JA, Ibla JC, Emani S, Steiner ME, Vogel AM, Parker RI, Nellis ME, Bembea MM. Plasma and Platelet Transfusions Strategies in Neonates and Children Undergoing Cardiac Surgery With Cardiopulmonary Bypass or Neonates and Children Supported by Extracorporeal Membrane Oxygenation: From the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding. Pediatr Crit Care Med 2022; 23:e25-e36. [PMID: 34989703 PMCID: PMC8769357 DOI: 10.1097/pcc.0000000000002856] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To present the recommendations and consensus statements with supporting literature for plasma and platelet transfusions in critically ill neonates and children undergoing cardiac surgery with cardiopulmonary bypass or supported by extracorporeal membrane oxygenation from the Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding. DESIGN Systematic review and consensus conference of international, multidisciplinary experts in platelet and plasma transfusion management of critically ill children. SETTING Not applicable. PATIENTS Critically ill neonates and children following cardiopulmonary bypass or supported by extracorporeal membrane oxygenation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A panel of nine experts developed evidence-based and, when evidence was insufficient, expert-based statements for plasma and platelet transfusions in critically ill neonates and children following cardiopulmonary bypass or supported by extracorporeal membrane oxygenation. These statements were reviewed and ratified by the 29 Transfusion and Anemia EXpertise Initiative-Control/Avoidance of Bleeding experts. A systematic review was conducted using MEDLINE, EMBASE, and Cochrane Library databases, from inception to December 2020. Consensus was obtained using the Research and Development/University of California, Los Angeles Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. We developed one good practice statement, two recommendations, and three expert consensus statements. CONCLUSIONS Whereas viscoelastic testing and transfusion algorithms may be considered, in general, evidence informing indications for plasma and platelet transfusions in neonatal and pediatric patients undergoing cardiac surgery with cardiopulmonary bypass or those requiring extracorporeal membrane oxygenation support is lacking.
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Affiliation(s)
- Jill M Cholette
- Department of Pediatrics, University of Rochester Golisano Children's Hospital, Rochester, NY
| | - Jennifer A Muszynski
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Juan C Ibla
- Division of Cardiac Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Sitaram Emani
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA
| | - Marie E Steiner
- Divisions of Critical Care and Hematology, Department of Pediatrics, University of Minnesota Masonic Children's Hospital, Minneapolis, MN
| | - Adam M Vogel
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Baylor College of Medicine, Houston, TX
| | - Robert I Parker
- Professor Emeritus, Department of Pediatrics, Hematology/Oncology, Renaissance School of Medicine, SUNY at Stony Brook, Stony Brook, NY
| | - Marianne E Nellis
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, NY Presbyterian Hospital - Weill Cornell Medicine, New York, NY
| | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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8
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Hanson SJ, Karam O, Birch R, Goel R, Patel RM, Sola-Visner M, Sachais BS, Hauser RG, Luban NLC, Gottschall J, Josephson CD, Hendrickson JE, Karafin MS, Nellis ME. Transfusion Practices in Pediatric Cardiac Surgery Requiring Cardiopulmonary Bypass: A Secondary Analysis of a Clinical Database. Pediatr Crit Care Med 2021; 22:978-987. [PMID: 34261944 PMCID: PMC8570986 DOI: 10.1097/pcc.0000000000002805] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To describe blood component usage in transfused children with congenital heart disease undergoing cardiopulmonary bypass surgery across perioperative settings and diagnostic categories. DESIGN Datasets from U.S. hospitals participating in the National Heart, Lung, and Blood Institute Recipient Epidemiology and Donor Evaluation Study-III were analyzed. SETTING Inpatient admissions from three U.S. hospitals from 2013 to 2016. PATIENTS Transfused children with congenital heart disease undergoing single ventricular, biventricular surgery, extracorporeal membrane oxygenation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Eight hundred eighty-two transfused patients were included. Most of the 185 children with single ventricular surgery received multiple blood products: 81% RBCs, 79% platelets, 86% plasma, and 56% cryoprecipitate. In the 678 patients undergoing biventricular surgery, 85% were transfused plasma, 75% platelets, 74% RBCs, and 48% cryoprecipitate. All 19 patients on extracorporeal membrane oxygenation were transfused RBCs, plasma, and cryoprecipitate, and 18 were transfused platelets. Intraoperatively, patients commonly received all three components, while postoperative transfusions were predominantly single blood components. Pretransfusion hemoglobin values were normal/low-normal for age for all phases of care for single ventricular surgery (median hemoglobin 13.2-13.5 g/dL). Pretransfusion hemoglobin values for biventricular surgeries were higher intraoperatively compared with other timing (12.2 g/dL vs 11.2 preoperative and postoperative; p < 0.0001). Plasma transfusions for all patients were associated with a near normal international normalized ratio: single ventricular surgeries median international normalized ratio was 1.3 postoperative versus 1.8 intraoperative and biventricular surgeries median international normalized ratio was 1.1 intraoperative versus 1.7 postoperative. Intraoperative platelet transfusions with biventricular surgeries had higher median platelet count compared with postoperative pretransfusion platelet count (244 × 109/L intraoperative vs 69 × 109/L postoperative). CONCLUSIONS Children with congenital heart disease undergoing cardiopulmonary bypass surgery are transfused many blood components both intraoperatively and postoperatively. Multiple blood components are transfused intraoperatively at seemingly normal/low-normal pretransfusion values. Pediatric evidence guiding blood component transfusion in this population at high risk of bleeding and with limited physiologic reserve is needed to advance safe and effective blood conservation practices.
