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Kelleher ST, Regan IE, Cox D, Shaw K, Franklin O, Kenny DP, Walsh KP, McMahon CJ. Aspirin Responsiveness in a Cohort of Pediatric Patients with Right Ventricle to Pulmonary Artery Conduits and Transcatheter Valve Replacement Systems. Pediatr Cardiol 2024:10.1007/s00246-024-03449-1. [PMID: 38489091 DOI: 10.1007/s00246-024-03449-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 02/10/2024] [Indexed: 03/17/2024]
Abstract
The aim of this study was to determine the rate of aspirin responsiveness in a cohort of pediatric patients with in situ xenograft valved right ventricle to pulmonary artery (RV-PA) conduits and/or transcatheter valve replacements (TVR). Aspirin is routinely prescribed to these patients. Optimizing anti-platelet therapy could promote valve longevity and reduce the risk of infective endocarditis in this at-risk group. This was a prospective, observational study. Patients were recruited from both ward and outpatient settings. Patients were eligible if under 18 years and taking aspirin. Non-response to aspirin was defined as > 20% platelet aggregation using light transmission platelet aggregometry (LTA) and < 50% platelet inhibition by thromboelastography with platelet mapping (TEGPM). Participants were invited to provide a confirmatory sample in cases of aspirin resistance and dose adjustments were made. Thirty patients participated. Median age was 9 years (2 months to 18 years). The majority (93%) had complex right ventricular outflow tract pathology. 13 (43%) had an RV-PA conduit and 24 (80%) had a TVR, with valve situated in conduit in 7 (23%) cases. Rate of aspirin non-response on initial testing was 23% (n = 7/30) with median LTA 74.55% (60-76%) and TEG 13.25% (0-44%) in non-responders. Non-responders were more likely to be under 1 year. Two patients required dose increases and one patient non-adherence to dose was identified. Four patients on repeat testing were responsive to aspirin by laboratory tests. The rate of aspirin non-response on laboratory testing in this cohort of patients was 23% and resulted in therapeutic intervention in 10%.
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Affiliation(s)
- Sean T Kelleher
- Department of Paediatric Cardiology, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Irene E Regan
- Department of Coagulation/Haematology, Children's Health Ireland at Crumlin, Dublin, Ireland
- School of Medicine, University College Dublin, Belfield, Dublin 4, Ireland
- National Children's Research Centre, Children's Health Ireland, Dublin, Ireland
| | - Dermot Cox
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons Ireland, Dublin, Ireland
| | - Kathryn Shaw
- Department of Paediatric Pharmacy, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Orla Franklin
- Department of Paediatric Cardiology, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Damien P Kenny
- Department of Paediatric Cardiology, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Kevin P Walsh
- Department of Paediatric Cardiology, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Colin J McMahon
- Department of Paediatric Cardiology, Children's Health Ireland at Crumlin, Dublin, Ireland.
- School of Medicine, University College Dublin, Belfield, Dublin 4, Ireland.
- School of Health Professions Education (SHE), Maastricht University, Maastricht, The Netherlands.
- National Children's Research Centre, Children's Health Ireland, Dublin, Ireland.
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Shimoda T, Liu C, Mathis BJ, Goto Y, Ageyama N, Kato H, Matsubara M, Ohigashi T, Gosho M, Suzuki Y, Hiramatsu Y. Effect of cardiopulmonary bypass on coagulation factors II, VII and X in a primate model: an exploratory pilot study. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2023; 37:ivad194. [PMID: 38015856 PMCID: PMC10701202 DOI: 10.1093/icvts/ivad194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 11/05/2023] [Accepted: 11/27/2023] [Indexed: 11/30/2023]
Abstract
OBJECTIVES The use of cardiopulmonary bypass (CPB) in cardiac surgery is a major risk factor for postoperative bleeding. We hypothesized that consumptive coagulopathy and haemodilution influence the coagulation factors; therefore, we aimed to estimate the activity profiles of coagulation factors II, VII and X during CPB circulation. METHODS A 120-min bypass was surgically established in cynomolgus monkeys (n = 7). Activities of coagulation factors II, VII and X were measured at 6 time points during the experiment (baseline, 0, 30, 60, 120 min of bypass and 60 min after bypass). To assess the influence of consumptive coagulopathy, the values were adjusted for haemodilution using the haematocrit values. Data were expressed as mean (standard deviation). RESULTS Activities of coagulation factors decreased during the experiment. In particular, the activities for II, VII and X were decreased the most by 44.2% (5.0), 61.4% (4.3) and 49.0% (3.7) at 30 min following CPB initiation (P < 0.001, P < 0.001 and P < 0.001, respectively). Following adjustments for haemodilution, change magnitudes lessened but remained significant for factor VII. The adjusted concentration of factor VII was observed to decrease from the baseline to the initiation of bypass circulation. CONCLUSIONS In conclusion, coagulation factor II, VII and X concentrations decreased during CPB. Following adjustment for haemodilution, a decrease in concentration was observed with factor VII.
