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Comas Collgros N, Zapridis V, Godolphin JD, Bacon N. Impact of a cell salvage device on blood transfusions to dogs undergoing surgery at a referral veterinary hospital. J Vet Emerg Crit Care (San Antonio) 2024; 34:376-386. [PMID: 38971979 DOI: 10.1111/vec.13403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 06/04/2023] [Accepted: 06/14/2023] [Indexed: 07/08/2024]
Abstract
OBJECTIVE To determine the number of homologous blood transfusions received by canine surgical patients after introducing a cell salvage device (CSD), trends in surgeries requiring blood transfusion, and the incidence of transfusion reactions. STUDY DESIGN Retrospective study. SETTING Single referral hospital. ANIMALS All dogs having surgery at a single center (November 2015 to February 2021). INTERVENTIONS Medical records of dogs having surgical treatment, including those that received either an autologous or homologous blood transfusion, were reviewed. The surgical patients were the baseline population, and the 2 transfusion groups were compared within this population to analyze the trends. MAIN RESULTS A total of 37 and 86 dogs received autologous and homologous blood transfusions, respectively. There was an upward trend in the number of total monthly blood transfusions. No significant increase in the monthly number of homologous transfusions was observed before or after acquisition of the CSD. There was also an upward trend in total monthly surgeries, including those with higher risks of hemorrhage. Dogs receiving homologous blood transfusions had a higher incidence of clinical signs consistent with transfusion reactions (6.98%). CONCLUSIONS An upward trend in autologous blood transfusions was seen with the introduction of a CSD. Hospitals with large surgical caseloads at high risk of hemorrhage may see a decreased need for outsourced blood products with the use of the CSD. The device can lead to a more responsible use of an increasingly scarce resource and decrease the risk of a blood transfusion reaction in dogs.
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Affiliation(s)
| | | | | | - Nicholas Bacon
- AURA Veterinary, Guildford, UK
- Department of Veterinary Medicine, University of Surrey, Guildford, UK
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Limratana P, Maisat W, Tsai A, Yuki K. Perioperative Factors and Radiographic Severity Scores for Predicting the Duration of Mechanical Ventilation After Arterial Switch Surgery. J Cardiothorac Vasc Anesth 2024; 38:992-1005. [PMID: 38365467 PMCID: PMC10947876 DOI: 10.1053/j.jvca.2024.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Revised: 12/26/2023] [Accepted: 01/14/2024] [Indexed: 02/18/2024]
Abstract
OBJECTIVES Cardiac surgery on cardiopulmonary bypass (CPB) during the neonatal period can cause perioperative organ injuries. The primary aim of this study was to determine the incidence and risk factors associated with postoperative mechanical ventilation duration and acute lung injury after the arterial switch operation (ASO). The secondary aim was to examine the utility of the Brixia score for characterizing postoperative acute lung injury (ALI). DESIGN A retrospective study. SETTING A single-center university hospital. PARTICIPANTS A total of 93 neonates with transposition of great arteries with intact ventricular septum (dTGA IVS) underwent ASO. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS From January 2015 to December 2022, 93 neonates with dTGA IVS were included in the study. The cohort had a median age of 4.0 (3.0-5.0) days and a mean weight of 3.3 ± 0.5 kg. About 63% of patients had ≥48 hours of postoperative mechanical ventilation after ASO. Risk factors included prematurity, post-CPB transfusion of salvaged red cells, platelets and cryoprecipitate, and postoperative fluid balance by univariate analysis. The larger transfused platelet volume was associated with the risk of ALI by multivariate analysis. The median baseline Brixia scores were 11.0 (9.0-12.0) and increased significantly in the postoperative day 1 in patients who developed moderate ALI 24 hours after admission to the intensive care unit (15.0 [13.0-16.0] v 12.0 [10.0-14.0], p = 0.046). CONCLUSIONS Arterial switch operation results in a high incidence of ≥48-hour postoperative mechanical ventilation. Blood component transfusion is a potentially modifiable risk factor. The Brixia scores also may be used to characterize postoperative acute lung injury.
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Affiliation(s)
- Panop Limratana
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA, USA
- Department of Anaesthesia, Harvard Medical School, Boston, MA, USA
- Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Wiriya Maisat
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA, USA
- Department of Anaesthesia, Harvard Medical School, Boston, MA, USA
- Department of Anesthesiology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Andy Tsai
- Department of Radiology, Boston Children’s Hospital, Boston, MA, USA
| | - Koichi Yuki
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA, USA
- Department of Anaesthesia, Harvard Medical School, Boston, MA, USA
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Pagano MB, Stanworth SJ, Valentine S, Metcalf R, Wood EM, Pavenski K, Cholette J, So-Osman C, Carson JL. The 2023 AABB international guidelines for red blood cell transfusions: What is new? Transfusion 2024; 64:727-732. [PMID: 38380850 DOI: 10.1111/trf.17764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 02/06/2024] [Indexed: 02/22/2024]
Affiliation(s)
- Monica B Pagano
- Transfusion Medicine, Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
- AABB Clinical Transfusion Practice Committee, Bethesda, Maryland, USA
| | - Simon J Stanworth
- Department of Haematology, Oxford University Hospitals NHS Trust; NHSBT, Oxford, UK
- Radcliffe Department of Medicine, Department of Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
| | - Stacey Valentine
- Department of Pediatrics, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Ryan Metcalf
- AABB Clinical Transfusion Practice Committee, Bethesda, Maryland, USA
- Department of Pathology, University of Utah, Salt Lake City, Utah, USA
| | - Erica M Wood
- Department of Haematology, Monash Health, Melbourne, Victoria, Australia
- Monash University School of Public Health and Preventive Medicine, Melbourne, Victoria, Australia
- International Society of Blood Transfusion, Amsterdam, Netherlands
| | - Katerina Pavenski
- Department of Laboratory Medicine and Pathobiology, University of Toronto and St Michael's Hospital-Unity Health Toronto, Toronto, Ontario, Canada
- International Collaboration for Transfusion Medicine Guidelines, British Columbia, Canada
| | - Jill Cholette
- Department of Pediatrics, University of Rochester, Golisano Children's Hospital, Rochester, New York, USA
| | - Cynthia So-Osman
- Department of Unit Transfusion Medicine (UTG), Sanquin Blood Bank, Amsterdam, the Netherlands
- Department Hematology, Erasmus Medical Center, Rotterdam, the Netherlands
- European Haematology Association, Transfusion-Specialized Working Group
| | - Jeffrey L Carson
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
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Tanyildiz M, Gungormus A, Erden SE, Ozden O, Bicer M, Akcevin A, Odemis E. Approach to red blood cell transfusions in post-operative congenital heart disease surgery patients: when to stop? Cardiol Young 2024; 34:676-683. [PMID: 37800309 DOI: 10.1017/s1047951123003463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
BACKGROUND The best transfusion approach for CHD surgery is controversial. Studies suggest two strategies: liberal (haemoglobin ≤ 9.5 g/dL) and restrictive (waiting for transfusion until haemoglobin ≤ 7.0 g/dL if the patient is stable). Here we compare liberal and restrictive transfusion in post-operative CHD patients in a cardiac intensive care unit. METHODS Retrospective analysis was conducted on CHD patients who received liberal transfusion (2019-2021, n=53) and restrictive transfusion (2021-2022, n=43). RESULTS The two groups were similar in terms of age, gender, Paediatric Risk of Mortality-3 score, Paediatric Logistic Organ Dysfunction-2 score, Risk Adjustment for Congenital Heart Surgery-1 score, cardiopulmonary bypass time, vasoactive inotropic score, total fluid balance, mechanical ventilation duration, length of cardiac intensive care unit stay, and mortality. The liberal transfusion group had a higher pre-operative haemoglobin level than the restrictive group (p < 0.05), with no differences in pre-operative anaemia. Regarding the minimum and maximum post-operative haemoglobin levels during a cardiac intensive care unit stay, the liberal group had higher haemoglobin levels in both cases (p<0.01 and p=0.019, respectively). The number of red blood cell transfusions received by the liberal group was higher than that of the restrictive group (p < 0.001). There were no differences between the two groups regarding lactate levels at the time of and after red blood cell transfusion. The incidence of bleeding, re-operation, acute kidney injury, dialysis, sepsis, and systemic inflammatory response syndrome was similar. CONCLUSIONS Restrictive transfusion may be preferable over liberal transfusion. Achieving similar outcomes with restrictive transfusions may provide promising evidence for future studies.
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Affiliation(s)
- Murat Tanyildiz
- Department of Pediatric Intensive Care, Koc University School of Medicine, Istanbul, Turkey
| | - Asiye Gungormus
- Department of Pediatric Intensive Care, Koc University School of Medicine, Istanbul, Turkey
| | - Selin Ece Erden
- Department of Pediatric Intensive Care, Koc University School of Medicine, Istanbul, Turkey
| | - Omer Ozden
- Department of Pediatric Intensive Care, Koc University School of Medicine, Istanbul, Turkey
| | - Mehmet Bicer
- Department of Cardiovascular Surgery, Koc University School of Medicine, Istanbul, Turkey
| | - Atif Akcevin
- Department of Cardiovascular Surgery, Koc University School of Medicine, Istanbul, Turkey
| | - Ender Odemis
- Department of Pediatric Cardiology, Koc University School of Medicine, Istanbul, Turkey
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Carson JL, Stanworth SJ, Guyatt G, Valentine S, Dennis J, Bakhtary S, Cohn CS, Dubon A, Grossman BJ, Gupta GK, Hess AS, Jacobson JL, Kaplan LJ, Lin Y, Metcalf RA, Murphy CH, Pavenski K, Prochaska MT, Raval JS, Salazar E, Saifee NH, Tobian AAR, So-Osman C, Waters J, Wood EM, Zantek ND, Pagano MB. Red Blood Cell Transfusion: 2023 AABB International Guidelines. JAMA 2023; 330:1892-1902. [PMID: 37824153 DOI: 10.1001/jama.2023.12914] [Citation(s) in RCA: 51] [Impact Index Per Article: 51.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
Importance Red blood cell transfusion is a common medical intervention with benefits and harms. Objective To provide recommendations for use of red blood cell transfusion in adults and children. Evidence Review Standards for trustworthy guidelines were followed, including using Grading of Recommendations Assessment, Development and Evaluation methods, managing conflicts of interest, and making values and preferences explicit. Evidence from systematic reviews of randomized controlled trials was reviewed. Findings For adults, 45 randomized controlled trials with 20 599 participants compared restrictive hemoglobin-based transfusion thresholds, typically 7 to 8 g/dL, with liberal transfusion thresholds of 9 to 10 g/dL. For pediatric patients, 7 randomized controlled trials with 2730 participants compared a variety of restrictive and liberal transfusion thresholds. For most patient populations, results provided moderate quality evidence that restrictive transfusion thresholds did not adversely affect patient-important outcomes. Recommendation 1: for hospitalized adult patients who are hemodynamically stable, the international panel recommends a restrictive transfusion strategy considering transfusion when the hemoglobin concentration is less than 7 g/dL (strong recommendation, moderate certainty evidence). In accordance with the restrictive strategy threshold used in most trials, clinicians may choose a threshold of 7.5 g/dL for patients undergoing cardiac surgery and 8 g/dL for those undergoing orthopedic surgery or those with preexisting cardiovascular disease. Recommendation 2: for hospitalized adult patients with hematologic and oncologic disorders, the panel suggests a restrictive transfusion strategy considering transfusion when the hemoglobin concentration is less than 7 g/dL (conditional recommendations, low certainty evidence). Recommendation 3: for critically ill children and those at risk of critical illness who are hemodynamically stable and without a hemoglobinopathy, cyanotic cardiac condition, or severe hypoxemia, the international panel recommends a restrictive transfusion strategy considering transfusion when the hemoglobin concentration is less than 7 g/dL (strong recommendation, moderate certainty evidence). Recommendation 4: for hemodynamically stable children with congenital heart disease, the international panel suggests a transfusion threshold that is based on the cardiac abnormality and stage of surgical repair: 7 g/dL (biventricular repair), 9 g/dL (single-ventricle palliation), or 7 to 9 g/dL (uncorrected congenital heart disease) (conditional recommendation, low certainty evidence). Conclusions and Relevance It is good practice to consider overall clinical context and alternative therapies to transfusion when making transfusion decisions about an individual patient.