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Affiliation(s)
| | - Oliver Karam
- Children’s Hospital of Richmond. Virginia Commonwealth University School of Medicine, Richmond, VA
| | | | - Ruchika Goel
- Johns Hopkins University School of Medicine, Baltimore, MD
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9
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Velik‐Salchner C, Tauber H, Rastner V, Pajk W, Mittermayr M, Wally D, Kilo J, Vondrys D, Fries D, Fritz J, Streif W. Administration of fibrinogen concentrate combined with prothrombin complex maintains hemostasis in children undergoing congenital heart repair (a long-term propensity score-matched study). Acta Anaesthesiol Scand 2021; 65:1178-1186. [PMID: 34152599 PMCID: PMC8518112 DOI: 10.1111/aas.13945] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 05/05/2021] [Accepted: 05/26/2021] [Indexed: 12/28/2022]
Abstract
Background Bleeding is a common problem in children with congenital heart disease undergoing major cardiac surgery requiring cardiopulmonary bypass (CPB). Little is known about optimal management with blood products. Objective To investigate clinical outcome and hemostatic effects of fibrinogen concentrate (FC) in combination with prothrombin complex concentrate (PCC) versus standard treatment with fresh frozen plasma (FFP) in children undergoing cardiac surgery. Methods For this single‐institution cohort study, data on 525 children were analyzed. Propensity score matching in 210 children was applied to reduce the impact of various baseline characteristics. Results Three children treated with FC/PCC developed surgical site bleeding requiring surgical revision. One child developed central venous line‐related thrombosis. Blood loss through chest tube drainage was independent of FC/PCC. Coagulation abnormalities were not present in any of these children. Time to extubation and ICU stay did not differ. In the FC/PCC group, children received (median, Q1, Q3) 52 mg/kg (32, 83) FC and 28IU/kg (13, 44) PCC. Fibrinogen concentration was comparable at baseline. On admission to the ICU, fibrinogen was higher in children receiving FC/PCC, namely, 232 mg/dL (196, 280), than in children receiving FFP (186 mg/dL, 149, 224; P < .001). On discharge from the ICU, values did not differ ((FC/PCC 416 mg/dL (288, 501)), non‐FC/PCC 418 mg/dL (272, 585; P = 1.000)). Conclusion FC/PCC was well tolerated and permitted hemostasis to be maintained, even in the very young. We were not able to detect a signal for inferiority of this treatment. We conclude that FC/PCC can safely replace FFP.
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Affiliation(s)
- Corinna Velik‐Salchner
- Department of Anaesthesiology and Intensive Care Medicine Medical University of Innsbruck Innsbruck Austria
| | - Helmuth Tauber
- Department of Anaesthesiology and Intensive Care Medicine Medical University of Innsbruck Innsbruck Austria
| | - Verena Rastner
- Department of Anaesthesiology and Intensive Care Medicine Medical University of Innsbruck Innsbruck Austria
| | - Werner Pajk
- Department of Anaesthesiology and Intensive Care Medicine Medical University of Innsbruck Innsbruck Austria
| | - Markus Mittermayr
- Department of Anaesthesiology and Intensive Care Medicine Medical University of Innsbruck Innsbruck Austria
| | - Dieter Wally
- Department of Anaesthesiology and Intensive Care Medicine Medical University of Innsbruck Innsbruck Austria
| | - Juliane Kilo
- Department of Cardiac Surgery Medical University of Innsbruck Innsbruck Austria
| | - David Vondrys
- Department of Cardiac Surgery Medical University of Innsbruck Innsbruck Austria
| | - Dietmar Fries
- Department of Anaesthesiology and Intensive Care Medicine Medical University of Innsbruck Innsbruck Austria
| | - Josef Fritz
- Department of Medical Statistics Informatics and Health Economics Medical University of Innsbruck Innsbruck Austria
| | - Werner Streif
- Department of Paediatrics Medical University of Innsbruck Innsbruck Austria
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10
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Cannata G, Mariotti Zani E, Argentiero A, Caminiti C, Perrone S, Esposito S. TEG ® and ROTEM ® Traces: Clinical Applications of Viscoelastic Coagulation Monitoring in Neonatal Intensive Care Unit. Diagnostics (Basel) 2021; 11:1642. [PMID: 34573982 PMCID: PMC8465234 DOI: 10.3390/diagnostics11091642] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 08/28/2021] [Accepted: 09/04/2021] [Indexed: 12/14/2022] Open
Abstract
The concentration of the majority of hemostatic proteins differs considerably in early life, especially in neonates compared to adulthood. Knowledge of the concept of developmental hemostasis is an essential prerequisite for the proper interpretation of conventional coagulation tests (CCT) and is critical to ensure the optimal diagnosis and treatment of hemorrhagic and thrombotic diseases in neonatal age. Viscoelastic tests (VETs) provide a point-of-care, real-time, global, and dynamic assessment of the mechanical properties of the coagulation system with the examination of both cellular and plasma protein contributions to the initiation, formation, and lysis of clots. In this work, we provide a narrative review of the basic principles of VETs and summarize current evidence regarding the two most studied point-of-care VETs, thromboelastography (TEG®) and rotational thromboelastometry (ROTEM®), in the field of neonatal care. A literature analysis shows that viscoelastic hemostatic monitoring appears to be a useful additive technique to CCT, allowing targeted therapy to be delivered quickly. These tools may allow researchers to determine the neonatal coagulation profile and detect neonatal patients at risk for postoperative bleeding, coagulation abnormalities in neonatal sepsis, and other bleeding events in a timely manner, guiding transfusion therapies using the goal-oriented transfusion algorithm. However, diagnosis and treatment algorithms incorporating VETs for neonatal patients in a variety of clinical situations should be developed and applied to improve clinical outcomes. Further studies should be performed to make routinary diagnostic and therapeutic application possible for the neonatal population.