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Affiliation(s)
- Tomonari Shimoda
- Department of Cardiovascular Surgery, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Chang Liu
- Department of Cardiovascular Surgery, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Bryan J Mathis
- International Medical Center, University of Tsukuba Hospital, Ibaraki, Japan
| | - Yukinobu Goto
- Department of Thoracic Surgery, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Naohide Ageyama
- Tsukuba Primate Research Center, National Institute of Biomedical Innovation, Tsukuba, Ibaraki, Japan
| | - Hideyuki Kato
- Department of Cardiovascular Surgery, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Muneaki Matsubara
- Department of Cardiovascular Surgery, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Tomohiro Ohigashi
- Tsukuba Clinical Research & Development Organization, University of Tsukuba Hospital, Ibaraki, Japan
| | - Masahiko Gosho
- Department of Biostatistics, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Yasuyuki Suzuki
- Department of Cardiovascular Surgery, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Yuji Hiramatsu
- Department of Cardiovascular Surgery, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
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Moiseiwitsch N, Nellenbach KA, Downey LA, Boorman D, Brown AC, Guzzetta NA. Influence of Fibrinogen Concentrate on Neonatal Clot Structure When Administered Ex Vivo After Cardiopulmonary Bypass. Anesth Analg 2023; 137:682-690. [PMID: 36727748 DOI: 10.1213/ane.0000000000006357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Bleeding is a serious complication of cardiopulmonary bypass (CPB) in neonates. Blood product transfusions are often needed to adequately restore hemostasis, but are associated with significant risks. Thus, neonates would benefit from other effective, and safe, hemostatic therapies. The use of fibrinogen concentrate (FC; RiaSTAP, CSL Behring, Marburg, Germany) is growing in popularity, but has not been adequately studied in neonates. Here, we characterize structural and degradation effects on the neonatal fibrin network when FC is added ex vivo to plasma obtained after CPB. METHODS After approval by the institutional review board and parental consent, blood samples were collected from neonates undergoing cardiac surgery and centrifuged to yield platelet poor plasma. Clots were formed ex vivo from plasma obtained at several time points: (1) baseline, (2) immediately post-CPB, and (3) post-transfusion of cryoprecipitate. In addition, we utilized post-CPB plasma to construct the following conditions: (4) post-CPB +0.5 mg/mL FC, and (5) post-CPB +0.9 mg/mL FC. The resultant fibrin networks were imaged using confocal microscopy to analyze overall structure, fiber density, and alignment. Clots were also analyzed using a microfluidic degradation assay. Fibrinogen content was quantified for all plasma samples. RESULTS The addition of 0.5 or 0.9 mg/mL FC to post-CPB samples significantly enhanced the median fiber density when compared to untreated post-CPB samples (post-CPB = 0.44 [interquartile range {IQR}: 0.36-0.52], post-CPB +0.5 mg/mL FC = 0.69 [0.56-0.77], post-CPB +0.9 mg/mL FC = 0.87 [0.59-0.96]; P = .01 and P = .006, respectively). The addition of 0.9 mg/mL FC to post-CPB samples resulted in a greater fiber density than that observed after the in vivo transfusion of cryoprecipitate (post-transfusion = 0.54 [0.45-0.77], post-CPB +0.9 mg/mL FC = 0.87 [0.59-0.96]; P = .002). Median fiber alignment did not differ significantly between post-CPB samples and samples treated with FC. Degradation rates were not statistically significant from baseline values with either 0.5 or 0.9 mg/mL FC. In addition, we found a significant correlation between the difference in the baseline and post-CPB fibrinogen concentration with patient age ( P = .033) after controlling for weight. CONCLUSIONS Our results show that clots formed ex vivo with clinically relevant doses of FC (0.9 mg/mL) display similar structural and degradation characteristics compared to the in vivo transfusion of cryoprecipitate. These findings suggest that FC is effective in restoring structural fibrin clot properties after CPB. Future studies after the administration of FC in vivo are needed to validate this hypothesis.
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Affiliation(s)
- Nina Moiseiwitsch
- From the Joint Department of Biomedical Engineering of University of North Carolina - Chapel Hill and North Carolina State University, Raleigh, North Carolina
- Comparative Medicine Institute, North Carolina State University, Raleigh, North Carolina
| | - Kimberly A Nellenbach
- From the Joint Department of Biomedical Engineering of University of North Carolina - Chapel Hill and North Carolina State University, Raleigh, North Carolina
- Comparative Medicine Institute, North Carolina State University, Raleigh, North Carolina
| | - Laura A Downey
- Department of Anesthesiology, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - David Boorman
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia
| | - Ashley C Brown
- From the Joint Department of Biomedical Engineering of University of North Carolina - Chapel Hill and North Carolina State University, Raleigh, North Carolina
- Comparative Medicine Institute, North Carolina State University, Raleigh, North Carolina
- Department of Material Science and Engineering, North Carolina State University, Raleigh, North Carolina
| | - Nina A Guzzetta
- Department of Anesthesiology, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
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Naguib AN, Carrillo SA, Corridore M, Bigelow AM, Walczak A, Tram NK, Hersey D, Galantowicz M, Tobias JD. A ROTEM-guided algorithm aimed to reduce blood product utilization during neonatal and infant cardiac surgery. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2023; 55:60-69. [PMID: 37378438 DOI: 10.1051/ject/2023017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 04/24/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND Neonates and infants undergoing cardiac surgery tend to receive high volumes of blood products. The use of rotational thromboelastometry (ROTEM®) has been shown to reduce the administration of blood products in adults after cardiac surgery. We sought to develop a targeted administration of blood products based on ROTEM® to reduce blood product utilization during and after neonatal and infant cardiac surgery. METHODS We conducted a retrospective review of data from a single center for neonates and infants undergoing congenital cardiac surgery using cardiopulmonary bypass (CPB) from September 2018-April 2019 (control group). Then, using a ROTEM® algorithm, we collected data prospectively between April-November 2021 (ROTEM group). Data collected included age, weight, gender, procedure, STAT score, CPB time, aortic cross-clamp time, volume, and type of blood products administered in the operating room and cardiothoracic intensive care unit (CTICU). In addition, ROTEM® data, coagulation profile in CTICU, chest tube output at 6 and 24 hours, use of factors concentrate, and thromboembolic complications were recorded. RESULTS The final cohort of patients included 28 patients in the control group and 40 patients in the ROTEM group. The cohort included neonates and infants undergoing the following procedures: arterial switch, aortic arch augmentation, Norwood procedure, and comprehensive stage II procedure. There were no differences in the demographics or procedure complexity between the two groups. Patients in the ROTEM® group received fewer platelets (36 ± 12 vs. 49 ± 27 mL/kg, p 0.028) and cryoprecipitate (8 ± 3 vs. 15 ± 10 mL/kg, p 0.001) intraoperatively when compared to the control group. CONCLUSION The utilization of ROTEM® may have contributed to a significant reduction in some blood product administration during cardiac surgery for infants and neonates. ROTEM® data may play a role in reducing blood product administration in neonatal and infant cardiac surgery.