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Affiliation(s)
- Jeffrey L Carson
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Simon J Stanworth
- Department of Haematology, Oxford University Hospitals NHS Trust, Oxford, United Kingdom
- NHSBT, Oxford, United Kingdom
- Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
- Department of Transfusion Medicine, NHS Blood and Transplant, Oxford, United Kingdom
| | - Gordon Guyatt
- Departments of Clinical Epidemiology and Biostatistics and Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Stacey Valentine
- Department of Pediatrics, University of Massachusetts Chan Medical School, Worcester
| | - Jane Dennis
- Cochrane Injuries Group, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Sara Bakhtary
- Department of Laboratory Medicine, University of California, San Francisco
| | - Claudia S Cohn
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis
| | | | - Brenda J Grossman
- Department of Pathology and Immunology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Gaurav K Gupta
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Aaron S Hess
- Departments of Anesthesiology and Pathology and Laboratory Medicine, University of Wisconsin-Madison, Madison
| | - Jessica L Jacobson
- Department of Pathology, New York University Grossman School of Medicine, New York
- NYC Health + Hospitals/Bellevue, New York, New York
| | - Lewis J Kaplan
- Department of Surgery, Division of Trauma, Surgical Critical Care and Surgical Emergencies, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Yulia Lin
- Precision Diagnostics and Therapeutics Program, Sunnybrook Health Sciences Centre, Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Ryan A Metcalf
- Department of Pathology, University of Utah, Salt Lake City
| | - Colin H Murphy
- Pathology Associates of Albuquerque, Albuquerque, New Mexico
| | - Katerina Pavenski
- Department of Laboratory Medicine and Pathobiology, University of Toronto and St Michael's Hospital-Unity Health Toronto, Toronto, Ontario, Canada
| | | | - Jay S Raval
- Department of Pathology, University of New Mexico, Albuquerque
| | - Eric Salazar
- Department of Pathology and Laboratory Medicine, UT Health San Antonio, San Antonio, Texas
| | - Nabiha H Saifee
- Department of Laboratory Medicine and Pathology, Seattle Children's Hospital, Seattle, Washington
| | - Aaron A R Tobian
- Department of Pathology, Johns Hopkins University, Baltimore, Maryland
| | - Cynthia So-Osman
- Department of Unit Transfusion Medicine (UTG), Sanquin Blood Bank, Amsterdam, the Netherlands
- Department Hematology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Jonathan Waters
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Erica M Wood
- Department of Haematology, Monash Health, Monash University School of Public Health and Preventive Medicine, Melbourne, Victoria, Australia
| | - Nicole D Zantek
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis
| | - Monica B Pagano
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle
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Itano H, Akiyama T, Yoshihara M. Clinical efficacy of intraoperative Cell Saver autologous blood salvage in emergency surgery for massive hemothorax. Indian J Thorac Cardiovasc Surg 2023; 39:359-366. [PMID: 37346430 PMCID: PMC10279592 DOI: 10.1007/s12055-023-01489-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 01/24/2023] [Accepted: 01/26/2023] [Indexed: 03/18/2023] Open
Abstract
The objective of this study was to investigate the efficacy of intraoperative Cell Saver blood salvage during emergency surgery for massive hemothorax on minimizing perioperative allogeneic red blood cell (RBC) transfusion. Fourteen consecutive patients of massive hemothorax with more than 800 cc of intrathoracic bleeding estimated by chest X-ray and/or chest computed tomography (CT) scan at presentation between 2009 and 2021 were retrospectively reviewed. Intraoperative Cell Saver blood salvage was performed in 11 patients (Cell Saver group) with a median volume of 820 cc (range, 421-1700 cc). The amount of perioperative allogeneic RBC transfusion in the Cell Saver group (median, 4 units) was significantly smaller than that in the non-Cell Saver group (median, 10 units) (P = 0.009). The volume of Cell Saver autologous transfusion in 6 patients without preoperative chest tube drainage (median, 1114 cc) was significantly larger than that in 5 patients who had preoperative drainage (median, 660 cc) (P = 0.0173). In conclusion, the utilization of intraoperative blood salvage in emergency surgery for massive hemothorax along with limiting the amount of preoperative chest tube drainage is an efficient strategy to minimize perioperative allogeneic RBC transfusion.
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Affiliation(s)
- Hideki Itano
- Department of Thoracic Surgery, Daiyu-kai General Hospital, Ichinomiya-shi, Aichi, Japan
- Department of Thoracic Surgery, Uji Tokushu-kai Hospital, Uji-shi, Kyoto, Japan
| | - Takashi Akiyama
- Department of Thoracic Surgery, Daiyu-kai General Hospital, Ichinomiya-shi, Aichi, Japan
| | - Masashi Yoshihara
- Department of Thoracic Surgery, Daiyu-kai General Hospital, Ichinomiya-shi, Aichi, Japan
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Al-Mozain N, Arora S, Goel R, Pavenski K, So-Osman C. Patient Blood Management in adults and children: what have we achieved, and what still needs to be addressed? Transfus Clin Biol 2023:S1246-7820(23)00041-1. [PMID: 36965848 DOI: 10.1016/j.tracli.2023.03.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/27/2023]
Abstract
An overview of Patient Blood Management (PBM), with its main scope to preserve the patient's own blood to improve the patient's outcome, is presented here, including the research gaps that needs to be addressed, particularly in the pediatric age group. Next, novel techniques to analyse PBM data and the challenges and strategies of PBM implementation will also be discussed.
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Affiliation(s)
- Nour Al-Mozain
- Department of Pathology & Laboratory Medicine, King Faisal Specialist Hospital, Riyadh, Saudi Arabia.
| | - Satyam Arora
- Department of Transfusion Medicine. Post Graduate Institute of Child Health, Noida, UP, India.
| | - Ruchika Goel
- Department of Pathology, Div. of Transfusion Medicine, Johns Hopkins University, Baltimore, MD, Department of Internal Medicine and Pediatrics, Div. of Hematology/Oncology, Simmons Cancer Institute at SIU School of Medicine, USA.
| | - Katerina Pavenski
- Departments of Laboratory Medicine and Medicine, St. Michael's Hospital - Unity Health Toronto, Toronto, Canada, Departments of Laboratory Medicine & Pathobiology and Medicine, University of Toronto, Toronto, Canada.
| | - Cynthia So-Osman
- Department of Transfusion medicine, Sanquin Blood Supply, Amsterdam and Department of Haematology, Erasmus Medical Centre, Rotterdam, The Netherlands.
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OuYang CL, Hao XY, Yu Y, Lou JS, Cao JB, Yu YQ, Mi WD. Intraoperative allogeneic transfusion is associated with postoperative delirium in older patients after total knee and hip arthroplasty. Front Surg 2023; 9:1048197. [PMID: 36684187 PMCID: PMC9849749 DOI: 10.3389/fsurg.2022.1048197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 11/28/2022] [Indexed: 01/07/2023] Open
Abstract
Objective To determine whether intraoperative transfusion of allogeneic or autologous blood is associated with an increased incidence of postoperative delirium (POD) after total knee arthroplasty (TKA) and total hip arthroplasty (THA). Methods The medical records of 1,143 older (≥65 years old) patients who received an intraoperative blood transfusion while undergoing total knee or hip arthroplasty at the First Medical Center of Chinese PLA General Hospital from 2014 to 2019 were reviewed; of these patients, 742 (64.92%) received allogeneic blood, while 401 (35.08%) received autologous blood. Patients who received autologous transfusion were paired with those received allogeneic transfusion using 1:1 propensity score matching method. The primary outcome was POD. The secondary outcomes were postoperative complications, including heart failure, deep vein thrombosis, myocardial infarction, stroke, and lung infection. Multivariable nominal logistic regression was used to identify any independent associations between intraoperative blood transfusions and POD, and secondary postoperative complications, respectively. Results Postoperative delirium occurred in 6.6% (49/742) of patients who had received an allogeneic blood transfusion and in 2.0% (8/401) of patients who had received an autologous blood transfusion. It is noteworthy that the multivariable logistic regression demonstrated a significant association between intraoperative allogeneic blood transfusion and POD (odds ratio [OR]: 4.11; 95% confidence interval [CI]: 1.95-9.77; p < 0.001). After PSM, Allogeneic transfusion was also the strongest predictor for POD (OR: 4.43; 95% CI: 2.09-10.58; p < 0.001). Conclusions In the patients who had received THA or TKA, intraoperative allogeneic blood transfusions were associated with an increased risk of POD.
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Affiliation(s)
- Chun-lei OuYang
- Department of Anesthesiology, The First Medical Center of PLA General Hospital, Beijing, China,Medical School of Chinese PLA, Beijing, China
| | - Xin-yu Hao
- Department of Anesthesiology, The First Medical Center of PLA General Hospital, Beijing, China,Medical School of Chinese PLA, Beijing, China
| | - Yao Yu
- Department of Anesthesiology, The First Medical Center of PLA General Hospital, Beijing, China
| | - Jing-sheng Lou
- Department of Anesthesiology, The First Medical Center of PLA General Hospital, Beijing, China
| | - Jiang-bei Cao
- Department of Anesthesiology, The First Medical Center of PLA General Hospital, Beijing, China
| | - Ying-qun Yu
- Department of Anesthesiology, The Fifth Medical Center of PLA General Hospital, Beijing, China,Correspondence: Wei-dong Mi Ying-qun Yu
| | - Wei-dong Mi
- Department of Anesthesiology, The First Medical Center of PLA General Hospital, Beijing, China,Correspondence: Wei-dong Mi Ying-qun Yu
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van Saet A, Tibboel D. The influence of cardiopulmonary bypass on pediatric pharmacokinetics. Expert Opin Drug Metab Toxicol 2023; 19:333-344. [PMID: 37334571 DOI: 10.1080/17425255.2023.2227556] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 06/16/2023] [Indexed: 06/20/2023]
Abstract
INTRODUCTION Every year thousands of children undergo surgery for congenital heart disease. Cardiac surgery requires the use of cardiopulmonary bypass, which can have unexpected consequences for pharmacokinetic parameters. AREAS COVERED We describe the pathophysiological properties of cardiopulmonary bypass that may influence pharmacokinetic parameters, with a focus on literature published in the last 10 years. We performed a PubMed database search with the keywords 'Cardiopulmonary bypass' AND 'Pediatric' AND 'Pharmacokinetics'. We searched related articles on PubMed and checked the references of articles for relevant studies. EXPERT OPINION Interest in the influence of cardiopulmonary bypass on pharmacokinetics has increased over the last 10 years, especially due to the use of population pharmacokinetic modeling. Unfortunately, study design usually limits the amount of information that can be obtained with sufficient power and the best way to model cardiopulmonary bypass is yet unknown. More information is needed on the pathophysiology of pediatric heart disease and cardiopulmonary bypass. Once adequately validated, PK models should be integrated in the patient electronic database integrating covariates and biomarkers influencing PK, making it possible to predict real-time drug concentrations and guide further clinical management for the individual patient at the bedside.
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Affiliation(s)
- Annewil van Saet
- Department of Anesthesiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Dick Tibboel
- Department of Intensive Care and Pediatric Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
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10
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Outcome of humanitarian patients with late complete repair of tetralogy of Fallot: A 13-year long single-center experience. INTERNATIONAL JOURNAL OF CARDIOLOGY CONGENITAL HEART DISEASE 2022. [DOI: 10.1016/j.ijcchd.2022.100414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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11
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Karimi M. A Surgeon's Perspective on Blood Conservation Practice in Pediatric Cardiac Surgery. World J Pediatr Congenit Heart Surg 2022; 13:782-787. [DOI: 10.1177/21501351221114846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Blood conservation practice in pediatric cardiac surgery has not been consistently adopted as quality improvement in many centers despite known risks associated with allogeneic blood products, shortage of donors, and costs. There are many blood conservation strategies available which collectively minimize exposure to allogeneic transfusion by maximizing the use of autologous red cells. These strategies are safe, reproducible, and have been implemented in clinical practice collectively with great efficacy for all patient ages and complexity levels. Institutional commitment to a set guideline will improve their blood conservation practice and quality outcome. The purpose of this article is to provide early career and practicing congenital cardiac surgeons with practical information concerning blood conservation strategies which can be considered for implementation in any pediatric cardiac surgery program, and which may be of particular value in resource-limited programs.