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Affiliation(s)
- Giulia Cannata
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, via Gramsci 14, 43126 Parma, Italy; (G.C.); (E.M.Z.); (A.A.)
| | - Elena Mariotti Zani
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, via Gramsci 14, 43126 Parma, Italy; (G.C.); (E.M.Z.); (A.A.)
| | - Alberto Argentiero
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, via Gramsci 14, 43126 Parma, Italy; (G.C.); (E.M.Z.); (A.A.)
| | - Caterina Caminiti
- Research and Innovation Unit, University Hospital of Parma, via Gramsci 14, 43126 Parma, Italy;
| | - Serafina Perrone
- Neonatology Unit, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, via Gramsci 14, 43126 Parma, Italy;
| | - Susanna Esposito
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, via Gramsci 14, 43126 Parma, Italy; (G.C.); (E.M.Z.); (A.A.)
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11
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Haas T, Faraoni D. Viscoelastic testing in pediatric patients. Transfusion 2021; 60 Suppl 6:S75-S85. [PMID: 33089938 DOI: 10.1111/trf.16076] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 06/04/2020] [Accepted: 06/14/2020] [Indexed: 12/18/2022]
Abstract
A tailored transfusion algorithm based on viscoelastic testing in the perioperative period or in trauma patients is recommended by guidelines for bleeding management. Bleeding management strategies in neonates and children are mostly extrapolated from the adult experience, as published evidence in the youngest age group is scarce. This manuscript is intended to give a structured overview of what has been published on the use of viscoelastic testing to guide bleeding management in neonates and children. Several devices that use either the traditional viscoelastic method or resonance viscoelastography technology are on the market. Reference ranges for children have been evaluated in only some of them. As most of the hemostasis maturation processes can be observed during the first year of life, adult reference ranges for viscoelastic testing could be applied over the age of 1 year. The majority of the published trials in children are based on retrospective analyses describing the correlation between viscoelastic testing and standard laboratory testing or focusing on the prediction of bleeding. Clinically more relevant studies in pediatric patients undergoing cardiac surgery have demonstrated that the implementation of a transfusion algorithm based on viscoelastic testing has significantly reduced transfusion requirements and that this approach has enabled a rapid detection of coagulation disorders in the presence of excessive bleeding. Although further studies are urgently needed, experts have reviewed the use of a transfusion algorithm based on viscoelastic testing in children as a feasible approach, as it has been shown to improve bleeding management and rationalize blood product transfusion.
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Affiliation(s)
- Thorsten Haas
- Department of Pediatric Anesthesia, Zurich University Children's Hospital, Zurich, Switzerland
| | - David Faraoni
- Division of Cardiac Anesthesia, Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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12
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Boettcher W, Schulz A, Sinzobahamvya N, Dehmel F, Redlin M, Schmitt K, Cho MY, O'Brien B, Photiadis J. Coagulation Profile of Neonates Undergoing Arterial Switch Surgery With Crystalloid Priming of the Cardiopulmonary Bypass Circuit. J Cardiothorac Vasc Anesth 2021; 36:1598-1605. [PMID: 34462202 DOI: 10.1053/j.jvca.2021.08.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 07/30/2021] [Accepted: 08/02/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The aim was to evaluate changes in the coagulation profile of cyanotic neonates, to analyze the effects of cardiopulmonary bypass (CPB) with crystalloid priming on their coagulation status, and to determine factors predicting a requirement for hemostasis-derived transfusion. DESIGN Retrospective cohort. SETTING Single-center, tertiary academic hospital. PARTICIPANTS In total, 100 consecutive neonates who underwent arterial switch surgery between December 2014 and June 2020. INTERVENTIONS Rotational thromboelastometry (ROTEM) and coagulation parameters before surgery and before termination of CPB were evaluated. Transfusion of platelets, fresh frozen plasma, and fibrinogen, defined as hemostasis-derived transfusion (HD transfusion), were determined. Patients with and without HD transfusion were compared to identify predictors. MEASUREMENTS AND MAIN RESULTS After CPB, fibrinogen was reduced by 24.5% (interquartile range [IQR] 8.9-32.1) to 201 mg/dL (IQR 172-249), resulting in a reduction of FIBTEM A10 by 20% (1.8-33.3) to 8 mm (6-11). The platelet count decreased by a median of 47.2% (25.6-61.3) to 162 × 103/µL (119-215). However, the median fibrinogen concentration and platelet count remained within normal range. Neonates with abnormal ROTEM results were more likely to receive HD transfusions. The HD transfusions were more likely with lower preoperative FIBTEM maximum clot firmness values (p = 0.031), lower hemoglobin concentrations at termination of CPB (p = 0.02), and longer CPB duration (p = 0.017). Perioperative hemostasis without any HD transfusion was achieved in 64 neonates. CONCLUSIONS Guidance from ROTEM analyses facilitates hemostasis management after neonatal CPB. Circuit miniaturization with transfusion-free CPB is associated with acceptable changes in ROTEM in most patients, and allows sufficient hemostasis without any HD transfusions in most patients.