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Affiliation(s)
- Aymen N Naguib
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Sergio A Carrillo
- Department of Cardiothoracic Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Marco Corridore
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Amee M Bigelow
- The Heart Center, Nationwide Children's Hospital, Department of Pediatrics, The Ohio State University, Columbus, Ohio, USA
| | - Ashley Walczak
- Department of Cardiothoracic Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Nguyen K Tram
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Diane Hersey
- Department of Cardiothoracic Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Mark Galantowicz
- Department of Cardiothoracic Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio, USA
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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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6
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Byeon GJ, Yoon JU, Kim HJ, Choi EJ, Kim EJ, Park S, Park SJ, Heo W, Kim HY. The influence of circulating fibrinogen level on postoperative blood loss and blood transfusion in pediatric cardiac surgery: a retrospective observational study. Transl Pediatr 2022; 11:514-525. [PMID: 35558986 PMCID: PMC9085943 DOI: 10.21037/tp-21-236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 07/13/2021] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Pediatric patients are at high risk of massive bleeding after cardiac surgery under cardiopulmonary bypass (CPB). Fibrinogen is essential for coagulation; however, pediatric patients with congenital heart disease (CHD) present abnormal fibrinogen function. The pre- and post-operative fibrinogen level may affect the bleeding and transfusion amount in patients undergoing cardiac surgery. However, the relationship between plasma fibrinogen levels and the bleeding and transfusion amount in pediatric cardiac surgery remains unclear. This study aimed to assess the association of pre-CPB fibrinogen levels (PreFib) and post-CPB fibrinogen levels (PostFib) with postoperative bleeding and transfusion volume in pediatric cardiac surgery. METHODS We reviewed the medical records of 375 newborns and infants who underwent cardiac surgery under CPB for CHD. The primary endpoint was the correlation of the PreFib and PostFib values, as well as their difference (FibGap), with the bleeding and transfusion amount within 24 postoperative hours. RESULTS There was no correlation of the PreFib, PostFib, and FibGap values with the bleeding and transfusion amounts at postoperative 24 hours. However, patients with PreFib and PostFib values of <150 and <100 mg/dL, respectively, showed a significantly higher frequency of postoperative platelet (PLT) transfusion. In patients with complex CHD, PreFib showed a weak negative correlation with the bleeding amount at postoperative 24 hours and the number of PLT-transfused patients. CONCLUSIONS Our findings suggest that in pediatric patients with CHD who cannot undergo point-of-care (POC) tests, those presenting PreFib and PostFib values of <150 and <100 mg/dL, respectively, have a significantly higher frequency of postoperative PLT transfusion.
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Affiliation(s)
- Gyeong-Jo Byeon
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea.,Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Yangsan, Korea
| | - Ji-Uk Yoon
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea.,Department of Anesthesia and Pain Medicine, School of Medicine, Pusan National University, Yangsan, Korea
| | - Hye-Jin Kim
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Eun-Ji Choi
- Department of Dental Anesthesia and Pain Medicine, Pusan National University Dental Hospital, Yangsan, Korea
| | - Eun-Jung Kim
- Department of Dental Anesthesia and Pain Medicine, Pusan National University Dental Hospital, Yangsan, Korea.,Department of Dental Anesthesia and Pain Medicine, School of Dentistry, Pusan National University, Dental Research Institute, Yangsan, Korea
| | - Seyeon Park
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Soon Ji Park
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Wonjae Heo
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Hee Young Kim
- Department of Anesthesia and Pain Medicine, Pusan National University Yangsan Hospital, Yangsan, Korea
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A Randomized Pilot Trial Assessing the Role of Human Fibrinogen Concentrate in Decreasing Cryoprecipitate Use and Blood Loss in Infants Undergoing Cardiopulmonary Bypass. Pediatr Cardiol 2022; 43:1444-1454. [PMID: 35305111 PMCID: PMC9489575 DOI: 10.1007/s00246-022-02866-4] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 03/03/2022] [Indexed: 10/30/2022]
Abstract
The objective of this study was to determine whether treatment with human fibrinogen concentrate decreases the need for component blood therapy and blood loss in neonate and infant patients undergoing cardiopulmonary bypass. Pediatric patients (N = 30) undergoing elective cardiac surgery were randomized to receive human fibrinogen concentrate or placebo following cardiopulmonary bypass termination. The primary endpoint was the amount of cryoprecipitate administered. Secondary endpoints included estimated blood loss during the 24 h post-surgery; perioperative blood product transfusion; effects of fibrinogen infusion on global hemostasis, measured by laboratory testing and rotational thromboelastometry; and adverse events. No clinically significant differences were identified in baseline characteristics between groups. A significantly lower volume of cryoprecipitate was administered to the treatment group during the perioperative period [median (interquartile range) 0.0 (0.0-0.0) cc/kg vs 12.0 (8.2-14.3) cc/kg; P < 0.0001] versus placebo. No difference was observed between treatment groups in blood loss, laboratory coagulation tests, use of other blood components, or incidence of adverse events. FIBTEM amplitude of maximum clot firmness values was significantly higher among patients treated with human fibrinogen concentrate versus placebo (P ≤ 0.0001). No significant differences were observed in post-drug HEPTEM, INTEM, and EXTEM results. Human fibrinogen concentrate (70 mg/kg) administered after the termination of cardiopulmonary bypass reduced the need for transfusion with cryoprecipitate in a neonate and infant patient population.ClinicalTrials.gov identifier: NCT02822599.