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Affiliation(s)
- Mohsen Karimi
- Department of Cardiothoracic Surgery, Stead Family Children’s Hospital, University of Iowa Healthcare, Iowa City, IA, USA
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Schmidbauer SL, Seyfried TF. Cell Salvage at the ICU. J Clin Med 2022; 11:3848. [PMID: 35807132 PMCID: PMC9267827 DOI: 10.3390/jcm11133848] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 06/10/2022] [Accepted: 06/22/2022] [Indexed: 02/07/2023] Open
Abstract
Patient Blood Management (PBM) is a patient-centered, systemic and evidence-based approach. Its target is to manage and to preserve the patient's own blood. The aim of PBM is to improve patient safety. As indicated by several meta-analyses in a systematic literature search, the cell salvage technique is an efficient method to reduce the demand for allogeneic banked blood. Therefore, cell salvage is an important tool in PBM. Cell salvage is widely used in orthopedic-, trauma-, cardiac-, vascular and transplant surgery. Especially in cases of severe bleeding cell salvage adds significant value for blood supply. In cardiac and orthopedic surgery, the postoperative use for selected patients at the intensive care unit is feasible and can be implemented well in practice. Since the retransfusion of unwashed shed blood should be avoided due to multiple side effects and low quality, cell salvage can be used to reduce postoperative anemia with autologous blood of high quality. Implementing quality management, compliance with hygienic standards as well as training and education of staff, it is a cost-efficient method to reduce allogeneic blood transfusion. The following article will discuss the possibilities, legal aspects, implementation and costs of using cell salvage devices in an intensive care unit.
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Affiliation(s)
- Stephan L. Schmidbauer
- Department of Anesthesiology, University Hospital Regensburg, 93053 Regensburg, Germany;
| | - Timo F. Seyfried
- Department of Anesthesiology, Ernst von Bergmann Hospital, 14467 Potsdam, Germany
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Migeot C, Ma I, El Arid JM, Soulé N, Garnier E, Neville P, Lefort B. Factors associated with red blood cells transfusion during first bloodless priming cardiac surgery in children. Arch Pediatr 2022; 29:370-375. [DOI: 10.1016/j.arcped.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 02/08/2022] [Accepted: 03/26/2022] [Indexed: 11/26/2022]
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Martinez MJ, Schwingshackl A, Romero T, Roach GD, Belperio JA, Federman MD. Cell saver blood transfusions may be associated with a decrease in inflammation and improved outcome measures in pediatric cardiac surgery patients. Perfusion 2022; 38:717-724. [PMID: 35411827 DOI: 10.1177/02676591221078420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Cardiopulmonary bypass (CPB) is a requisite for correction of congenital heart disease by open-heart surgery and induces a systemic inflammatory response that can lead to complications such as acute lung injury and acute kidney injury. In addition, blood transfusions are commonly required for this type of surgery, and they may further exacerbate this inflammatory response and increase morbidity and mortality. We hypothesized that, in contrast to red blood cells, intraoperative cell saver (CS) blood transfusions attenuate the post-CPB proinflammatory cytokine response. METHODS Serum cytokine concentrations of IL-10, IL-1RA, IL-6, IL-8, and TNF-α were measured at four time points (preoperatively and postoperatively on postoperative days 0, 1, and 2). RESULTS Anti-inflammatory IL-10 levels were significantly lower in the CS group on POD 0 than in the control group (mean 1083.2 pg/mL vs 2080.2 pg/mL, 95%CI 357.4-1636.6, p = .0026). Of the clinical parameters measured, mean BUN and creatinine levels on POD 2 were significantly lower in the CS group (13.79 vs 21.88, p = .004 and 0.45 vs 0.55, p = .055, respectively). In addition, the duration of milrinone use decreased by 80% in the CS group (0.20, 95%CI 0.04, 0.94; p = .048), the median time to extubation in hours was significantly lower in the CS group (3.5 vs 6.5; 95%CI -38.00, -0.50; p = .026), and hospital length of stay was decreased by 60% in the CS group (p = .003). CONCLUSIONS CS transfusions in children may lower postoperative anti-inflammatory IL-10 levels, possibly due to an overall decrease in proinflammatory state, and may be associated with improvements in renal and pulmonary functions.
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Affiliation(s)
- Michael J Martinez
- Division of Critical Care Medicine, Department of Pediatrics, 549938Mattel Children's Hospital at UCLA, Los Angeles, CA, USA
| | - Andreas Schwingshackl
- Division of Critical Care Medicine, Department of Pediatrics, 549938Mattel Children's Hospital at UCLA, Los Angeles, CA, USA
| | - Tahmineh Romero
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, Los Angeles, CA, USA
| | - Gavin D Roach
- Division of Hematology and Oncology, Department of Pediatrics, 549938Mattel Children's Hospital at UCLA, Los Angeles, CA, USA
| | - John A Belperio
- Division of Pulmonary, Critical Care Medicine, Allergy and Clinical Immunology, Department of Medicine, The David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Myke D Federman
- Division of Critical Care Medicine, Department of Pediatrics, 549938Mattel Children's Hospital at UCLA, Los Angeles, CA, USA
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15
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Cell Saver Blood Reinfusion Up to 24 Hours Post Collection in Pediatric Cardiac Surgical Patients Does Not Increase Incidence of Hospital-Acquired Infections or Mortality. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2021; 53:161-169. [PMID: 34658406 DOI: 10.1182/ject-2100015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 05/17/2021] [Indexed: 11/20/2022]
Abstract
Cell saver blood reinfusion, a blood conservation technique recently available for pediatric use, is typically limited to 6 hours post processing to guard against bacterial contamination. We hypothesize that reinfusion of cell saver blood up to 24 hours post collection in children after cardiac surgery will not increase the incidence of hospital-acquired infections (HAI). The primary aim is to compare incidence of HAI between children receiving cell saver blood ≤6 hours vs. >6 to ≤24 hours from its collection. The secondary aim is to compare mortality and clinical outcomes. Retrospective chart review of children ≤18 years undergoing cardiac surgery with cardiopulmonary bypass (CPB) from 2013 to 2018 when cell saver collection and bedside temperature controlled storage became standard of care. Patients on extracorporeal membrane oxygenation (ECMO) within 48 hours postoperatively and those who did not receive cell saver were excluded. The primary outcome was HAI incidence postoperative days 0-6. Demographic data included diagnosis, surgical severity score, and clinical outcomes. 466 patients, 45% female. No significant between-group differences identified. There was no significant difference in HAI (control 8.5% vs. treatment 8.0%, p = .80) and death (control 7.9% vs. treatment 4.9%, p = .20). Noninferiority testing indicated the treatment group was not statistically inferior to the control group (p = .0028). Kaplan-Meier curve depicted similar status between-group rates of no infection or death; 92% treatment vs. 91% control. Total volume allogeneic red blood cell transfusion (allogeneic blood transfusion [ABT]) up to 24 hours postoperatively was significantly less in the treatment group, p < .0001. Incidence of HAI or mortality was not increased in patients receiving cell saver blood reinfusion >6 to ≤24 hours post collection. Treatment subjects received significantly less volume of ABT. Considering the risks of ABT, these findings support cell saver blood reinfusion up to 24 hours post collection.
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16
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In Vitro and In Vivo Comparison of Hemoglobin and Electrolytes Following the Collection of Cell Saver Blood Washed with Either Normal Saline or Plasma-Lyte A. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2021; 53:214-219. [PMID: 34658415 DOI: 10.1182/ject-2100018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 06/07/2021] [Indexed: 11/20/2022]
Abstract
Cell saver blood is typically washed with normal saline (NS); however, recent studies have reported decreased red blood cell hemolysis and increased platelet function when a more physiologic washing solution, such as Plasma-Lyte A (PL-A) is used. We evaluated the in vitro and in vivo effects of NS compared to PL-A as washing solutions for cell saver blood in pediatric cardiac surgery. Cell saver blood was re-infused for up to 24 hours post-collection. Laboratory and clinical data were collected from infants receiving cell saver washed with either NS (n = 20) or PL-A (n = 21). Compositions of the cell saver blood were compared between groups at 5 in vitro time points and in vivo patient blood at 24 hours post-bypass. Although there were differences in in vitro laboratory values between groups; 24 hours post-bypass, in vivo results were similar. Our data supports 24-hour reinfusion of cell saver washed with either NS versus PL-A in pediatric cardiac surgery patients, and provides data on the differences in cell saver composition to guide future studies.
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17
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Sebastian R, Ahmed MI. Blood Conservation and Hemostasis Management in Pediatric Cardiac Surgery. Front Cardiovasc Med 2021; 8:689623. [PMID: 34490364 PMCID: PMC8416772 DOI: 10.3389/fcvm.2021.689623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 05/17/2021] [Indexed: 11/13/2022] Open
Abstract
Pediatric cardiac surgery is associated with significant perioperative blood loss needing blood product transfusion. Transfusion carries serious risks and implications on clinical outcomes in this vulnerable population. The need for transfusion is higher in children and is attributed to several factors including immaturity of the hemostatic system, hemodilution from the CPB circuit, excessive activation of the hemostatic system, and preoperative anticoagulant drugs. Other patient characteristics such as smaller relative size of the patient, higher metabolic and oxygen requirements make successful blood transfusion management extremely challenging in this population and require meticulous planning and multidisciplinary teamwork. In this narrative review we aim to summarize risks and complications associated with blood transfusion in pediatric cardiac surgery and also to summarize perioperative coagulation management and blood conservation strategies.
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Affiliation(s)
- Roby Sebastian
- Department of Anesthesiology and Pain Management, UT Southwestern Medical Center, Children's Medical Center, Dallas, TX, United States
| | - M Iqbal Ahmed
- Department of Anesthesiology and Pain Management, UT Southwestern Medical Center, Children's Medical Center, Dallas, TX, United States
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18
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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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Steffen KM, Spinella PC, Holdsworth LM, Ford MA, Lee GM, Asch SM, Proctor EK, Doctor A. Factors Influencing Implementation of Blood Transfusion Recommendations in Pediatric Critical Care Units. Front Pediatr 2021; 9:800461. [PMID: 34976903 PMCID: PMC8718763 DOI: 10.3389/fped.2021.800461] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 11/25/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose: Risks of red blood cell transfusion may outweigh benefits for many patients in Pediatric Intensive Care Units (PICUs). The Transfusion and Anemia eXpertise Initiative (TAXI) recommendations seek to limit unnecessary and potentially harmful transfusions, but use has been variable. We sought to identify barriers and facilitators to using the TAXI recommendations to inform implementation efforts. Materials and Methods: The integrated Promoting Action on Research Implementation in Health Services (iPARIHS) framework guided semi-structured interviews conducted in 8 U.S. ICUs; 50 providers in multiple ICU roles completed interviews. Adapted Framework analysis, a form of content analysis, used the iPARIHS innovation, recipient, context and facilitation constructs and subconstructs to categorize data and identify patterns as well as unique informative statements. Results: Providers perceived that the TAXI recommendations would reduce transfusion rates and practice variability, but adoption faced challenges posed by attitudes around transfusion and care in busy and complex units. Development of widespread buy-in and inclusion in implementation, integration into workflow, designating committed champions, and monitoring outcomes data were expected to enhance implementation. Conclusions: Targeted activities to create buy-in, educate, and plan for use are necessary for TAXI implementation. Recognition of contextual challenges posed by the PICU environment and an approach that adjusts for barriers may optimize adoption.