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Affiliation(s)
- Wolfgang Boettcher
- Department of Congenital Heart Surgery and Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany.
| | - Antonia Schulz
- Department of Congenital Heart Surgery and Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany
| | - Nicodème Sinzobahamvya
- Department of Congenital Heart Surgery and Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany
| | - Frank Dehmel
- Department of Congenital Heart Surgery and Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany
| | - Mathias Redlin
- Department of Cardiac Anesthesiology and Intensive Care Medicine, German Heart Center Berlin, Berlin, Germany
| | - Katharina Schmitt
- Department of Congenital Heart Disease-Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Mi-Young Cho
- Department of Congenital Heart Surgery and Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany
| | - Benjamin O'Brien
- Department of Cardiac Anesthesiology and Intensive Care Medicine, German Heart Center Berlin, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany; Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité Universitaetsmedizin, Berlin, Germany
| | - Joachim Photiadis
- Department of Congenital Heart Surgery and Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany
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13
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Understanding and managing the complex balance between bleeding and thrombosis following cardiopulmonary bypass in paediatric cardiac surgical patients. Cardiol Young 2021; 31:1251-1257. [PMID: 34024303 DOI: 10.1017/s1047951121001955] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Bleeding in the perioperative period of congenital heart surgery with cardiopulmonary bypass is associated with increased morbidity and mortality both from the direct effects of haemorrhage as well as the therapies deployed to restore haemostasis. Perioperative bleeding is complex and multifactorial with both patient and procedural contributions. Moreover, neonates and infants are especially at risk. The objective of this review is to summarise the evidence regarding bleeding management in paediatric surgical patients and identify strategies that might facilitate appropriate bleeding management while minimising the risk of thrombosis. We will address the use of standard and point-of-care tests, and the role of contemporary coagulation factors and other novel drugs.
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14
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Donahue BS. Commentary: Coagulation Testing in Pediatric Cardiac Surgery: The Small Picture and the Big Picture. Semin Thorac Cardiovasc Surg 2021; 34:291-292. [PMID: 33662556 DOI: 10.1053/j.semtcvs.2021.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 02/16/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Brian S Donahue
- Division of Pediatric Cardiac Anesthesia, Departments of Anesthesiology and Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee.
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15
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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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16
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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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17
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Siemens K, Hunt BJ, Harris J, Nyman AG, Parmar K, Tibby SM. Individualized, Intraoperative Dosing of Fibrinogen Concentrate for the Prevention of Bleeding in Neonatal and Infant Cardiac Surgery Using Cardiopulmonary Bypass (FIBCON): A Phase 1b/2a Randomized Controlled Trial. Circ Cardiovasc Interv 2020; 13:e009465. [PMID: 33213194 DOI: 10.1161/circinterventions.120.009465] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Mediastinal bleeding is common following pediatric cardiopulmonary bypass surgery for congenital heart disease. Fibrinogen concentrate (FC) represents a potential therapy for preventing bleeding. METHODS We performed a single-center, phase 1b/2a, randomized controlled trial on infants 2.5 to 12 kg undergoing cardiopulmonary bypass surgery, aimed at (1) demonstrating the feasibility of an intraoperative point-of-care test, rotational thromboelastometry, to screen out patients at low risk of postoperative bleeding and then guide individualized FC dosing in high-risk patients and (2) determining the dose, safety, and efficacy of intraoperative FC supplementation. Screening occurred intraoperatively 1-hour before bypass separation using the rotational thromboelastometry variable fibrinogen thromboelastometry maximum clot firmness (FibTEM-MCF; fibrinogen contribution to clot firmness). If FibTEM-MCF ≥7 mm, patients entered the monitoring cohort. If FibTEM-MCF ≤6 mm, patients were randomized to receive FC/placebo (2:1 ratio). Individualized FC dose calculation included weight, bypass circuit volume, hematocrit, and intraoperative measured and desired FibTEM-MCF. The coprimary outcomes, measured 5 minutes post-FC administration were FibTEM-MCF (desired range, 8-13 mm) and fibrinogen levels (desired range, 1.5-2.5 g/L). Secondary outcomes were thrombosis and thrombosis-related major complications and postoperative 24-hour mediastinal blood loss. RESULTS We enrolled 111 patients (cohort, n=21; FC, n=60; placebo, n=30); mean (SD) age, 6.4 months (5.8); weight, 5.9 kg (2.0). Intraoperative rotational thromboelastometry screening effectively excluded low-risk patients, in that none in the cohort arm (FibTEM-MCF, ≥7 mm) demonstrated clinically significant early postoperative bleeding (>10 mL/kg per 4 hours). Among randomized patients, the median (range) FC administered dose was 114 mg/kg (51-218). Fibrinogen levels increased from a mean (SD) of 0.91 (0.22) to 1.7 g/L (0.41). The postdose fibrinogen range was 1.2 to 3.3 g/L (72% within the desired range). The corresponding FibTEM-MCF values were as follows: pre-dose, 5.3 mm (1.9); post-dose, 13 mm (3.2). Ten patients (8 FC and 2 placebo) exhibited 12 possible thromboses; none were clearly related to FC. There was an overall difference in mean (SD) 24-hour mediastinal drain loss: cohort, 12.6 mL/kg (6.4); FC, 11.6 mL/kg (5.2); placebo, 17.1 mL/kg (14.3; ANOVA P=0.02). CONCLUSIONS Intraoperative, individualized dosing of FC appears feasible. The need for individualized dosing is supported by the finding that a 4-fold variation in FC dose is required to achieve therapeutic fibrinogen levels. Registration: URL: https://eudract.ema.europa.eu/; Unique identifier: 2013-003532-68. URL: https://www.isrctn.com/; Unique identifier: 50553029.