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A systematic review of the evidence supporting post-operative antithrombotic use following cardiopulmonary bypass in children with CHD. Cardiol Young 2022; 32:10-20. [PMID: 34986908 DOI: 10.1017/s1047951121005205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES To determine the optimal antithrombotic agent choice, timing of initiation, dosing and duration of therapy for paediatric patients undergoing cardiac surgery with cardiopulmonary bypass. METHODS We used PubMed and EMBASE to systematically review the existing literature of clinical trials involving antithrombotics following cardiac surgery from 2000 to 2020 in children 0-18 years. Studies were assessed by two reviewers to ensure they met eligibility criteria. RESULTS We identified 10 studies in 1929 children across three medications classes: vitamin K antagonists, cyclooxygenase inhibitors and indirect thrombin inhibitors. Four studies were retrospective, five were prospective observational cohorts (one of which used historical controls) and one was a prospective, randomised, placebo-controlled, double-blind trial. All included were single-centre studies. Eight studies used surrogate biomarkers and two used clinical endpoints as the primary endpoint. There was substantive variability in response to antithrombotics in the immediate post-operative period. Studies of warfarin and aspirin showed that laboratory monitoring levels were frequently out of therapeutic range (variably defined), and findings were mixed on the association of these derangements with bleeding or thrombotic events. Heparin was found to be safe at low doses, but breakthrough thromboembolic events were common. CONCLUSION There are few paediatric prospective randomised clinical trials evaluating antithrombotic therapeutics post-cardiac surgery; most studies have been observational and seldom employed clinical endpoints. Standardised, validated endpoints and pragmatic trial designs may allow investigators to determine the optimal drug, timing of initiation, dosing and duration to improve outcomes by limiting post-operative morbidity and mortality related to bleeding or thrombotic events.
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Boettcher W, Schulz A, Sinzobahamvya N, Dehmel F, Redlin M, Schmitt K, Cho MY, O'Brien B, Photiadis J. Coagulation Profile of Neonates Undergoing Arterial Switch Surgery With Crystalloid Priming of the Cardiopulmonary Bypass Circuit. J Cardiothorac Vasc Anesth 2021; 36:1598-1605. [PMID: 34462202 DOI: 10.1053/j.jvca.2021.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 07/30/2021] [Accepted: 08/02/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The aim was to evaluate changes in the coagulation profile of cyanotic neonates, to analyze the effects of cardiopulmonary bypass (CPB) with crystalloid priming on their coagulation status, and to determine factors predicting a requirement for hemostasis-derived transfusion. DESIGN Retrospective cohort. SETTING Single-center, tertiary academic hospital. PARTICIPANTS In total, 100 consecutive neonates who underwent arterial switch surgery between December 2014 and June 2020. INTERVENTIONS Rotational thromboelastometry (ROTEM) and coagulation parameters before surgery and before termination of CPB were evaluated. Transfusion of platelets, fresh frozen plasma, and fibrinogen, defined as hemostasis-derived transfusion (HD transfusion), were determined. Patients with and without HD transfusion were compared to identify predictors. MEASUREMENTS AND MAIN RESULTS After CPB, fibrinogen was reduced by 24.5% (interquartile range [IQR] 8.9-32.1) to 201 mg/dL (IQR 172-249), resulting in a reduction of FIBTEM A10 by 20% (1.8-33.3) to 8 mm (6-11). The platelet count decreased by a median of 47.2% (25.6-61.3) to 162 × 103/µL (119-215). However, the median fibrinogen concentration and platelet count remained within normal range. Neonates with abnormal ROTEM results were more likely to receive HD transfusions. The HD transfusions were more likely with lower preoperative FIBTEM maximum clot firmness values (p = 0.031), lower hemoglobin concentrations at termination of CPB (p = 0.02), and longer CPB duration (p = 0.017). Perioperative hemostasis without any HD transfusion was achieved in 64 neonates. CONCLUSIONS Guidance from ROTEM analyses facilitates hemostasis management after neonatal CPB. Circuit miniaturization with transfusion-free CPB is associated with acceptable changes in ROTEM in most patients, and allows sufficient hemostasis without any HD transfusions in most patients.