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Affiliation(s)
- Katherine M Steffen
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Stanford University, Palo Alto, CA, United States
| | - Philip C Spinella
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University in Saint Louis, Saint Louis, MO, United States
| | - Laura M Holdsworth
- Department of Medicine, Primary Care and Population Health, Stanford University, Stanford, CA, United States
| | - Mackenzie A Ford
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University, Palo Alto, CA, United States
| | - Grace M Lee
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Stanford University, Stanford, CA, United States
| | - Steven M Asch
- Department of Medicine, Primary Care and Population Health, Stanford University, Stanford, CA, United States
| | - Enola K Proctor
- George Warren Brown School of Social Work, Washington University in St. Louis, St. Louis, MO, United States
| | - Allan Doctor
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Maryland, Baltimore, MD, United States
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20
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Wise R, Bishop D, Gibbs M, Govender K, James MFM, Kabambi F, Louw V, Mdladla N, Moipalai L, Motchabi-Chakane P, Nolte D, Rodseth R, Schneider F, Turton E. South African Society of Anaesthesiologists Perioperative Patient Blood Management Guidelines 2020. SOUTHERN AFRICAN JOURNAL OF ANAESTHESIA AND ANALGESIA 2020. [DOI: 10.36303/sajaa.2020.26.6.s1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Anaesthesiologists regularly request and administer blood components to their patients, a potentially life-saving intervention. All anaesthesiologists must be familiar with the indications and appropriate use of blood and blood components and their alternatives, but close liaison with haematologists and their local haematology blood sciences laboratory is encouraged. In the last decade, there have been considerable changes in approaches to optimal use of blood components, together with the use of alternative products, with a need to update previous guidelines and adapt them for anaesthesiologists working throughout the hospital system.
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Affiliation(s)
- R Wise
- University of KwaZulu-Natal
| | | | | | | | | | | | | | - N Mdladla
- Sefako Makgatho Health Sciences University
| | | | | | - D Nolte
- University of the Witwatersrand
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21
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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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22
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Melchior RW, Dreher M, Shade B, Chappell A, Fisher D, Rosenthal T. Comparison of three autotransfusion devices for utilization in the pediatric population. Perfusion 2020; 36:57-62. [DOI: 10.1177/0267659120921090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction: A device that may help attenuate the amount of homologous blood product given to pediatric cardiac surgical patients is the autotransfusion device. Three separate autotransfusion devices were selected for evaluation. The Sorin Xtra, Fresenius Continuous Autotransfusion System Plus (CATS*plus), and the Fresenius Continuous Autotransfusion System Smart (CATSmart) were evaluated based on the mechanical processes of each device, hematocrit value of the salvaged packed red cell product, time of processing, and the advantageous accessories with each device. Methods: Each of the autotransfusion devices were used to collect salvageable blood from the surgical field as well as to process residual blood from the cardiopulmonary bypass circuit after decannulation. The cell salvage process was performed in accordance with the manufacturer’s instructions for use and the recommended settings for processing and washing. The Sorin Xtra device had the 55 mL bowl set up for all cases, while the Fresenius continuous autotransfusion systems utilized the standard disposable for each device. Results: Each cell salvage device was employed during 30 pediatric cardiac surgery procedures, and data for each device, was broken down into four groups based on patient weight (0-10, 10-20, 20-40, and >40 kg). For all patient sizes, the Sorin Xtra tended to produce the greatest volume of cell saver product (55-825 mL) as compared to the CATS*plus and CATSmart devices (7-550 mL and 0-860 mL, respectively). The Continuous Autotransfusion System Smart tended to produce the highest hematocrit product, ranging from 44 to 81%. Discussion: Through this evaluation, it was determined the continuous autotransfusion systems provided the highest hematocrit with the lowest recovered packed red cell volume, while the Sorin Xtra packed red cell product showed to have a lower hematocrit with a larger packed red cell volume. Each device proved effective within our pediatric population.
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Affiliation(s)
- Richard W Melchior
- Department of Perfusion Services, Cardiac Center, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Molly Dreher
- Department of Perfusion Services, Cardiac Center, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Brandon Shade
- Department of Perfusion Services, Cardiac Center, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Alexander Chappell
- Department of Perfusion Services, Cardiac Center, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Douglas Fisher
- Department of Perfusion Services, Cardiac Center, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Tami Rosenthal
- Department of Perfusion Services, Cardiac Center, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
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23
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Hinson WD, Rogovskyy AS, Lawhon SD, Thieman Mankin KM. Influence of a cell salvage washing system and leukocyte reduction filtration on bacterial contamination of canine whole blood ex vivo. Vet Surg 2020; 49:989-996. [PMID: 32166777 DOI: 10.1111/vsu.13410] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 12/12/2019] [Accepted: 02/24/2020] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To determine the ability of cell salvage washing and leukoreduction filtration to remove bacterial contamination from canine whole blood. STUDY DESIGN Ex vivo nested cohort study. SAMPLE POPULATION Commercially purchased fresh canine whole blood (n = 33 units). METHODS Commercially obtained canine whole blood was inoculated with known concentrations of one of three species of bacteria, Escherichia coli (ATCC 25922), Staphylococcus pseudintermedius (quality control strain; Texas A&M University), or Pseudomonas aeruginosa (ATCC 27853). Negative controls were inoculated with sterile saline. The inoculated blood was processed through a cell salvage system and filtered through a series of two leukocyte reduction filters. Samples were aseptically collected at five points during processing (inoculum, prewash, postwash, post-first filtration, and post-second filtration) for bacterial enumeration. RESULTS Bacterial concentrations were reduced by 85.2%, 91.5%, and 93.9% for E coli, S pseudintermedius, and P aeruginosa, respectively, after washing (P < .0001), and bacterial concentrations were reduced by 99.9%, 100%, and 100%, respectively, after the first filtration (P < .0001). After the second filtration, none of the three species of bacteria could be isolated (100% reduction). No bacterial growth was obtained from negative controls throughout the study. The type of bacteria (P = .29) did not allow prediction of bacterial reduction. CONCLUSION Cell salvage washing combined with leukoreduction filtration eliminated bacterial contamination of whole dog blood (P < .0001). CLINICAL SIGNIFICANCE Cell salvage washing and leukoreduction filtration could be applied to intraoperative autotransfusion in clinical animals, especially those treated for trauma or hemorrhage with concurrent bacterial contamination.
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Affiliation(s)
- Whitney D Hinson
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Texas A&M College of Veterinary Medicine, College Station, Texas
| | - Artem S Rogovskyy
- Department of Veterinary Pathobiology, College of Veterinary Medicine and Biomedical Sciences, Texas A&M College of Veterinary Medicine, College Station, Texas
| | - Sara D Lawhon
- Department of Veterinary Pathobiology, College of Veterinary Medicine and Biomedical Sciences, Texas A&M College of Veterinary Medicine, College Station, Texas
| | - Kelley M Thieman Mankin
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Texas A&M College of Veterinary Medicine, College Station, Texas
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24
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Palaniswamy SR, Beniwal M, Venkataramaiah S, Srinivas D. Perioperative Management of Pediatric Giant Supratentorial Tumors: Challenges and Management Strategies. J Pediatr Neurosci 2019; 14:211-217. [PMID: 31908662 PMCID: PMC6935985 DOI: 10.4103/jpn.jpn_51_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 06/26/2019] [Accepted: 09/04/2019] [Indexed: 11/20/2022] Open
Abstract
Background: Intracranial tumors are the most common pediatric solid tumors. Only one-third of these tumors arise from the supratentorial compartment. The abnormal intracranial tumors are unusual but can bleed to an extent causing hemorrhagic shock necessitating blood transfusion in the perioperative period. The perioperative management of these subset of patients poses a unique challenge to both the neurosurgeons and the neuroanesthetic team. Materials and Methods: This study included a case series of 30 patients with giant supratentorial neoplasms who underwent craniotomy and tumor resection from 2014 to 2017 in our Tertiary Care Institute. The clinical data were collected from the patient’s records obtained from the Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, Karnataka, India. The aim of this case series was to characterize the perioperative challenges, management strategies, course, and outcome in 30 children who were operated for elective or emergency resection of giant supratentorial lesions in our hospital. We also reviewed the literature available to guide the anesthetic management of pediatric patients with intracranial tumors. Results: Among the 30 patients, four had significant intraoperative fluid shifts necessitating massive blood transfusion perioperatively. The overall incidence of mortality in our study cohort was 16.67% (5/30). Conclusion: The maintenance of systemic physiological homeostasis by anticipation of complications, vigilant monitoring, and prompt resuscitation is critical to foster favorable outcomes in unison with optimal and safe surgical extirpation of the primary cerebral lesion.
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Affiliation(s)
- Sangeetha R Palaniswamy
- Department of Neuroanaesthesia and Neuro-Critical Care, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, Karnataka, India
| | - Manish Beniwal
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, Karnataka, India
| | - Sudhir Venkataramaiah
- Department of Neuroanaesthesia and Neuro-Critical Care, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, Karnataka, India
| | - Dwarakanath Srinivas
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, Karnataka, India
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25
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Faraoni D, Meier J, New HV, Van der Linden PJ, Hunt BJ. Patient Blood Management for Neonates and Children Undergoing Cardiac Surgery: 2019 NATA Guidelines. J Cardiothorac Vasc Anesth 2019; 33:3249-3263. [DOI: 10.1053/j.jvca.2019.03.036] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 03/17/2019] [Accepted: 03/18/2019] [Indexed: 12/22/2022]
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26
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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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27
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Fernandez A, Chasovskyi K. The Use of Umbilical Cord Blood for Autologous Transfusion in Neonatal Open Heart Surgery. J Cardiothorac Vasc Anesth 2019; 34:483-488. [PMID: 31151859 DOI: 10.1053/j.jvca.2019.05.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 05/03/2019] [Accepted: 05/05/2019] [Indexed: 12/29/2022]
Abstract
In the last few decades, the use of umbilical cord blood (UCB) has received increasing attention, not only as a source of stem cells, but also as a transfusion product for the treatment of anemia in the neonatal and even the adult population. This review focuses on data reports and collection efforts related to the autologous transfusion of UCB in full-term neonates with prenatally diagnosed critical congenital heart defects. This review summarizes different aspects of UCB transfusion, including indications and contraindications; the collection procedure; storage timing; and special properties of one of its constituents, fetal hemoglobin, in the setting of hypothermic cardiopulmonary bypass.
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Affiliation(s)
- Adam Fernandez
- Perfusion Department, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Kyrylo Chasovskyi
- Perfusion Department, BC Children's Hospital, Vancouver, British Columbia, Canada.
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28
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Abstract
Cell salvage is an efficient method to reduce the transfusion of homologous banked blood, as documented by several meta-analyses detected in a systematic literature search. Cell salvage is widely used in orthopedics, trauma surgery, cardiovascular and abdominal transplantation surgery. The retransfusion of unwashed shed blood from wounds or drainage is not permitted according to German regulations. Following irradiation of wound blood, salvaged blood can also be used in tumor surgery. Cell salvage makes a valuable contribution to providing sufficient compatible blood for transfusions in cases of massive blood loss. Certain surgical procedures for Jehovah's Witnesses are only possible with the use of cell salvage. Another possible use is the washing of homologous banked blood, e. g. to prevent potassium-induced arrhythmia or sequestration of autologous platelets. Other advantages besides a good compatibility are the high vitality and functionality of the unstored autologous red blood cells. These have been declared a pharmaceutical product by the German transfusion task force in 2014, so that the autologous red blood cells are now under the control of the Pharmaceutical Products Act (AMG). The new hemotherapy guidelines, however, tolerate cell salvage only under strict rules, whereby the production of autologous blood during or after surgery is still possible without additional special permits. The new guidelines now require the introduction of a quality management system for cell salvage and regular quality controls. These quality controls include a control of the product hematocrit for every application, monthly controls of the protein and albumin elimination rates and the erythrocyte recovery rate for each cell salvage device. Testing for infection markers is not required. The application of cell salvage has to be reported to the appropriate authorities.