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Affiliation(s)
- Kristina Siemens
- Department of Paediatric Intensive Care, Evelina London Children's Hospital, United Kingdom (K.S., J.H., A.G.N., S.M.T.)
| | - Beverley J Hunt
- Department of Haematology, St Thomas' Hospital, London, United Kingdom (B.J.H., K.P.)
| | - Julia Harris
- Department of Paediatric Intensive Care, Evelina London Children's Hospital, United Kingdom (K.S., J.H., A.G.N., S.M.T.)
| | - Andrew G Nyman
- Department of Paediatric Intensive Care, Evelina London Children's Hospital, United Kingdom (K.S., J.H., A.G.N., S.M.T.)
| | - Kiran Parmar
- Department of Haematology, St Thomas' Hospital, London, United Kingdom (B.J.H., K.P.)
| | - Shane M Tibby
- Department of Paediatric Intensive Care, Evelina London Children's Hospital, United Kingdom (K.S., J.H., A.G.N., S.M.T.)
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18
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The Use of Hemostatic Blood Products in Children Following Cardiopulmonary Bypass and Associated Outcomes. Crit Care Explor 2020; 2:e0172. [PMID: 32832911 PMCID: PMC7418899 DOI: 10.1097/cce.0000000000000172] [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] [Indexed: 02/06/2023] Open
Abstract
To describe the use of hemostatic transfusions in children following cardiac surgery with cardiopulmonary bypass and the association of hemostatic transfusions postoperatively with clinical outcomes.
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19
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Switzer T, Faraoni D. Blood Conservation in Pediatric Surgical Patients. CURRENT ANESTHESIOLOGY REPORTS 2020. [DOI: 10.1007/s40140-020-00399-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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20
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Bianchi P, Beccaris C, Norbert M, Dunlop B, Ranucci M. Use of Coagulation Point-of-Care Tests in the Management of Anticoagulation and Bleeding in Pediatric Cardiac Surgery: A Systematic Review. Anesth Analg 2020; 130:1594-1604. [PMID: 32224832 DOI: 10.1213/ane.0000000000004563] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Bleeding and coagulation management are essential aspects in the management of neonates and children undergoing cardiac surgery. The use of point-of-care tests (POCTs) in a pediatric setting is not as widely used as in the adult setting. This systematic review aims to summarize the evidence showed by the literature regarding the use of POCTs in children undergoing cardiac surgery. We included all studies examining the pediatric population (<18 years old) undergoing cardiac surgery in which the coagulation profile was assessed with POCTs. Three electronic databases (PubMed, Embase, and the Cochrane Controlled Clinical Trials register) were searched. Tests involved were heparin effect tests, viscoelastic tests, and platelet function tests. Due to the wide heterogeneity of the patients and tests studied, a formal meta-analysis was impossible, and the results are therefore presented through a systematic review. Eighty articles were found, of which 47 are presented in this review. At present, literature data are too weak to define POCTs as a "gold standard" for the treatment of perioperative bleeding in pediatric cardiac surgery. Nevertheless, introduction of POCTs into postoperative algorithms has shown to improve bleeding management, patient outcome, and cost efficiency.
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Affiliation(s)
- Paolo Bianchi
- From the Department of Anesthesia and Intensive Care, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
| | - Camilla Beccaris
- Great Ormond Street Hospital NHS Foundation Trust, Cardiac Intensive Care Unit, London, United Kingdom
| | | | | | - Marco Ranucci
- Department of Cardiothoracic, Vascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, Milan, Italy
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Scala E, Coutaz C, Gomez F, Alberio L, Marcucci C. Comparison of ROTEM Sigma to Standard Laboratory Tests and Development of an Algorithm for the Management of Coagulopathic Bleeding in a Tertiary Center. J Cardiothorac Vasc Anesth 2020; 34:640-649. [DOI: 10.1053/j.jvca.2019.10.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 10/03/2019] [Accepted: 10/07/2019] [Indexed: 01/17/2023]
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Cholette JM, Faraoni D, Goobie SM, Ferraris V, Hassan N. Patient Blood Management in Pediatric Cardiac Surgery: A Review. Anesth Analg 2019; 127:1002-1016. [PMID: 28991109 DOI: 10.1213/ane.0000000000002504] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Efforts to reduce blood product transfusions and adopt blood conservation strategies for infants and children undergoing cardiac surgical procedures are ongoing. Children typically receive red blood cell and coagulant blood products perioperatively for many reasons, including developmental alterations of their hemostatic system, and hemodilution and hypothermia with cardiopulmonary bypass that incites inflammation and coagulopathy and requires systemic anticoagulation. The complexity of their surgical procedures, complex cardiopulmonary interactions, and risk for inadequate oxygen delivery and postoperative bleeding further contribute to blood product utilization in this vulnerable population. Despite these challenges, safe conservative blood management practices spanning the pre-, intra-, and postoperative periods are being developed and are associated with reduced blood product transfusions. This review summarizes the available evidence regarding anemia management and blood transfusion practices in the perioperative care of these critically ill children. The evidence suggests that adoption of a comprehensive blood management approach decreases blood transfusions, but the impact on clinical outcomes is less well studied and represents an area that deserves further investigation.