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Affiliation(s)
- Wolfgang Boettcher
- Department of Congenital Heart Surgery and Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany.
| | - Antonia Schulz
- Department of Congenital Heart Surgery and Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany
| | - Nicodème Sinzobahamvya
- Department of Congenital Heart Surgery and Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany
| | - Frank Dehmel
- Department of Congenital Heart Surgery and Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany
| | - Mathias Redlin
- Department of Cardiac Anesthesiology and Intensive Care Medicine, German Heart Center Berlin, Berlin, Germany
| | - Katharina Schmitt
- Department of Congenital Heart Disease-Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Mi-Young Cho
- Department of Congenital Heart Surgery and Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany
| | - Benjamin O'Brien
- Department of Cardiac Anesthesiology and Intensive Care Medicine, German Heart Center Berlin, Berlin, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany; Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité Universitaetsmedizin, Berlin, Germany
| | - Joachim Photiadis
- Department of Congenital Heart Surgery and Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany
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Hu J, Li P, Chen X, Yan J, Zhang J, Zhang C. Effects of modified ultrafiltration and conventional ultrafiltration combination on perioperative clinical outcomes in pediatric cardiac surgery: A meta-analysis. Medicine (Baltimore) 2021; 100:e24221. [PMID: 33546042 PMCID: PMC7837856 DOI: 10.1097/md.0000000000024221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 12/16/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND This meta-analysis was performed to review the effects of the addition of modified ultrafiltration (MUF) and conventional ultrafiltration (CUF) to CUF alone on postoperative hemoglobin, surgical and ultrafiltration data, and postoperative clinical outcomes in pediatric patients undergoing cardiac surgery. METHODS A systematic search was performed to identify randomized controlled clinical trials that compared MUF and CUF combination with CUF alone in pediatric cardiac surgery undergoing cardiopulmonary bypass (CPB) in PubMed, Embase, Cochrane Library, and Web of Science without any language or date limitation in February 2020. For each included trial, the primary outcomes including post-CPB and postoperative hematocrit, surgical and ultrafiltration data, postoperative clinical outcomes including volume of chest tube drainage within 48 hours after surgery and perioperative blood requirement, ventilation support duration, and length of stay day in the intensive care unit (ICU) and hospital were collected and analyzed. The analysis was conducted using STATA version 12.0. RESULTS A total of 8 trials encompassing 405 patients were included in this analysis. Analysis indicated that MUF + CUF increased the post-CPB hematocrit (Standard mean difference, SMD = 1.85, 95% confidence interval, 95% CI 0.91-2.79). Meanwhile, ultrafiltration volume was higher in CUF+MUF infants than CUF-alone infants (SMD = 1.46, 95% CI 0.51-2.41, P = .003). The clinical outcomes, including postoperative hemodynamic changes, prime volume, blood requirement, chest tube drainage volume, mechanical ventilation duration, and ICU duration, were unclear because of the unstable sensitivity analyses. CONCLUSIONS Beneficial effects of using MUF and CUF for pediatric cardiac surgery, including increase post-CPB hematocrit and ultrafiltration volume when compared with CUF alone. Meanwhile, MUF and CUF did not significantly influence the postoperative hospital stay duration, CPB, and aortic occlusion duration.
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Affiliation(s)
| | - Ping Li
- Department of Obstetrics
- Hunan Engineering Research Center of Early Life Development and Disease Prevention
| | - Xuliang Chen
- Department of Cardiovascular Surgery, Xiangya Hospital, Changsha, China
| | | | | | - Chengliang Zhang
- Department of Cardiovascular Surgery, Xiangya Hospital, Changsha, China
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Hatami F, Valizadeh N, Salehi F, Hosseinzadeh Maleki M. Topical versus low-dose systemic tranexamic acid in pediatric cardiac surgery: A randomized clinical study. J Card Surg 2020; 35:3368-3373. [PMID: 32989825 DOI: 10.1111/jocs.15082] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 09/13/2020] [Accepted: 09/15/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The current study aimed to compare the benefits of topical and low-dose systemic tranexamic acid administration in pediatric cardiac surgery. METHODS A total of 117 children undergoing cardiac surgery for congenital heart disease were assigned into three groups. Patients in the systemic group received 20 mg/kg-1 tranexamic acid through the cardiopulmonary bypass followed by another dose of 20 mg/kg-1 after cardiopulmonary bypass separation. Patients in the topical group were administered with 50 mg/kg-1 tranexamic acid poured into the pericardium, while the control group received no antifibrinolytics. The outcome measures of bleeding and blood products transfusion were recorded over the first 48 h postoperatively. RESULTS Chest tube drainage was significantly lower in both topical and systemic groups than the control group, but it did not differ between the case groups. Blood products requirement did not show a difference between groups. Neurological or thromboembolic events did not variate among the groups, and no deaths occurred in this study. CONCLUSION Topical or systemic tranexamic acid administration reduced postoperative blood loss effectively without adding an extra risk.
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Affiliation(s)
- Farbod Hatami
- Department of Cardiology, Cardiovascular Diseases Research Center, Birjand University of Medical Sciences, Birjand, Iran
| | - Niloufar Valizadeh
- Department of Cardiology, Cardiovascular Diseases Research Center, Birjand University of Medical Sciences, Birjand, Iran
| | - Forod Salehi
- Department of Cardiology, Cardiovascular Diseases Research Center, Birjand University of Medical Sciences, Birjand, Iran
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Sniderman J, Monagle P, Annich GM, MacLaren G. Hematologic concerns in extracorporeal membrane oxygenation. Res Pract Thromb Haemost 2020; 4:455-468. [PMID: 32548547 PMCID: PMC7292669 DOI: 10.1002/rth2.12346] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 03/27/2020] [Accepted: 03/31/2020] [Indexed: 12/16/2022] Open
Abstract
This ISTH "State of the Art" review aims to critically evaluate the hematologic considerations and complications in extracorporeal membrane oxygenation (ECMO). ECMO is experiencing a rapid increase in clinical use, but many questions remain unanswered. The existing literature does not address or explicitly state many pertinent details that may influence hematologic complications and, ultimately, patient outcomes. This review aims to broadly introduce modern ECMO practices, circuit designs, circuit materials, hematologic complications, transfusion-related considerations, age- and size-related differences, and considerations for choosing outcome measures. Relevant studies from the 2019 ISTH Congress in Melbourne, which further advanced our understanding of these processes, will also be highlighted.