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Valentine SL, Bembea MM, Muszynski JA, Cholette JM, Doctor A, Spinella PC, Steiner ME, Tucci M, Hassan NE, Parker RI, Lacroix J, Argent A, Carson JL, Remy KE, Demaret P, Emeriaud G, Kneyber MCJ, Guzzetta N, Hall MW, Macrae D, Karam O, Russell RT, Stricker PA, Vogel AM, Tasker RC, Turgeon AF, Schwartz SM, Willems A, Josephson CD, Luban NLC, Lehmann LE, Stanworth SJ, Zantek ND, Bunchman TE, Cheifetz IM, Fortenberry JD, Delaney M, van de Watering L, Robinson KA, Malone S, Steffen KM, Bateman ST. Consensus Recommendations for RBC Transfusion Practice in Critically Ill Children From the Pediatric Critical Care Transfusion and Anemia Expertise Initiative. Pediatr Crit Care Med 2018; 19:884-898. [PMID: 30180125 PMCID: PMC6126913 DOI: 10.1097/pcc.0000000000001613] [Citation(s) in RCA: 105] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVES To date, there are no published guidelines to direct RBC transfusion decision-making specifically for critically ill children. We present the recommendations from the Pediatric Critical Care Transfusion and Anemia Expertise Initiative. DESIGN Consensus conference series of multidisciplinary, international experts in RBC transfusion management of critically ill children. SETTING Not applicable. INTERVENTION None. SUBJECTS Children with, or children at risk for, critical illness who receive or are at risk for receiving a RBC transfusion. METHODS A panel of 38 content and four methodology experts met over the course of 2 years to develop evidence-based, and when evidence lacking, expert consensus-based recommendations regarding decision-making for RBC transfusion management and research priorities for transfusion in critically ill children. The experts focused on nine specific populations of critically ill children: general, respiratory failure, nonhemorrhagic shock, nonlife-threatening bleeding or hemorrhagic shock, acute brain injury, acquired/congenital heart disease, sickle cell/oncology/transplant, extracorporeal membrane oxygenation/ventricular assist/ renal replacement support, and alternative processing. Data to formulate evidence-based and expert consensus recommendations were selected based on searches of PubMed, EMBASE, and Cochrane Library from 1980 to May 2017. Agreement was obtained using the Research and Development/UCLA Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. MEASUREMENTS AND RESULTS The Transfusion and Anemia Expertise Initiative consensus conference developed and reached consensus on a total of 102 recommendations (57 clinical [20 evidence based, 37 expert consensus], 45 research recommendations). All final recommendations met agreement, defined a priori as greater than 80%. A decision tree to aid clinicians was created based on the clinical recommendations. CONCLUSIONS The Transfusion and Anemia Expertise Initiative recommendations provide important clinical guidance and applicable tools to avoid unnecessary RBC transfusions. Research recommendations identify areas of focus for future investigation to improve outcomes and safety for RBC transfusion.
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Affiliation(s)
- Stacey L Valentine
- Division of Pediatric Critical Care, Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA
| | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD
| | - Jennifer A Muszynski
- Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH
- The Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Jill M Cholette
- Department of Pediatrics, University of Rochester, Rochester, NY
| | - Allan Doctor
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Phillip C Spinella
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Marie E Steiner
- Department of Pediatrics, University of Minnesota, Minneapolis, MN
| | - Marisa Tucci
- Department of Pediatrics, University of Montreal, Montreal, QC, Canada
| | - Nabil E Hassan
- Department of Pediatrics, University of Illinois College of Medicine, Peoria, IL
| | - Robert I Parker
- Department of Pediatrics, Stony Brook University, Stony Brook, NY
| | - Jacques Lacroix
- Department of Pediatrics, University of Montreal, Montreal, QC, Canada
| | - Andrew Argent
- Department of Pediatrics, University of Cape Town, Cape Town, South Africa
| | - Jeffrey L Carson
- Department of Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Kenneth E Remy
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | | | | | - Martin C J Kneyber
- Department of Pediatrics, University of Groningen, Groningen, The Netherlands
| | - Nina Guzzetta
- Department of Anesthesiology, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA
| | - Mark W Hall
- Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH
- The Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Duncan Macrae
- Pediatric Critical Care, Royal Brompton Hospital, London, United Kingdom
| | - Oliver Karam
- Department of Pediatrics, Professor and Director Pediatric Nephrology, Childrens Hospital of Richmond, Virginia Commonwealth University, Richmond, VA
| | - Robert T Russell
- Department of Surgery, University of Alabama Birmingham, Birmingham, AL
| | - Paul A Stricker
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA
| | - Adam M Vogel
- Division of Pediatric Surgery and Pediatrics, Baylor College of Medicine, Houston, TX
| | - Robert C Tasker
- Departments of Neurology and Anesthesia (Pediatrics), Harvard Medical School, Boston, MA
| | - Alexis F Turgeon
- Department of Anesthesiology and Critical Care Medicine, Univesite Laval Research Center, Quebec City, QC, Canada
| | - Steven M Schwartz
- Department of Critical Care Medicine and Paediatrics, University of Toronto, ON, Canada
| | - Ariane Willems
- Pediatric Intensive Care Unit, University of Brussels, Brussels, Belgium
| | - Cassandra D Josephson
- Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA
| | - Naomi L C Luban
- Department of Pediatrics and Pathology, George Washington University, Washington, DC
| | | | - Simon J Stanworth
- Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Nicole D Zantek
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN
| | - Timothy E Bunchman
- Department of Pediatrics, Professor and Director Pediatric Nephrology, Childrens Hospital of Richmond, Virginia Commonwealth University, Richmond, VA
| | | | - James D Fortenberry
- Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA
| | - Meghan Delaney
- Division of Pathology and Laboratory Medicine, Children's National Health System, Washington, DC
| | | | - Karen A Robinson
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sara Malone
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Katherine M Steffen
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA
| | - Scot T Bateman
- Division of Pediatric Critical Care, Department of Pediatrics, University of Massachusetts Medical School, Worcester, MA
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Doctor A, Cholette JM, Remy KE, Argent A, Carson JL, Valentine SL, Bateman ST, Lacroix J. Recommendations on RBC Transfusion in General Critically Ill Children Based on Hemoglobin and/or Physiologic Thresholds From the Pediatric Critical Care Transfusion and Anemia Expertise Initiative. Pediatr Crit Care Med 2018; 19:S98-S113. [PMID: 30161064 PMCID: PMC6125789 DOI: 10.1097/pcc.0000000000001590] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To present the consensus recommendations and supporting literature for RBC transfusions in general critically ill children from the Pediatric Critical Care Transfusion and Anemia Expertise Initiative. DESIGN Consensus conference series of international, multidisciplinary experts in RBC transfusion management of critically ill children. METHODS The panel of 38 experts developed evidence-based and, when evidence was lacking, expert-based recommendations and research priorities regarding RBC transfusions in critically ill children. The subgroup on RBC transfusion in general critically ill children included six experts. Electronic searches were conducted using PubMed, EMBASE, and Cochrane Library databases from 1980 to May 30, 2017, using a combination of keywords to define concepts of RBC transfusion and critically ill children. Recommendation consensus was obtained using the Research and Development/UCLA Appropriateness Method. The results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. RESULTS Three adjudicators reviewed 4,399 abstracts; 71 papers were read, and 17 were retained. Three papers were added manually. The general Transfusion and Anemia Expertise Initiative subgroup developed, and all Transfusion and Anemia Expertise Initiative members voted on two good practice statements, six recommendations, and 11 research questions; in all instances, agreement was reached (> 80%). The good practice statements suggest a framework for RBC transfusion in PICU patients. The good practice statements and recommendations focus on hemoglobin as a threshold and/or target. The research questions focus on hemoglobin and physiologic thresholds for RBC transfusion, alternatives, and risk/benefit ratio of transfusion. CONCLUSIONS Transfusion and Anemia Expertise Initiative developed pediatric-specific good practice statements and recommendations regarding RBC transfusion management in the general PICU population, as well as recommendations to guide future research priorities. Clinical recommendations emphasized relevant hemoglobin thresholds, and research recommendations emphasized a need for further understanding of physiologic thresholds, alternatives to RBC transfusion, and hemoglobin thresholds in populations with limited pediatric literature.
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Affiliation(s)
- Allan Doctor
- Allan Doctor, MD, Professor of Pediatrics and Biochemistry, Division of Pediatric Critical Care Medicine, Washington University in St. Louis, St. Louis Children’s Hospital, United States
| | - Jill M. Cholette
- Jill M. Cholette, MD, Associate Professor of Pediatrics, Medical Director, Pediatric Cardiac Care Center, University of Rochester, Golisano Children’s Hospital, United States
| | - Kenneth E. Remy
- Kenneth E. Remy, MD, MHSc, Assistant Professor of Pediatrics. Division of Pediatric Critical Care Medicine, Washington University in St. Louis, St. Louis Children’s Hospital, United States
| | - Andrew Argent
- Andrew Argent, MD, Professor of Pediatrics, Medical Director, Paediatric Intensive Care, University of Cape Town and Red Cross War Memorial Children’s Hospital, South Africa
| | - Jeffrey L. Carson
- Jeffrey L. Carson, MD, Provost – New Brunswick Distinguished Professor of Medicine, Richard C. Reynolds Chair of General Internal Medicine; Rutgers Robert Wood Johnson Medical School, Rutgers, The State University of New Jersey, United States
| | - Stacey L. Valentine
- Stacey L. Valentine, MD, MPH, Assistant Professor of Pediatrics, University of Massachusetts Medical School, United States
| | - Scot T. Bateman
- Scot T. Bateman, MD, Professor of Pediatrics, Division Chief of Pediatric Critical Care Medicine, University of Massachusetts Medical School, United States
| | - Jacques Lacroix
- Jacques Lacroix, MD, Professor of Pediatrics, Division of Pediatric Critical Care, Department of Pediatrics, Sainte-Justine Hospital, Université de Montréal, Canada
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Recommendations on RBC Transfusion in Infants and Children With Acquired and Congenital Heart Disease From the Pediatric Critical Care Transfusion and Anemia Expertise Initiative. Pediatr Crit Care Med 2018; 19:S137-S148. [PMID: 30161069 PMCID: PMC6126364 DOI: 10.1097/pcc.0000000000001603] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To present the recommendations and supporting literature for RBC transfusions in critically ill children with acquired and congenital heart disease developed by the Pediatric Critical Care Transfusion and Anemia Expertise Initiative. DESIGN Consensus conference series of 38 international, multidisciplinary experts in RBC transfusion management of critically ill children. METHODS Experts developed evidence-based and, when evidence was lacking, expert-based clinical recommendations and research priorities for RBC transfusions in critically ill children. The cardiac disease subgroup included three experts. Electronic searches were conducted using PubMed, EMBASE, and Cochrane Library databases from 1980 to May 2017. Agreement was obtained using the Research and Development/UCLA appropriateness method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method. RESULTS Twenty-one recommendations were developed and reached agreement. For children with myocardial dysfunction and/or pulmonary hypertension, there is no evidence that transfusion greater than hemoglobin of 10 g/dL is beneficial. For children with uncorrected heart disease, we recommended maintaining hemoglobin greater than 7-9.0 g/dL depending upon their cardiopulmonary reserve. For stable children undergoing biventricular repairs, we recommend not transfusing if the hemoglobin is greater than 7.0 g/dL. For infants undergoing staged palliative procedures with stable hemodynamics, we recommend avoiding transfusions solely based upon hemoglobin, if hemoglobin is greater than 9.0 g/dL. We recommend intraoperative and postoperative blood conservation measures. There are insufficient data supporting shorter storage duration RBCs. The risks and benefits of RBC transfusions in children with cardiac disease requires further study. CONCLUSIONS We present RBC transfusion management recommendations for the critically ill child with cardiac disease. Clinical recommendations emphasize relevant hemoglobin thresholds, and research recommendations emphasize need for further understanding of physiologic and hemoglobin thresholds and alternatives to RBC transfusion in subpopulations lacking pediatric literature.