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Affiliation(s)
- Jill M Cholette
- From the Department of Pediatrics, Golisano Children's Hospital, University of Rochester, Rochester, New York
| | - David Faraoni
- Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Susan M Goobie
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston, Massachusetts.,Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Victor Ferraris
- Department of Surgery, University of Kentucky Chandler Medical Center & Lexington Veterans Affairs Medical Center, Lexington, Kentucky
| | - Nabil Hassan
- Division of Pediatric Critical Care, Children's Hospital of Illinois At OSF St Frances, University of Illinois at Peoria, Peoria, Illinois
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Machovec KA, Jooste EH. Pediatric Transfusion Algorithms: Coming to a Cardiac Operating Room Near You. J Cardiothorac Vasc Anesth 2019; 33:2017-2029. [DOI: 10.1053/j.jvca.2018.12.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Indexed: 01/27/2023]
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Bojan M. Recent achievements and future developments in neonatal cardiopulmonary bypass. Paediatr Anaesth 2019; 29:414-425. [PMID: 30714261 DOI: 10.1111/pan.13597] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 01/11/2019] [Accepted: 01/18/2019] [Indexed: 12/21/2022]
Abstract
A primary goal of improving neonatal cardiopulmonary bypass has been making the circuit smaller and reduce the blood contacting surfaces. As bypass circuit size has decreased, bloodless surgery has become possible even in neonates. Since transfusion guidelines are difficult to construct based on existing literature, these technical advances should be taken advantage of in conjunction with an individualized transfusion scheme, based on monitoring of oxygen availability to the tissues. For the majority of neonatal heart operations, several centers have shifted toward normothermic bypass even for complex neonatal surgeries, in order to avoid the adverse effects of hypothermia. Deep hypothermic circulatory arrest is no longer a necessity but an option, and selective antegrade cerebral perfusion has become common practice; however, technical uncertainties with regard to this technique have to be addressed, based on reliable neurologic monitoring. Maintenance of patient-specific heparin concentrations during bypass is another key goal, since neonates have lower baseline antithrombin concentrations and, therefore, a higher risk for inadequate thrombin inhibition and postoperative bleeding. Due to the immaturity of their hemostatic system, the standard coagulation tests alone are inappropriate to guide hemostatic therapy in neonates. The use of indirect heparin concentration assays and global viscoelastic assays in the operating room is likely to represent the optimal strategy, and requires validation in neonates. Monitoring of global and regional indexes of oxygen availability and consumption on bypass have become possible; however, their use in neonates still has outstanding technical issues which should be addressed and hence needs further validation. Due to the immaturity of the neonatal myocardium, single-shot cold cardioplegia solutions are thought to confer the best myocardial protection; their superiority when compared to more conventional modalities, however, remains to be demonstrated.
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Affiliation(s)
- Mirela Bojan
- Congenital Cardiac Unit, Department of Anesthesiology, Marie Lannelongue Hospital, Le Plessis Robinson, France
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Topf HG, Strasser ER, Breuer G, Rascher W, Rauh M, Fahlbusch FB. Closing the gap - detection of clinically relevant von Willebrand disease in emergency settings through an improved algorithm based on rotational Thromboelastometry. BMC Anesthesiol 2019; 19:10. [PMID: 30630422 PMCID: PMC6329185 DOI: 10.1186/s12871-018-0672-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 12/26/2018] [Indexed: 01/25/2023] Open
Abstract
Background Hemorrhage and blood loss are still among the main causes of preventable death. Global hemostatic assays are useful point-of-care test (POCT) devices to rapidly detect cumulative effects of plasma factors and platelets on coagulation. Thromboelastography (TEG) and Thromboelastometry (ROTEM) are established methods in many anesthesiological departments for guided hemostatic treatment. However, von Willebrand disease remains undetected by standard ROTEM, especially during emergency care, despite being the most prevalent congenital hemostatic disorder. Methods In our monocentric cohort pilot study we focused on hemostatic challenges associated with von Willebrand disease. Twenty-seven patients with suspected von Willebrand disease were included. We modified the routine ROTEM assay by adding a preincubation with ristocetin and commercially available plasma-derived von Willebrand factor to identify clinically relevant von Willebrand disease (VWD). Results Addition of von Willebrand factor to the ristocetin assay of a VWD type 3 patient restored the reaction of the whole blood probe to match the response of a healthy person. Our modified ROTEM assay with ristocetin (Ricotem) showed that all high responders (n = 7) had VWD. In the low responder group (n = 16) – 10 of 16 had VWD and in the normal responder group (n = 5), 2 of 5 had mild type 1 VWD. Conclusions This new modification of the standard ROTEM assay enables the detection of otherwise unnoticed critical von Willebrand disease based on alterations in clot formation and might serve as a novel approach to reliably assess severe VWD patients by platelet-mediated blood clotting in an emergency setting. We recommend incorporating this new VWD-focused screening tool into the current ROTEM-based management algorithm of acute microvascular bleeding. Electronic supplementary material The online version of this article (10.1186/s12871-018-0672-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- H-G Topf
- Department of Pediatrics and Adolescent Medicine, University of Erlangen-Nurnberg, Loschgestr. 15, 91054, Erlangen, Germany.