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Affiliation(s)
| | - Paul Monagle
- Department of PaediatricsDepartment of HaematologyUniversity of MelbourneThe Royal Children's HospitalHaematology Research Murdoch Children’s Research InstituteMelbourneVic.Australia
| | - Gail M. Annich
- Department of Critical Care MedicineThe Hospital for Sick ChildrenUniversity of TorontoTorontoOntarioCanada
| | - Graeme MacLaren
- Paediatric ICURoyal Children’s HospitalMelbourneVic.Australia
- Department of PaediatricsUniversity of MelbourneParkvilleVic.Australia
- Cardiothoracic ICUNational University Health SystemSingapore CitySingapore
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Downey LA, Andrews J, Hedlin H, Kamra K, McKenzie ED, Hanley FL, Williams GD, Guzzetta NA. Fibrinogen Concentrate as an Alternative to Cryoprecipitate in a Postcardiopulmonary Transfusion Algorithm in Infants Undergoing Cardiac Surgery. Anesth Analg 2020; 130:740-751. [DOI: 10.1213/ane.0000000000004384] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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14
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von Stumm M, Subbotina I, Biermann D, Gottschalk U, Mueller G, Kozlik-Feldmann R, Reichenspurner H, Riso A, Sachweh JS. Impact of delayed systemic heparinization on postoperative bleeding and thromboembolism during post-cardiotomy extracorporeal membrane oxygenation in neonates. Perfusion 2020; 35:626-632. [PMID: 32072861 DOI: 10.1177/0267659120906046] [Citation(s) in RCA: 2] [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
INTRODUCTION Veno-arterial extracorporeal membrane oxygenation is well-established for pediatric patients with post-cardiotomy heart failure. However, extracorporeal membrane oxygenation support is associated with major complications, that is, hemorrhage and thromboembolism. We seek to report our experience with delayed systemic heparinization during neonatal cardiac extracorporeal membrane oxygenation and its impact on bleeding and thromboembolism. METHODS We retrospectively identified 15 consecutive neonates who were placed on extracorporeal membrane oxygenation after congenital heart surgery during a period of 3 years (2015-2017). Our anticoagulation protocol consisted of full heparin reversal by protamine after switching from cardiopulmonary bypass to extracorporeal membrane oxygenation (target activated clotting time: 120 ± 20 seconds). Administration of systemic heparinization was delayed until postoperative drainage volume declined to <1 mL/kg/h. Primary study endpoints were thromboembolism, bleeding, and requirement of blood products on extracorporeal membrane oxygenation. RESULTS Our cohort (mean age: 13 ± 2.6 days; mean weight: 3.1 ± 0.3 kg; 66.7% male) required post-cardiotomy extracorporeal membrane oxygenation with a mean support time of 4.5 ± 2.2 days. Systemic heparinization was delayed averagely for 18.1 ± 9.3 hours. No thromboembolic events were observed on extracorporeal membrane oxygenation or after weaning. Relevant surgical site bleeding occurred in two patients (13.3%) requiring re-thoracotomy on the first postoperative day. Analysis of transfusion volumes revealed 24.5 ± 21.9 mL/kg/d mean packed red blood cells, 9.6 ± 7.1 mL/kg/d mean fresh frozen plasma, and 7.5 ± 5.7 mL/kg/d mean platelets. In-hospital survival was 86.6% (n = 13). CONCLUSION In this retrospective analysis, the results of delayed systemic heparinization in neonatal post-cardiotomy extracorporeal membrane oxygenation could lead one to conclude that this routine is safe and favorable with low risk for thromboembolic events, reduced postoperative hemorrhage, and reduced blood product utilization.
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Affiliation(s)
- Maria von Stumm
- Department of Cardiovascular Surgery, University Heart & Vascular Center, Hamburg, Germany
| | - Irina Subbotina
- Department of Cardiovascular Surgery, University Heart & Vascular Center, Hamburg, Germany
| | - Daniel Biermann
- Department of Cardiac Surgery for Congenital Heart Disease, University Heart & Vascular Center, Hamburg, Germany
| | - Urda Gottschalk
- Department of Paediatric Cardiology, University Heart & Vascular Center, Hamburg, Germany
| | - Goetz Mueller
- Department of Paediatric Cardiology, University Heart & Vascular Center, Hamburg, Germany
| | - Rainer Kozlik-Feldmann
- Department of Paediatric Cardiology, University Heart & Vascular Center, Hamburg, Germany
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, University Heart & Vascular Center, Hamburg, Germany
| | - Arlindo Riso
- Department of Cardiac Surgery for Congenital Heart Disease, University Heart & Vascular Center, Hamburg, Germany
| | - Joerg S Sachweh
- Department of Cardiac Surgery for Congenital Heart Disease, University Heart & Vascular Center, Hamburg, Germany
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15
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Fresh Frozen Plasma versus Crystalloid Priming of Cardiopulmonary Bypass Circuit in Pediatric Surgery. Anesthesiology 2020; 132:95-106. [DOI: 10.1097/aln.0000000000003017] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Abstract
Editor’s Perspective
What We Already Know about This Topic
What This Article Tells Us That Is New
Background
In congenital cardiac surgery, priming cardiopulmonary bypass (CPB) with fresh frozen plasma (FFP) is performed to prevent coagulation abnormalities. The hypothesis was that CPB priming with crystalloids would be different compared with FFP in terms of bleeding and/or need for blood product transfusion.