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Vörös E, Piety NZ, Strachan BC, Lu M, Shevkoplyas SS. Centrifugation-free washing: A novel approach for removing immunoglobulin A from stored red blood cells. Am J Hematol 2018; 93:518-526. [PMID: 29285804 DOI: 10.1002/ajh.25026] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 12/20/2017] [Accepted: 12/26/2017] [Indexed: 01/28/2023]
Abstract
Washed red blood cells (RBCs) are indicated for immunoglobulin A (IgA) deficient recipients. Centrifugation-based cell processors commonly used by hospital blood banks cannot consistently reduce IgA below the recommended levels, hence double washing is frequently required. Here, we describe a prototype of a simple, portable, disposable system capable of washing stored RBCs without centrifugation, while reducing IgA below 0.05 mg/dL in a single run. Samples from RBC units (n = 8, leukoreduced, 4-6 weeks storage duration) were diluted with normal saline to a hematocrit of 10%, and then washed using either the prototype washing system, or via conventional centrifugation. The efficiency of the two washing methods was quantified and compared by measuring several key in vitro quality metrics. The prototype of the washing system was able to process stored RBCs at a rate of 300 mL/hour, producing a suspension of washed RBCs with 43 ± 3% hematocrit and 86 ± 7% cell recovery. Overall, the two washing methods performed similarly for most measured parameters, lowering the concentration of free hemoglobin by >4-fold and total free protein by >10-fold. Importantly, the new washing system reduced the IgA level to 0.02 ± 0.01 mg/mL, a concentration 5-fold lower than that produced by conventional centrifugation. This proof-of-concept study showed that centrifugation may be unnecessary for washing stored RBCs. A simple, disposable, centrifugation-free washing system could be particularly useful in smaller medical facilities and resource limited settings that may lack access to centrifugation-based cell processors.
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Affiliation(s)
- Eszter Vörös
- Department of Biomedical Engineering; University of Houston; Houston Texas 77204
| | - Nathaniel Z. Piety
- Department of Biomedical Engineering; University of Houston; Houston Texas 77204
| | - Briony C. Strachan
- Department of Biomedical Engineering; University of Houston; Houston Texas 77204
| | - Madeleine Lu
- Department of Biomedical Engineering; University of Houston; Houston Texas 77204
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Klein AA, Bailey CR, Charlton AJ, Evans E, Guckian-Fisher M, McCrossan R, Nimmo AF, Payne S, Shreeve K, Smith J, Torella F. Association of Anaesthetists guidelines: cell salvage for peri-operative blood conservation 2018. Anaesthesia 2018; 73:1141-1150. [DOI: 10.1111/anae.14331] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2018] [Indexed: 01/03/2023]
Affiliation(s)
- A. A. Klein
- Department of Anaesthesia and Intensive Care; Royal Papworth Hospital; Cambridge UK
| | - C. R. Bailey
- Department of Anaesthesia, Guys and St; Thomas' NHS Foundation Trust; London UK
| | - A. J. Charlton
- NHS Blood and Transplant; Newcastle upon Tyne NHS Foundation Trust; Newcastle UK
| | - E. Evans
- Department of Obstetric Anaesthesia; St George's University Hospitals NHS Foundation Trust; London UK
| | - M. Guckian-Fisher
- Immediate Past President; The Association for Peri-operative Practice (AFPP); UK
| | - R. McCrossan
- Northern School of Anaesthesia; Royal Victoria Infirmary; Newcastle upon Tyne NHS Foundation Trust; Newcastle UK
| | - A. F. Nimmo
- Department of Anaesthesia; Royal Infirmary of Edinburgh; Edinburgh UK
| | | | - K. Shreeve
- Better Blood Transfusion Team; Welsh Blood Service; Co-chair of UK Cell Salvage Action Group; UK
| | - J. Smith
- Department of Paediatric Cardiothoracic Anaesthesia and Intensive Care; Freeman Hospital; Newcastle upon Tyne NHS Foundation Trust; Newcastle UK
| | - F. Torella
- Liverpool Vascular and Endovascular Service; Liverpool UK
- School of Physical Sciences; University of Liverpool; Liverpool UK
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Reagor JA, Clingan S, Kulat BT, Matte GS, Voss J, Tweddell JS. The Norwood Stage 1 procedure - conduct of perfusion: 2017 Survey results from NPC-QIC member institutions. Perfusion 2018; 33:667-678. [DOI: 10.1177/0267659118781173] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Hypoplastic left heart syndrome (HLHS) is a rare and severe congenital cardiac defect. Approximately 1000 infants are born with HLHS in the United States every year. Healthcare collaboratives over the last decade have focused on sharing patient experiences and techniques in an effort to improve outcomes. In 2010, cardiologists and patient families joined together to improve the care of HLHS patients by forming the National Pediatric Cardiology Quality Improvement Collaborative (NPC-QIC). Sixty-six of the approximately 110 institutions caring for patients with HLHS in the United States and Canada are now members of NPC-QIC. In 2017, cardiovascular perfusionists joined the collaborative as another specialty involved in the care of HLHS patients. Perfusionists and cardiac surgeons developed the collaborative’s first conduct of perfusion survey for the Norwood Stage 1 procedure, specifically targeting the provision of cardiopulmonary bypass for patients with HLHS. This manuscript discusses the results of this survey, unveiling a significant variance in the conduct of perfusion for this patient population.
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Affiliation(s)
- James A. Reagor
- Department of Cardiovascular Perfusion, Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Sean Clingan
- Department of Cardiovascular Perfusion, Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Bradley T. Kulat
- Department of Cardiovascular Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
| | | | - Jordan Voss
- The Heart Center, Nationwide Children’s Hospital, Columbus, OH, USA
| | - James S. Tweddell
- Division of Cardiothoracic Surgery Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
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Nathan M, Tishler B, Gauvreau K, Matte GS, Howe RJ, Durham L, Boyle S, Mathieu D, Fynn-Thompson F, DiNardo JA, Ibla JC. A red cell preservation strategy reduces postoperative transfusions in pediatric heart surgery patients. Paediatr Anaesth 2018; 28:450-457. [PMID: 29575610 DOI: 10.1111/pan.13368] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/25/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Blood transfusion has well-documented adverse effects. As part of a blood conservation initiative at our center, we began routine use of cell saver for all congenital heart surgery performed on cardiopulmonary bypass since 2014. AIMS This study aimed to compare transfusion rates prior to, and in the first and second year after this initiative. We hypothesized that cell saver use would decrease transfusion requirements in second year after use of the cell saver compared to the pre cell saver group. METHODS Consecutive patients under 18 years undergoing congenital heart surgery on cardiopulmonary bypass were retrospectively analyzed as 3 one-year cohorts defined above. We excluded patients who required mechanical support or reoperation at index admission. Baseline characteristics, and use of blood intraoperatively and postoperatively were compared between groups. RESULTS The 3 groups had similar baseline characteristics. Blood use was significantly lower in year 2 after cell saver initiation as compared to the pre cell saver group both intra- and postoperatively. The median difference in volume of intraoperative blood transfusion was lower by 138 mL/m2 (-266, -10 mL/m2 ) in year 2 when compared to the pre cell saver group. Similarly, the proportion of subjects requiring red blood cell transfusion postoperatively on day of surgery was lower by 10% (-15%, -6%). CONCLUSION Standardized use of cell saver significantly decreased perioperative blood use in children undergoing cardiac surgery at our center. A risk-adjusted transfusion threshold for children undergoing heart surgery needs to be developed to further decrease exposure to blood products and associated costs.
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Affiliation(s)
- Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA.,Department of Surgery, Harvard Medical School, Boston, MA, USA
| | - Brielle Tishler
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Gregory S Matte
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Robert J Howe
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Linda Durham
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Sharon Boyle
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Derek Mathieu
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Francis Fynn-Thompson
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA.,Department of Surgery, Harvard Medical School, Boston, MA, USA
| | - James A DiNardo
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, MA, USA.,Department of Anesthesiology, Harvard Medical School, Boston, MA, USA
| | - Juan C Ibla
- Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, MA, USA.,Department of Anesthesiology, Harvard Medical School, Boston, MA, USA
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Crighton GL, New HV, Liley HG, Stanworth SJ. Patient blood management, what does this actually mean for neonates and infants? Transfus Med 2018; 28:117-131. [PMID: 29667253 DOI: 10.1111/tme.12525] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 03/08/2018] [Accepted: 03/12/2018] [Indexed: 12/18/2022]
Abstract
Patient blood management (PBM) refers to an evidence-based package of care that aims to improve patient outcomes by optimal use of transfusion therapy, including managing anaemia, preventing blood loss and improving anaemia tolerance in surgical and other patients who may need transfusion. In adults, PBM programmes are well established, yet the definition and implementation of PBM in neonates and children lags behind. Neonates and infants are frequently transfused, yet they are often under-represented in transfusion trials. Adult PBM programmes may not be directly applicable to these populations. We review the literature in neonatal (and applicable paediatric) transfusion medicine and propose specific neonatal PBM definitions and elements.
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Affiliation(s)
- G L Crighton
- Royal Children's Hospital, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - H V New
- Clinical Research, NHS Blood and Transplant, London, UK
- Centre for Haematology, Imperial College, London, UK
| | - H G Liley
- Neonatology, Mater Mothers' Hospital, Brisbane, Queensland, Australia
- Mater Medical Research Institute, Brisbane, Queensland, Australia
| | - S J Stanworth
- Clinical Haematology, John Radcliffe Hospital, NHS Blood and Transplant Oxford, Oxford, UK
- Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Radcliffe Department of Medicine, University of Oxford, and Oxford BRC Haematology Theme, Oxford, UK
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Khanal G, Huynh RA, Torabian K, Xia H, Vörös E, Shevkoplyas SS. Towards bedside washing of stored red blood cells: a prototype of a simple apparatus based on microscale sedimentation in normal gravity. Vox Sang 2017; 113:31-39. [PMID: 29067695 DOI: 10.1111/vox.12605] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Revised: 09/02/2017] [Accepted: 09/20/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND OBJECTIVES Infusion of by-products of red blood cell (RBC) storage-induced degradation as well as of the residual plasma proteins and the anticoagulant-preservative solution contained in units of stored blood serve no therapeutic purpose and may be harmful to some patients. Here, we describe a prototype of a gravity-driven system for bedside washing of stored RBCs. MATERIALS AND METHODS Stored RBCs were diluted to 10% haematocrit (Hct) with normal saline, matching the conventional washing procedure. The dilute RBC suspensions were passed through a column of coiled tubing to allow RBC sedimentation in normal gravity, thus separating them from the washing solution. Washed RBCs were collected using bifurcations located along the tubing. Washing efficiency was quantified by measuring Hct, morphology, deformability, free haemoglobin and total-free protein. RESULTS The gravity-driven washing system operating at 0·5 ml/min produced washed RBCs with final Hct of 36·7 ± 3·4% (32·3-41·2%, n = 10) and waste Hct of 3·4 ± 0·7% (2·4-4·3%, n = 10), while removing 80% of free haemoglobin and 90% of total-free protein. Washing improved the ability of stored RBCs to perfuse an artificial microvascular network by 20%. The efficiency of washing performed using the gravity-driven system was not significantly different than that of conventional centrifugation. CONCLUSIONS This proof-of-concept study demonstrates the feasibility of washing stored RBCs using a simple, disposable system with efficiency comparable to that of conventional centrifugation, and thus represents a significant first step towards enabling low-cost washing of stored blood at bedside.
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Affiliation(s)
- G Khanal
- Department of Biomedical Engineering, University of Houston, Houston, TX, USA
| | - R A Huynh
- Department of Biomedical Engineering, University of Houston, Houston, TX, USA
| | - K Torabian
- Department of Biomedical Engineering, University of Houston, Houston, TX, USA
| | - H Xia
- Department of Biomedical Engineering, University of Houston, Houston, TX, USA
| | - E Vörös
- Department of Biomedical Engineering, University of Houston, Houston, TX, USA
| | - S S Shevkoplyas
- Department of Biomedical Engineering, University of Houston, Houston, TX, USA
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Karimi M, Sullivan JM, Linthicum C, Mathew A. Blood conservation pediatric cardiac surgery in all ages and complexity levels. World J Cardiol 2017; 9:332-338. [PMID: 28515851 PMCID: PMC5411967 DOI: 10.4330/wjc.v9.i4.332] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 12/21/2016] [Accepted: 01/14/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To demonstrate the feasibility of blood conservation methods and practice across all ages and risk categories in congenital cardiac surgery.
METHODS We retrospectively analyzed a collected database of 356 patients who underwent cardiac surgery using cardiopulmonary bypass (CPB) from 2010-2015. The patients were grouped into blood conservation (n = 138) and non-conservation (n = 218) groups and sub-grouped based on their ages and procedural complexity scores.