| | - E R Strasser
- Department of Transfusion Medicine and Hemostasis, University of Erlangen-Nurnberg, Erlangen, Germany
| | - G Breuer
- Department of Anesthesiology, University of Erlangen-Nurnberg, Erlangen, Germany
| | - W Rascher
- Department of Pediatrics and Adolescent Medicine, University of Erlangen-Nurnberg, Loschgestr. 15, 91054, Erlangen, Germany
| | - M Rauh
- Department of Pediatrics and Adolescent Medicine, University of Erlangen-Nurnberg, Loschgestr. 15, 91054, Erlangen, Germany
| | - F B Fahlbusch
- Department of Pediatrics and Adolescent Medicine, University of Erlangen-Nurnberg, Loschgestr. 15, 91054, Erlangen, Germany
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26
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Scott JP, Niebler RA, Stuth EAE, Newman DK, Tweddell JS, Bercovitz RS, Benson DW, Cole R, Simpson PM, Yan K, Woods RK. Rotational Thromboelastometry Rapidly Predicts Thrombocytopenia and Hypofibrinogenemia During Neonatal Cardiopulmonary Bypass. World J Pediatr Congenit Heart Surg 2018; 9:424-433. [PMID: 29945504 DOI: 10.1177/2150135118771318] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Thrombocytopenia and hypofibrinogenemia during neonatal cardiopulmonary bypass (CPB) contribute to bleeding and morbidity. Rotational thromboelastometry (ROTEM) is a viscoelastic assay with a rapid turnaround time. Data validating ROTEM during neonatal cardiac surgery remain limited. This study examined perioperative hemostatic trends in neonates treated with standardized platelet and cryoprecipitate transfusion during CPB. We hypothesized that ROTEM would predict thrombocytopenia, hypofibrinogenemia, and the correction thereof. METHODS Forty-four neonates undergoing CPB were included in this prospective observational study. Blood samples were obtained at Baseline, On CPB, Post-CPB, and Postoperative. The ROTEM analysis included extrinsically activated (Extem) and fibrinogen-specific (Fibtem) assays. Platelet-specific thromboelastometry (Pltem) values were calculated. Platelet and cryoprecipitate transfusion was initiated prior to termination of CPB. RESULTS Platelet count and Extem amplitude decreased significantly On CPB ( P < .0001), increased significantly Post-CPB ( P < .0001), and Postoperative values were not significantly different from Baseline. Extem amplitude at 10 minutes (A10) > 46.5 mm (AUC = 0.941) and Pltem A10 > 37.5 mm [area under curve (AUC) = 0.960] predicted platelet count > 100 × 103/μL, and they highly correlated with platelet count ( R = 0.89 and R = 0.90, respectively). Fibrinogen concentration and Fibtem amplitude decreased significantly On CPB ( P ≤ .0001) and normalized after cryoprecipitate transfusion. Fibtem A10 > 9.5 mm predicted fibrinogen >200 mg/dL (AUC = 0.817), but it correlated less well with fibrinogen concentration ( R = 0.65). CONCLUSIONS ROTEM analysis during neonatal cardiac surgery is sensitive and specific for thrombocytopenia and hypofibrinogenemia, identifying deficits within 10 minutes. Platelet and cryoprecipitate transfusion during neonatal CPB normalizes platelet count, fibrinogen level, and ROTEM amplitudes.
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Affiliation(s)
- John P Scott
- 1 Section of Pediatric Anesthesiology, Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, USA.,2 Section of Pediatric Critical Care, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Robert A Niebler
- 2 Section of Pediatric Critical Care, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Eckehard A E Stuth
- 1 Section of Pediatric Anesthesiology, Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Debra K Newman
- 3 Blood Research Institute, Blood Center of Southeastern Wisconsin, Milwaukee, WI, USA
| | - James S Tweddell
- 4 Section of Pediatric Cardiothoracic Surgery, Department of Cardiothoracic Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Rachel S Bercovitz
- 5 Section of Pediatric Hematology, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - D Woodrow Benson
- 6 Section of Pediatric Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Regina Cole
- 6 Section of Pediatric Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Pippa M Simpson
- 7 Division of Quantitative Health Sciences, Department of Biostatistics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ke Yan
- 7 Division of Quantitative Health Sciences, Department of Biostatistics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ronald K Woods
- 8 Section of Pediatric Cardiothoracic Surgery, Department of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
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27
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Curry NS, Davenport R, Pavord S, Mallett SV, Kitchen D, Klein AA, Maybury H, Collins PW, Laffan M. The use of viscoelastic haemostatic assays in the management of major bleeding: A British Society for Haematology Guideline. Br J Haematol 2018; 182:789-806. [PMID: 30073664 DOI: 10.1111/bjh.15524] [Citation(s) in RCA: 113] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Nicola S Curry
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,NIHR BRC, Blood Theme, Oxford University, Oxford, UK
| | - Ross Davenport
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Sue Pavord
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,NIHR BRC, Blood Theme, Oxford University, Oxford, UK
| | - Susan V Mallett
- Department of Anaesthesia, Royal Free London NHS Foundation Trust, London, UK
| | | | - Andrew A Klein
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital, Cambridge, UK
| | - Helena Maybury
- Department of Obstetrics, Leicester Royal Infirmary, Leicester, UK
| | - Peter W Collins
- Department of Haematology, School of Medicine, Cardiff University, Cardiff, UK
| | - Mike Laffan
- Department of Haematology, Imperial College and Hammersmith Hospital, London, UK
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Abstract
PURPOSE OF REVIEW Managing the bleeding pediatric patient perioperatively can be extremely challenging. The primary goals include avoiding hypotension, maintaining adequate tissue perfusion and oxygenation, and maintaining hemostasis. Traditional bleeding management has consisted of transfusion of autologous blood products, however, there is strong evidence that transfusion-related side-effects are associated with increased morbidity and mortality in children. Especially concerning is the increased reported incidence of noninfectious adverse events such as transfusion-related acute lung injury, transfusion-related circulatory overload and transfusion-related immunomodulation. The current approach in perioperative bleeding management of the pediatric patient should focus on the diagnosis and treatment of anemia and coagulopathy with the transfusion of blood products only when clinically indicated and guided by goal-directed strategies. RECENT FINDINGS Current guidelines recommend that a comprehensive multimodal patient blood management strategy is critical in optimizing patient care, avoiding unnecessary transfusion of blood and blood product and limiting transfusion-related side-effects. SUMMARY This article will highlight current guidelines in perioperative bleeding management for our most vulnerable pediatric patients with emphasis on individualized targeted intervention using point-of-care testing and specific coagulation products.