Methods
In this parallel-arm double-blinded study, patients weighing between 7 and 15 kg were randomly assigned to a CPB priming with 15 ml · kg−1 PlasmaLyte or 15 ml · kg−1 FFP in addition to a predefined amount of packed red blood cells used in all patients. The decision to transfuse was clinical and guided by point-of-care tests. The primary endpoints included postoperative bleeding tracked by chest tubes, number of patients transfused with any additional blood products, and the total number of additional blood products administered intra- and postoperatively. The postoperative period included the first 6 h after intensive care unit arrival.
Results
Respectively, 30 and 29 patients in the FFP and in the crystalloid group were analyzed in an intention-to-treat basis. Median postoperative blood loss was 7.1 ml · kg−1 (5.1, 9.4) in the FFP group and 5.7 ml · kg−1 (3.8, 8.5) in the crystalloid group (P = 0.219); difference (95% CI): 1.2 (−0.7 to 3.2). The proportion of patients additionally transfused was 26.7% (8 of 30) and 37.9% (11 of 29) in the FFP and the crystalloid groups, respectively (P = 0.355; odds ratio [95% CI], 1.7 [0.6 to 5.1]). The median number of any blood products transfused in addition to priming was 0 (0, 1) and 0 (0, 2) in the FFP and crystalloid groups, respectively (P = 0.254; difference [95% CI], 0 [0 to 0]). There were no study-related adverse events.
Conclusions
The results demonstrate that in infants and children, priming CPB with crystalloids does not result in a different risk of postoperative bleeding and need for transfusion of allogeneic blood products.
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Bierer J, Stanzel R, Henderson M, Sett S, Horne D. Ultrafiltration in Pediatric Cardiac Surgery Review. World J Pediatr Congenit Heart Surg 2019; 10:778-788. [DOI: 10.1177/2150135119870176] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction: The use of cardiopulmonary bypass in pediatric cardiac surgery is associated with significant inflammation, fluid overload, and end-organ dysfunction yielding morbidity and mortality. For decades, various intraoperative ultrafiltration techniques such as conventional ultrafiltration, modified ultrafiltration (MUF), zero-balance ultrafiltration (ZBUF), and combination techniques (ZBUF-MUF) have been used to mitigate these toxicities and promote improved postoperative outcomes. However, there is currently no consensus on the ultrafiltration technique or strategy that yields the most benefit for infants and children undergoing open heart surgery. Methods: A librarian-conducted PubMed literature search from 1990 to 2018 yielded 90 clinical studies or publications on the various forms of ultrafiltration and the impact on physiologic markers and clinical outcomes. All publications were reviewed, summarized, and conclusions synthesized. The data sets were not combined for systematic or meta-analysis due to significant heterogeneity in study protocols and patient populations. Results: Modified ultrafiltration significantly promotes improved myocardial function, reduction in fluid overload, and reduced bleeding and transfusion complications. Furthermore, ZBUF has shown a consistent reduction in inflammatory cytokines and improved pulmonary function and compliance. There is conflicting evidence that MUF, ZBUF, and ZBUF-MUF culminate in reduced ventilation time and intensive care unit stay. Conclusion: Various modes of ultrafiltration have been shown to be associated with improved physiologic function or clinical outcomes in pediatric cardiac surgery. There are some inconsistent trial results that can be explained by heterogeneity in ultrafiltration, clinical staff preferences, and institution protocols. Ultrafiltration has some essential benefit as it is ubiquitously used at pediatric heart centers; however, the optimal protocol could be yet identified.
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Affiliation(s)
- Joel Bierer
- Division of Cardiac Surgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Roger Stanzel
- Department of Clinical Perfusion, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Mark Henderson
- Department of Clinical Perfusion, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Suvro Sett
- Division of Cardiac Surgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - David Horne
- Division of Cardiac Surgery, Department of Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
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17
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Sweeney RE, Nguyen V, Alouidor B, Budiman E, Wong RK, Yoon JY. Flow Rate and Raspberry Pi-based Paper Microfluidic Blood Coagulation Assay Device. IEEE SENSORS JOURNAL 2019; 19:4743-4751. [PMID: 32863779 PMCID: PMC7450985 DOI: 10.1109/jsen.2019.2902065] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Monitoring blood coagulation in response to an anticoagulant (heparin) and its reversal agent (protamine) is essential during and after surgery, especially with cardiopulmonary bypass (CPB). A current clinical standard is the use of activated clotting time (ACT), where the mechanical movement of a plunger through a whole blood-filled channel is monitored to evaluate the endpoint time of coagulation. As a rapid, simple, low-volume, and cost-effective alternative, we have developed a paper microfluidic assay and Raspberry Pi-based device with the aim of quantifying the extent of blood coagulation in response to varying doses of heparin and protamine. The flow rate of blood through the paper microfluidic channel is automatically monitored using Python-coded edge detection algorithm. For each set of assay, 8 μL of fresh human whole blood (untreated and undiluted) from human subjects is loaded onto each of 8 sample pads, which have been preloaded with varying amounts of heparin or protamine. Total assay time is 3-5 minutes including the time for sample loading and incubation.