RESULTS There were no statistical differences in gender, weight, pre-operative and pre-CPB hematocrit levels in both groups. Despite equivalent hematocrit levels during and after CPB for both groups, there was significantly less operative homologous blood utilized in blood conservation group across all ages and complexity levels.
CONCLUSION Blood conservation surgery can be performed in congenital patients needing cardiac surgery in all age groups and complexity categories. The above findings in addition to attendant risks and side effects of blood transfusion and the rising cost of safer blood products justify blood conservation in congenital cardiac surgery.
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39
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Karimi M, Sullivan JM, Lerer T, Hronek C. National trends and variability in blood utilization in paediatric cardiac surgery. Interact Cardiovasc Thorac Surg 2017; 24:938-943. [DOI: 10.1093/icvts/ivw439] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Accepted: 11/17/2016] [Indexed: 12/12/2022] Open
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40
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Abstract
Cardiac surgery accounts for the majority of blood transfusions in a hospital. Blood transfusion has been associated with complications and major adverse events after cardiac surgery. Compared to adults it is more difficult to avoid blood transfusion in children after cardiac surgery. This article takes into account the challenges and emphasizes on the various strategies that could be implemented, to conserve blood during pediatric cardiac surgery.
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Affiliation(s)
- Sarvesh Pal Singh
- Department of CTVS, Cardiac Surgical Intensive Care Unit, Cardiothoracic Sciences Centre, All India Institute of Medical Sciences, New Delhi, India
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New HV, Berryman J, Bolton-Maggs PHB, Cantwell C, Chalmers EA, Davies T, Gottstein R, Kelleher A, Kumar S, Morley SL, Stanworth SJ. Guidelines on transfusion for fetuses, neonates and older children. Br J Haematol 2016; 175:784-828. [DOI: 10.1111/bjh.14233] [Citation(s) in RCA: 173] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Helen V. New
- NHS Blood and Transplant; London UK
- Imperial College Healthcare NHS Trust; London UK
| | | | | | | | | | | | - Ruth Gottstein
- St. Mary's Hospital; Manchester/University of Manchester; Manchester UK
| | | | - Sailesh Kumar
- Mater Research Institute; University of Queensland; Brisbane Australia
| | - Sarah L. Morley
- Addenbrookes Hospital/NHS Blood and Transplant; Cambridge UK
| | - Simon J. Stanworth
- Oxford University Hospitals NHS Trust/NHS Blood and Transplant; Oxford UK
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Goel R, Cushing MM, Tobian AAR. Pediatric Patient Blood Management Programs: Not Just Transfusing Little Adults. Transfus Med Rev 2016; 30:235-41. [PMID: 27559005 DOI: 10.1016/j.tmrv.2016.07.004] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 07/19/2016] [Accepted: 07/21/2016] [Indexed: 01/29/2023]
Abstract
Red blood cell transfusions are a common life-saving intervention for neonates and children with anemia, but transfusion decisions, indications, and doses in neonates and children are different from those of adults. Patient blood management (PBM) programs are designed to assist clinicians with appropriately transfusing patients. Although PBM programs are well recognized and appreciated in the adult setting, they are quite far from standard of care in the pediatric patient population. Adult PBM standards cannot be uniformly applied to children, and there currently is significant variation in transfusion practices. Because transfusing unnecessarily can expose children to increased risk without benefit, it is important to design PBM programs to standardize transfusion decisions. This article assesses the key elements necessary for a successful pediatric PBM program, systematically explores various possible pediatric specific blood conservation strategies and the current available literature supporting them, and outlines the gaps in the evidence suggesting need for further/improved research. Pediatric PBM programs are critically important initiatives that not only involve a cooperative effort between pediatric surgery, anesthesia, perfusion, critical care, and transfusion medicine services but also need operational support from administration, clinical leadership, finance, and the hospital information technology personnel. These programs also expand the scope for high-quality collaborative research. A key component of pediatric PBM programs is monitoring pediatric blood utilization and assessing adherence to transfusion guidelines. Data suggest that restrictive transfusion strategies should be used for neonates and children similar to adults, but further research is needed to assess the best oxygenation requirements, hemoglobin threshold, and transfusion strategy for patients with active bleeding, hemodynamic instability, unstable cardiac disease, and cyanotic cardiac disease. Perioperative blood management strategies include minimizing blood draws, restricting transfusions, intraoperative cell salvage, acute normovolemic hemodilution, antifibrinolytic agents, and using point-of-care tests to guide transfusion decisions. However, further research is needed for the use of intravenous iron, erythropoiesis-stimulating agents, and possible use of whole blood and pathogen inactivation. There are numerous areas where newly formed collaborations could be used to investigate pediatric transfusion, and these studies would provide critical data to support vital pediatric PBM programs to optimize neonatal and pediatric care.
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Affiliation(s)
- Ruchika Goel
- Division of Transfusion Medicine, Department of Pathology, New York Presbyterian Hospital, Weill Cornell Medical College, New York, NY; Division of Pediatric Hematology/Oncology, Department of Pediatrics, New York Presbyterian Hospital, Weill Cornell Medical College, New York, NY
| | - Melissa M Cushing
- Division of Transfusion Medicine, Department of Pathology, New York Presbyterian Hospital, Weill Cornell Medical College, New York, NY
| | - Aaron A R Tobian
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins University, Baltimore, MD.
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Meybohm P, Choorapoikayil S, Wessels A, Herrmann E, Zacharowski K, Spahn DR. Washed cell salvage in surgical patients: A review and meta-analysis of prospective randomized trials under PRISMA. Medicine (Baltimore) 2016; 95:e4490. [PMID: 27495095 PMCID: PMC4979849 DOI: 10.1097/md.0000000000004490] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Revised: 06/20/2016] [Accepted: 07/12/2016] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Cell salvage is commonly used as part of a blood conservation strategy. However concerns among clinicians exist about the efficacy of transfusion of washed cell salvage. METHODS We performed a meta-analysis of randomized controlled trials in which patients, scheduled for all types of surgery, were randomized to washed cell salvage or to a control group with no cell salvage. Data were independently extracted, risk ratio (RR), and weighted mean differences (WMD) with 95% confidence intervals (CIs) were calculated. Data were pooled using a random effects model. The primary endpoint was the number of patients exposed to allogeneic red blood cell (RBC) transfusion. RESULTS Out of 1140 search results, a total of 47 trials were included. Overall, the use of washed cell salvage reduced the rate of exposure to allogeneic RBC transfusion by a relative 39% (RR = 0.61; 95% CI 0.57 to 0.65; P < 0.001), resulting in an average saving of 0.20 units of allogeneic RBC per patient (weighted mean differences [WMD] = -0.20; 95% CI -0.22 to -0.18; P < 0.001), reduced risk of infection by 28% (RR = 0.72; 95% CI 0.54 to 0.97; P = 0.03), reduced length of hospital stay by 2.31 days (WMD = -2.31; 95% CI -2.50 to -2.11; P < 0.001), but did not significantly affect risk of mortality (RR = 0.92; 95% CI 0.63 to 1.34; P = 0.66). No statistical difference could be observed in the number of patients exposed to re-operation, plasma, platelets, or rate of myocardial infarction and stroke. CONCLUSIONS Washed cell salvage is efficacious in reducing the need for allogeneic RBC transfusion and risk of infection in surgery.
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Affiliation(s)
- Patrick Meybohm
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt
| | - Suma Choorapoikayil
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt
| | - Anke Wessels
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt
| | - Eva Herrmann
- Institute for Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Kai Zacharowski
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt
| | - Donat R. Spahn
- Institute of Biostatistics and Mathematical Modelling, Goethe University Frankfurt, Germany
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Klein AA, Arnold P, Bingham RM, Brohi K, Clark R, Collis R, Gill R, McSporran W, Moor P, Rao Baikady R, Richards T, Shinde S, Stanworth S, Walsh TS. AAGBI guidelines: the use of blood components and their alternatives 2016. Anaesthesia 2016; 71:829-42. [PMID: 27062274 DOI: 10.1111/anae.13489] [Citation(s) in RCA: 128] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2016] [Indexed: 12/13/2022]
Abstract
Blood transfusion can be life-saving. Anaesthetists regularly request and administer blood components to their patients. All anaesthetists must be familiar with indications and appropriate use of blood and blood components and their alternatives, but close liaison with haematology specialists and their local blood sciences laboratory is encouraged. Considerable changes in approaches to optimal use of blood components, together with the use of alternative products, have become apparent over the past decade, leading to a need to update previous guidelines and adapt them for the use of anaesthetists working throughout the hospital system.
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Affiliation(s)
- A A Klein
- Department of Anaesthesia and Intensive Care, Papworth Hospital, Cambridge, UK
| | - P Arnold
- Department of Paediatric Anaesthesia, Alder Hey Children's Hospital, University of Liverpool, Liverpool, UK
| | - R M Bingham
- Department of Paediatric Anaesthesia, Great Ormond Street Hospital for Children, London, UK
| | - K Brohi
- Centre for Trauma Sciences, Barts Health NHS Trust and Queen Mary University of London, London, UK
| | - R Clark
- Department of Anaesthesia, Glasgow Royal Infirmary, Glasgow, UK
| | - R Collis
- Department of Anaesthesia, University Hospital of Wales, Cardiff, UK
| | - R Gill
- Department of Anaesthesia, University Hospital Southampton, UK
| | | | - P Moor
- Department of Anaesthesia, Derriford Hospital, Plymouth, UK
| | - R Rao Baikady
- Department of Anaesthesia, The Royal Marsden Hospital, London, UK
| | - T Richards
- Division of Surgery and Interventional Science, University College Hospital, London, UK
| | - S Shinde
- Department of Anaesthesia, Southmead Hospital, Bristol, UK
| | - S Stanworth
- Department of Haematology, Oxford Radcliffe Hospitals, Oxford, UK
| | - T S Walsh
- Department of Anaesthetics, Critical Care and Pain Medicine, Edinburgh University, Edinburgh, UK
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45
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Timpa JG, O’Meara LC, Goldberg KG, Phillips JP, Crawford JH, Jackson KW, Alten JA. Implementation of a Multidisciplinary Bleeding and Transfusion Protocol Significantly Decreases Perioperative Blood Product Utilization and Improves Some Bleeding Outcomes. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2016; 48:11-18. [PMID: 27134303 PMCID: PMC4850217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 02/27/2016] [Indexed: 06/05/2023]
Abstract
Perioperative transfusion of blood products is associated with increased morbidity and mortality after pediatric cardiac surgery. We report the results of a quality improvement project aimed at decreasing perioperative blood product administration and bleeding after pediatric cardiopulmonary bypass (CPB) surgery. A multidisciplinary team evaluated baseline data from 99 consecutive CPB patients, focusing on the variability in transfusion management and bleeding outcomes, to create a standardized bleeding and transfusion management protocol. A total of 62 subsequent patients were evaluated after implementation of the protocol: 17 with single pass hemoconcentrated (SPHC) blood transfusion and 45 with modified ultrafiltration (MUF). Implementation of the protocol with SPHC blood led to significant decrease in transfusion of every blood product in the cardiovascular operating room and first 6 hours in cardiovascular intensive care unit ([CVICU] p < .05). Addition of MUF to the protocol led to further decrease in transfusion of all blood products compared to preprotocol. Patients <2 months old had 49% decrease in total blood product administration: 155 mL/kg preprotocol, 117 mL/kg protocol plus SPHC, and 79 mL/kg protocol plus MUF (p < .01). There were significant decreases in postoperative bleeding in the first hour after CVICU admission: 6 mL/kg preprotocol, 3.8 mL/kg protocol plus SPHC, and 2 mL/kg protocol plusMUF (p = .02). There was also significantly decreased incidence of severe postoperative bleeding (>10 mL/kg) in the first CVICU hour for protocol plus MUF patients (p < .01). Implementation of a multidisciplinary bleeding and transfusion protocol significantly decreases perioperative blood product transfusion and improves some bleeding outcomes.
