Red blood cell transfusion threshold after pediatric cardiac surgery: A systematic review and meta-analysis

Analysis of haemodynamics surrounding blood transfusions after the arterial switch operation: a pilot study utilising real-time telemetry high-frequency data capture

BACKGROUND

Packed red blood cell transfusions occur frequently after congenital heart surgery to augment haemodynamics, with limited understanding of efficacy. The goal of this study was to analyse the hemodynamic response to packed red blood cell transfusions in a single cohort, as "proof-of-concept" utilising high-frequency data capture of real-time telemetry monitoring.

METHODS

Retrospective review of patients after the arterial switch operation receiving packed red blood cell transfusions from 15 July 2020 to 15 July 2021. Hemodynamic parameters were collected from a high-frequency data capture system (SickbayTM) continuously recording vital signs from bedside monitors and analysed in 5-minute intervals up to 6 hours before, 4 hours during, and 6 hours after packed red blood cell transfusions-up to 57,600 vital signs per packed red blood cell transfusions. Variables related to oxygen balance included blood gas co-oximetry, lactate levels, near-infrared spectroscopy, and ventilator settings. Analgesic, sedative, and vasoactive infusions were also collected.

RESULTS

Six patients, at 8.5[IQR:5-22] days old and weighing 3.1[IQR:2.8-3.2]kg, received transfusions following the arterial switch operation. There were 10 packed red blood cell transfusions administered with a median dose of 10[IQR:10-15]mL/kg over 169[IQR:110-190]min; at median post-operative hour 36[IQR:10-40]. Significant increases in systolic and mean arterial blood pressures by 5-12.5% at 3 hours after packed red blood cell transfusions were observed, while renal near-infrared spectroscopy increased by 6.2% post-transfusion. No significant changes in ventilation, vasoactive support, or laboratory values related to oxygen balance were observed.

CONCLUSIONS

Packed red blood cell transfusions given after the arterial switch operation increased arterial blood pressure by 5-12.5% for 3 hours and renal near-infrared spectroscopy by 6.2%. High-frequency data capture systems can be leveraged to provide novel insights into the hemodynamic response to commonly used therapies such as packed red blood cell transfusions after paediatric cardiac surgery.

Continuous hemoglobin measurement during frontal advancement operations can improve patient outcomes

Massive hemorrhage in pediatric cranioplasty operations may necessitate blood transfusion, which may cause many complications. Radical-7 Pulse CO-Oximeter (Massimo Corporation, Irvine, CA) can provide continuous hemoglobin concentration (SpHb) measurements noninvasively. In this study, we aimed to evaluate the effects of SpHb measurement on perioperative transfusion management and postoperative patient outcomes. For this retrospective case-control study, we collected the data of pediatric patients undergoing fronto-orbital advancement surgery for plagiocephaly and trigonocephaly between 2018 and 2021. Perioperative SpHb monitoring was performed for patients in the SpHb Group. Other patients that were managed conventionally were considered as the control group (C Group). The data on patients' demographic and clinical characteristics, intraoperative hemodynamic and laboratory variables such as blood gases, intraoperative blood losses, the amount of the transfused blood products, the length of postoperative intensive care unit (ICU) stay, and the duration of hospital stay were collected. The data of 42 patients were collected, and 29 of these patients were males (69%). In 16 of the patients, SpHb monitoring was performed. The demographic, clinical, and perioperative hemodynamic characteristics of the patients were comparable between the groups. Compared to the C Group, the SpHb Group had significantly lower perioperative packed red blood cell (PRBC) transfusion (136.3 ± 40.1 vs. 181.5 ± 74.8 mL, P = 0.015), less postoperative drainage (125.3 ± 47.7 vs. 185.8 ± 97.6 mL, P = 0.013), and shorter ICU stay (37.1 ± 12.0 vs. 64.8 ± 24.9 h, P < 0.001). There was a positive correlation between the amount of PRBC transfusion and the length of ICU stay (r = 0.459, P = 0.003). Patients with perioperative continuous SpHb measurement have lower intraoperative PRBC transfusion, less postoperative bleeding, and shorter ICU stay. When necessary, SpHb, together with clinical judgment and laboratory confirmation, can be used in decision-making for perioperative PRBC transfusion.

The risk factors for delayed recovery in patients with cardiopulmonary bypass: Why should we care?

Cardiopulmonary bypass (CPB) is very commonly performed among the cardiovascular surgeries, and delayed recovery (DR) is a kind of serious complications in patients with CPB. It is necessary to assess the risk factors for DR in patients with CPB, to provide evidence into the management of CPB patients.Patients undergoing CPB in our hospital from January 2018 to March 2020 were included. Cases that consciousness has not recovered 12 hours after anesthesia were considered as DR. The preoperative and intraoperative variables of CPB patients were collected and analyzed. Logistic regressions were conducted to analyze the potential influencing factor.A total of 756 CPB patients were included, and the incidence of DR was 9.79%. There were significant differences on the age, aspartate aminotransferase (AST), glutamic pvruvic transaminase (ALT), blood urea nitrogen (BUN), and serum creatinine (SCr) between patients with and without DR (all P < .05); there were no significant differences in the types of surgical procedure (all P > .05); there were significant differences on the duration of CPB, duration of aortic cross clamp (ACC), duration of surgery, minimum nasopharyngeal temperature, and transfusion of packed red blood cells between patients with and without DR (all P < .05). Logistic regression analysis indicated that duration of CPB ≥132 minutes (odds ratio [OR] 4.12, 1.02-8.33), BUN ≥9 mmol/L (OR 4.05, 1.37-8.41), infusion of red blood cell suspension (OR 3.93, 1.25-7.63), duration of surgery ≥350 minutes (OR 3.17, 1.24-5.20), age ≥6 (OR 3.01, 1.38-6.84) were the independent risk factors for DR in patients with CPB (all P < .05).Extra attention and care are needed for those CPB patients with duration of CPB ≥132 minutes, BUN ≥9 mmol/L, infusion of red blood cell suspension, duration of surgery ≥350 minutes, and age ≥60.

Transfusion Strategies for Pediatric Cardiac Surgery: A Meta-Analysis and Trial Sequential Analysis

This study aimed to compare the effects of restrictive and liberal red blood cell (RBC) transfusion strategies on pediatric patients undergoing cardiac surgery, including cyanotic and non-cyanotic children. A literature search of the MEDLINE, EMBASE, PubMed, and the Cochrane Library database was conducted. Meta-analyses were carried out comparing restrictive and liberal transfusion strategies. Subgroup analyses were performed based on the basis of cyanotic status. Five randomized controlled trials with a total of 497 children were included. There was no significant difference in the risk of in-hospital mortality between the two transfusion strategies (risk ratio 1.21; 95% confidence interval 0.49 to 2.99; P = 0.68). The trial sequential analysis suggested that the current meta-analysis had an absence of evidence for in-hospital mortality, and the data were insufficient. Moreover, no significant differences existed between groups in terms of risk of infection, blood loss, duration of mechanical ventilation, pediatric intensive care unit (PICU) stay duration, or hospital stay duration. Cyanotic children treated with a liberal transfusion strategy had a shorter ventilator duration, but the transfusion strategy did not affect in-hospital mortality, infection, hospital stay, or PICU stay duration. On the basis of the available data, our analysis indicates that a liberal transfusion strategy did not lead to a better outcomes, but the data are extremely sparse, which highlights the need for clearer transfusion guidelines specific to this specific population.Trial registration number CRD42018102283.