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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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Faraoni D, Emani S, Halpin E, Bernier R, Emani SM, DiNardo JA, Ibla JC. Relationship Between Transfusion of Blood Products and the Incidence of Thrombotic Complications in Neonates and Infants Undergoing Cardiac Surgery. J Cardiothorac Vasc Anesth 2017; 31:1943-1948. [DOI: 10.1053/j.jvca.2017.04.039] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Indexed: 12/26/2022]
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31
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The 2017 Seventh World Congress of Pediatric Cardiology & Cardiac Surgery: week in review: congenital cardiac anaesthesia. Cardiol Young 2017; 27:2012-2017. [PMID: 29286275 DOI: 10.1017/s1047951117002190] [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] [Indexed: 11/06/2022]
Abstract
The seventh meeting of the World Congress of Pediatric Cardiology and Cardiac Surgery was an opportunity for healthcare professionals from around the world to meet and discuss current issues affecting patients with acquired and CHD. A dedicated anaesthesia track facilitated the exchange of ideas and fostered many new friendships. This review highlights the congenital cardiac anaesthesia track and the involvement of the Congenital Cardiac Anesthesia Society in the congress.
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Current and future trends in coagulation management for congenital heart surgery. J Thorac Cardiovasc Surg 2017; 153:1511-1515. [DOI: 10.1016/j.jtcvs.2016.11.075] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 11/09/2016] [Accepted: 11/15/2016] [Indexed: 01/04/2023]
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Spiezia L, Di Gregorio G, Campello E, Maggiolo S, Bortolussi G, Stellin G, Simioni P, Vida V. Predictors of postoperative bleeding in children undergoing cardiopulmonary bypass: A preliminary Italian study. Thromb Res 2017; 153:85-89. [DOI: 10.1016/j.thromres.2017.03.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Revised: 03/15/2017] [Accepted: 03/21/2017] [Indexed: 11/15/2022]
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35
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Laskine-Holland ML, Kahr WHA, Crawford-Lean L, Humpl T, Honjo O, Foreman C, Jain M, O’Leary JD. The Association Between Cyanosis and Thromboelastometry (ROTEM) in Children With Congenital Heart Defects. Anesth Analg 2017; 124:23-29. [DOI: 10.1213/ane.0000000000001708] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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36
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Kim E, Shim HS, Kim WH, Lee SY, Park SK, Yang JH, Jun TG, Kim CS. Predictive Value of Intraoperative Thromboelastometry for the Risk of Perioperative Excessive Blood Loss in Infants and Children Undergoing Congenital Cardiac Surgery: A Retrospective Analysis. J Cardiothorac Vasc Anesth 2016; 30:1172-8. [DOI: 10.1053/j.jvca.2016.03.132] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Indexed: 11/11/2022]
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Perez-Ferrer A, Vicente-Sanchez J, Carceles-Baron M, Van der Linden P, Faraoni D. Early thromboelastometry variables predict maximum clot firmness in children undergoing cardiac and non-cardiac surgery. Br J Anaesth 2015; 115:896-902. [DOI: 10.1093/bja/aev369] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
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38
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Rotational thromboelastometry in the diagnosis of coagulopathy in major pediatric surgical operations. J Pediatr Surg 2015; 50:2001-4. [PMID: 26364878 DOI: 10.1016/j.jpedsurg.2015.08.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Revised: 08/04/2015] [Accepted: 08/09/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To examine the correlation between rotational thromboelastometry (ROTEM) and coagulopathy after major pediatric surgical operations. METHODS From November 2013 until April 2015, pediatric cases who underwent major noncardiac surgeries and met the coagulopathy-risk criteria were reviewed for postoperative clinically significant coagulopathy (CSC). Two ROTEM studies, EXTEM and INTEM, were performed at the immediately postoperatively without the results being taken into any clinical decision making. RESULTS Seventy-seven operations on 73 patients were included in this analysis. CSC occurred following 24 operations (32%) with a significantly higher incidence when a patient had a higher coagulopathy risk. On univariate analysis, evidence of diffuse bleeding in the operative field and massive bleeding were the 2 parameters with the strongest association with CSC. INTEM and EXTEM had specificities in diagnosing CSC of 75.5% and 94.3%, respectively. When each individual EXTEM and INTEM item was analyzed against CSC using ROC analysis, clot forming time (CFT) gave the largest under the curve area. The cut-off CFTs that gave the highest sensitivity and specificity in this study were 120seconds for EXTEM and 100seconds for INTEM. CONCLUSION Postoperative coagulopathy is a risk that should always be considered in pediatric surgical operations. Thromboelastometry can be a hemostatic test providing high predictive value for this condition.
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