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Affiliation(s)
- Joseph G. Timpa
- Department of Cardiovascular Perfusion, Childrens of Alabama, Birmingham, Alabama
| | - L. Carlisle O’Meara
- Department of Cardiovascular Perfusion, Childrens of Alabama, Birmingham, Alabama
| | - Kellen G. Goldberg
- Department of Cardiovascular Perfusion, Childrens of Alabama, Birmingham, Alabama
| | - Jay P. Phillips
- Department of Cardiovascular Perfusion, Childrens of Alabama, Birmingham, Alabama
| | - Jack H. Crawford
- Division of Cardiothoracic Anesthesia, Department of Anesthesiology and Perioperative Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Kimberly W. Jackson
- Division of Pediatric Cardiology, Section of Cardiac Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jeffrey A. Alten
- Division of Pediatric Cardiology, Section of Cardiac Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama
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Nacoti M, Corbella D, Fazzi F, Rapido F, Bonanomi E. Coagulopathy and transfusion therapy in pediatric liver transplantation. World J Gastroenterol 2016; 22:2005-23. [PMID: 26877606 PMCID: PMC4726674 DOI: 10.3748/wjg.v22.i6.2005] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2015] [Revised: 11/23/2015] [Accepted: 12/30/2015] [Indexed: 02/06/2023] Open
Abstract
Bleeding and coagulopathy are critical issues complicating pediatric liver transplantation and contributing to morbidity and mortality in the cirrhotic child. The complexity of coagulopathy in the pediatric patient is illustrated by the interaction between three basic models. The first model, "developmental hemostasis", demonstrates how a different balance between pro- and anticoagulation factors leads to a normal hemostatic capacity in the pediatric patient at various ages. The second, the "cell based model of coagulation", takes into account the interaction between plasma proteins and cells. In the last, the concept of "rebalanced coagulation" highlights how the reduction of both pro- and anticoagulation factors leads to a normal, although unstable, coagulation profile. This new concept has led to the development of novel techniques used to analyze the coagulation capacity of whole blood for all patients. For example, viscoelastic methodologies are increasingly used on adult patients to test hemostatic capacity and to guide transfusion protocols. However, results are often confounding or have limited impact on morbidity and mortality. Moreover, data from pediatric patients remain inadequate. In addition, several interventions have been proposed to limit blood loss during transplantation, including the use of antifibrinolytic drugs and surgical techniques, such as the piggyback and lowering the central venous pressure during the hepatic dissection phase. The rationale for the use of these interventions is quite solid and has led to their incorporation into clinical practice; yet few of them have been rigorously tested in adults, let alone in children. Finally, the postoperative period in pediatric cohorts of patients has been characterized by an enhanced risk of hepatic vessel thrombosis. Thrombosis in fact remains the primary cause of early graft failure and re-transplantation within the first 30 d following surgery, and it occurs despite prolongation of standard coagulation assays. Data, however, are currently lacking regarding the use of anti-aggregation/anticoagulation therapies and how to best monitor for thrombosis in the early postoperative period in pediatric patients. Therefore, further studies are necessary to elucidate the interaction between the development of the coagulation system and cirrhosis in children. Moreover, strategies to optimize blood transfusion and anticoagulation must be tested specifically in pediatric patients. In conclusion, data from the adult world can be translated with difficulty into the pediatric field as indication for transplantation, baseline pathologies and levels of pro- and anticoagulation factors are not comparable between the two populations.
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47
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Li XL, Dong P, Tian M, Ni JX, Smith FG. Oxygen carrying capacity of salvaged blood in patients undergoing off-pump coronary artery bypass grafting surgery: a prospective observational study. J Cardiothorac Surg 2015; 10:126. [PMID: 26466895 PMCID: PMC4604709 DOI: 10.1186/s13019-015-0330-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 09/08/2015] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Intraoperative cell salvage (ICS), hereby referred to 'mechanical red cell salvage', has been widely used and proven to be an effective way to reduce or avoid the need for allogeneic red blood cells (RBCs)transfusion and its associated complications in surgeries involving major blood loss. However, little is known about the influence of this technique on the functional state of salvaged RBCs. Furthermore, there are no articles that describe the change of free hemoglobin (fHb) in salvage blood during storage, which is a key index of the quality control of salvaged blood. Therefore, in this study, the influence of ICS on the function of salvaged RBCs and the changes of salvaged RBCs during storage were studied with respect to the presence of oxyhemoglobin affinity (recorded as a P50 value) and the level of 2, 3-diphosphoglycerate (2, 3-DPG) and fHb by comparing salvaged RBCs with self-venous RBCs and 2-week-old packed RBCs. METHODS Fifteen patients undergoing off-pump coronary artery bypass grafting (OPCAB) surgery were enrolled. Blood was collected and processed using a Dideco Electa device. The level of P50, 2, 3-DPG and fHB from salvaged RBCs, venous RBCs and 2-week-old packed RBCs was measured. We also measured the changes of these indicators among salvaged RBCs at 4 h (storage at 21-24 °C) and at 24 h (storage at 1-6 °C). RESULTS The P50 value of salvaged RBCs at 0 h (28.77 ± 0.27 mmHg) was significantly higher than the value of venous RBCs (27.07 ± 0.23 mmHg, p=0.000) and the value of the 2-week-old packed RBCs (16.26 ± 0.62 mmHg, p=0.000). P50 value did not change obviously at 4 h (p=0.121) and 24 h (p=0.384) compared with the value at 0 h. The 2, 3-DPG value of salvaged RBCs at 0 h (17.94 ± 6.91 μmol/g Hb) was significantly higher than the value of venous RBCs (12.73 ± 6.52 mmHg, p = 0.007) and the value of the 2-week-old packed RBCs (2.62 ± 3.13 mmHg, p=0.000). The level of 2, 3-DPG slightly decreased at 4 h (p=0.380) and 24 h (p=0.425) compared with the value at 0 h. Percentage of hemolysis of the salvaged blood at 0 h(0.51 ± 0.27 %) was significantly higher than the level of venous blood (0.07 ± 0.05 %, p=0.000) and the value of 2-week-old packed RBCs (0.07 ± 0.05 %, p=0.000), and reached 1.11 ± 0.42 % at 4 h (p=0.002) and 1.83 ± 0.77 % at 24 h (p=0.000). CONCLUSIONS The oxygen transport function of salvaged RBCs at 0 h was not influenced by the cell salvage process and was better than that of the venous RBCs and 2-week-old packed RBCs. At the end of storage, the oxygen transport function of salvaged RBCs did not change obviously, but percentage of hemolysis significantly increased.
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Affiliation(s)
- Xiu Liang Li
- Department of Pain Management, Xuanwu Hospital of Capital Medical University, No. 45, Changchun Street, Xicheng District, 100053, Beijing, China.
| | - Peng Dong
- Department of Anaesthesiology, Beijing Friendship Hospital, Capital Medical University, No. 95, Yong'an Road, Xicheng District, 100050, Beijing, China.
| | - Ming Tian
- Department of Anaesthesiology, Beijing Friendship Hospital, Capital Medical University, No. 95, Yong'an Road, Xicheng District, 100050, Beijing, China.
| | - Jia Xiang Ni
- Department of Pain Management, Xuanwu Hospital of Capital Medical University, No. 45, Changchun Street, Xicheng District, 100053, Beijing, China.
| | - Fang Gao Smith
- Department of Anaesthesiology, the 2nd Affiliated Hospital & Yuying Children Hospital of Wenzhou Medical University, Wenzhou, China.
- Perioperative, Critical Care and Trauma Trials Group, University of Birmingham, Edgbaston B15 2WB, Birmingham, UK.
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Mazine A, Rached-D'Astous S, Ducruet T, Lacroix J, Poirier N. Blood Transfusions After Pediatric Cardiac Operations: A North American Multicenter Prospective Study. Ann Thorac Surg 2015; 100:671-7. [PMID: 26141778 DOI: 10.1016/j.athoracsur.2015.04.033] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2014] [Revised: 04/04/2015] [Accepted: 04/07/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND Red blood cell transfusion is an important supportive measure after pediatric cardiac operations. However, no clear hemoglobin threshold has been established. This study characterized anemia development and red blood cell transfusions in the pediatric intensive care unit (PICU) after cardiac operations. METHODS A prospective, multicenter, 6-month cohort study on the management of anemia in critically ill pediatric patients was conducted in 30 North American PICUs. This observational study enrolled 977 consecutive children (aged <18 years) who stayed in the PICU for 48 hours or more. We analyzed a subgroup of postcardiac surgical patients from this study. RESULTS Included were 175 cardiac patients, 56% of whom had cyanotic heart disease. The mean Pediatric Risk of Mortality (PRISM III) score was 6.4 ± 5.4. Fifty-four percent of children were anemic in the PICU (20% on admission, 34% during PICU stay). Most patients (79%) received at least one red blood cell transfusion in the PICU. Patients who received a transfusion had a significantly longer PICU stay (9.3 ± 6.3 vs 6.1 ± 5.4 days, p = 0.01). Pretransfusion hemoglobin was different in acyanotic and cyanotic patients (mean ± standard deviation: 11.1 ± 2.2 g/dL and 11.8 ± 2.1 g/dL, respectively). According to the attending physician, a low hemoglobin level was the primary indication for transfusion in only 17% of cases. CONCLUSIONS Pediatric cardiac surgical patients are at high risk of receiving red blood cell transfusions. This study, which showed great variability in transfusion practices across North American PICUs, highlights the need for clearer transfusion guidelines in this specific population.
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Affiliation(s)
- Amine Mazine
- Department of Cardiac Surgery, Centre hospitalier universitaire (CHU) Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
| | - Soha Rached-D'Astous
- Department of Pediatrics, Centre hospitalier universitaire (CHU) Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
| | - Thierry Ducruet
- Department of Biostatistics, Centre hospitalier universitaire (CHU) Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
| | - Jacques Lacroix
- Department of Pediatrics, Centre hospitalier universitaire (CHU) Sainte-Justine, Université de Montréal, Montréal, Québec, Canada.
| | - Nancy Poirier
- Department of Cardiac Surgery, Centre hospitalier universitaire (CHU) Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
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Kapitein B, van Saet AW, Golab HD, de Hoog M, de Wildt S, Tibboel D, Bogers AJJC. Does pharmacotherapy influence the inflammatory responses during cardiopulmonary bypass in children? J Cardiovasc Pharmacol 2015; 64:191-7. [PMID: 24949583 DOI: 10.1097/fjc.0000000000000098] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Cardiopulmonary bypass (CPB) induces a systemic inflammatory response syndrome (SIRS) by factors such as contact of the blood with the foreign surface of the extracorporeal circuit, hypothermia, reduction of pulmonary blood flow during CPB and endotoxemia. SIRS is maintained in the postoperative phase, co-occurring with a counter anti-inflammatory response syndrome. Research on the effects of drugs administered before the surgery, especially in the induction phase of anesthesia, as well as drugs used during extracorporeal circulation, has revealed that they greatly influence these postoperative inflammatory responses. A better understanding of these processes may not only improve postoperative recovery but also enable tailor-made pharmacotherapy, with both health and economic benefits. In this review, we describe the pathophysiology of SIRS and counter anti-inflammatory response syndrome in the light of CPB in children and the influence of drugs used on these syndromes.
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Affiliation(s)
- Berber Kapitein
- *Intensive Care Unit, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands; †Department of Anesthesiology, Intensive Care Unit, Erasmus MC, Erasmus MC-Sophia Children's Hospital, Rotterdam, the Netherlands; and ‡Department of Cardiothoracic Surgery, Erasmus MC, Rotterdam, the Netherlands
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50
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Seyfried T, Breu A, Gruber M, Reipert J, Hansen E. Processing of small volumes in blood salvage devices. Transfusion 2014; 54:2775-81. [DOI: 10.1111/trf.12765] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Revised: 05/20/2014] [Accepted: 05/20/2014] [Indexed: 12/22/2022]
Affiliation(s)
- Timo Seyfried
- Department of Anesthesiology; University Hospital Regensburg; Regensburg Germany
| | - Anita Breu
- Department of Anesthesiology; University Hospital Regensburg; Regensburg Germany
| | - Michael Gruber
- Department of Anesthesiology; University Hospital Regensburg; Regensburg Germany
| | - Julia Reipert
- Department of Anesthesiology; University Hospital Regensburg; Regensburg Germany
| | - Ernil Hansen
- Department of Anesthesiology; University Hospital Regensburg; Regensburg Germany
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