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Affiliation(s)
- Robin E Sweeney
- Department of Biomedical Engineering, The University of Arizona, Tucson, AZ 85721, USA; Unchained Labs, Pleasanton, CA, USA
| | - Vina Nguyen
- Perfusion Sciences Graduate Program, Department of Medical Pharmacology, The University of Arizona College of Medicine, Tucson, AZ 85721, USA; Pacific Life Lines, San Carlos, CA, USA
| | - Benjamin Alouidor
- Perfusion Sciences Graduate Program, Department of Medical Pharmacology, The University of Arizona College of Medicine, Tucson, AZ 85721, USA; Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Elizabeth Budiman
- Department of Biomedical Engineering, The University of Arizona, Tucson, AZ 85721, USA
| | - Raymond K Wong
- Perfusion Sciences Graduate Program, Department of Medical Pharmacology, The University of Arizona College of Medicine, Tucson, AZ 85721, USA
| | - Jeong-Yeol Yoon
- Department of Biomedical Engineering, The University of Arizona, Tucson, AZ 85721, USA`
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18
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José Curi-Curi P, Aguilar Alanis E, Calderón- Colmenero J, Luis Cervantes-Salazar J, Reyes Pavón R, Ramírez-Marroquín S. Impact of Modified Ultrafiltration in Congenital Heart Disease Patients Treated with Cardiopulmonary Bypass. CONGENIT HEART DIS 2018. [DOI: 10.5772/intechopen.80599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Baumann Kreuziger L, Karkouti K, Tweddell J, Massicotte MP. Antithrombotic therapy management of adult and pediatric cardiac surgery patients. J Thromb Haemost 2018; 16:2133-2146. [PMID: 30153372 DOI: 10.1111/jth.14276] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Indexed: 12/16/2022]
Abstract
Despite the development of catheter-based interventions for ischemic and valvular heart disease, hundreds of thousands of people undergo open heart surgery annually for coronary artery bypass graft (CABG), valve replacement or cardiac assist device implantation. Cardiac surgery patients are unique because therapeutic anticoagulation is required during cardiopulmonary bypass. Developmental hemostasis and altered drug metabolism affect management in children. This narrative review summarizes the current evidence-based and consensus guidelines regarding perioperative, intraoperative and postoperative antithrombotic therapy in patients undergoing cardiac surgery. Anticoagulation preoperatively is required in the setting of cardiac arrhythmias, prior valve replacement or history of venous thromboembolism. In patients with ischemic heart disease, aspirin is continued in the perioperative period, whereas oral P2Y12 antagonists are withheld for 5-7 days to reduce the risk of perioperative bleeding. Intraoperative management of cardiopulmonary bypass in adults and children includes anticoagulation with unfractionated heparin. Variability in dose-response to heparin and influence of other medical conditions on dosing and reversal of heparin make intraoperative anticoagulation challenging. Vitamin K antagonist therapy is the standard anticoagulant after mechanical heart valve or left ventricular assist device (LVAD) implantation. Longer duration of dual antiplatelet therapy is recommended after CABG if patients undergo surgery because of acute coronary syndrome. Antiplatelet therapy after LVAD implantation includes aspirin, dipyridamole and/or clopidogrel in children and aspirin in adults. A coordinated approach between hematology, cardiology, anesthesiology, critical care and cardiothoracic surgery can assist to balance the risk of thrombosis and bleeding in patients undergoing cardiac surgery.
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Affiliation(s)
- L Baumann Kreuziger
- BloodCenter of Wisconsin, Blood Research Institute, Milwaukee, WI, USA
- Medical College of Wisconsin, Department of Medicine, Division of Hematology and Oncology, Milwaukee, WI, USA
| | - K Karkouti
- Department of Anesthesia and Pain Management, Toronto General Hospital Research Institute, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - J Tweddell
- Department of Surgery and Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH, USA
| | - M P Massicotte
- University of Alberta, Department of Pediatrics, Edmonton, Alberta, Canada
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20
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Scott JP, Niebler RA, Stuth EAE, Newman DK, Tweddell JS, Bercovitz RS, Benson DW, Cole R, Simpson PM, Yan K, Woods RK. Rotational Thromboelastometry Rapidly Predicts Thrombocytopenia and Hypofibrinogenemia During Neonatal Cardiopulmonary Bypass. World J Pediatr Congenit Heart Surg 2018; 9:424-433. [PMID: 29945504 DOI: 10.1177/2150135118771318] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Thrombocytopenia and hypofibrinogenemia during neonatal cardiopulmonary bypass (CPB) contribute to bleeding and morbidity. Rotational thromboelastometry (ROTEM) is a viscoelastic assay with a rapid turnaround time. Data validating ROTEM during neonatal cardiac surgery remain limited. This study examined perioperative hemostatic trends in neonates treated with standardized platelet and cryoprecipitate transfusion during CPB. We hypothesized that ROTEM would predict thrombocytopenia, hypofibrinogenemia, and the correction thereof. METHODS Forty-four neonates undergoing CPB were included in this prospective observational study. Blood samples were obtained at Baseline, On CPB, Post-CPB, and Postoperative. The ROTEM analysis included extrinsically activated (Extem) and fibrinogen-specific (Fibtem) assays. Platelet-specific thromboelastometry (Pltem) values were calculated. Platelet and cryoprecipitate transfusion was initiated prior to termination of CPB. RESULTS Platelet count and Extem amplitude decreased significantly On CPB ( P < .0001), increased significantly Post-CPB ( P < .0001), and Postoperative values were not significantly different from Baseline. Extem amplitude at 10 minutes (A10) > 46.5 mm (AUC = 0.941) and Pltem A10 > 37.5 mm [area under curve (AUC) = 0.960] predicted platelet count > 100 × 103/μL, and they highly correlated with platelet count ( R = 0.89 and R = 0.90, respectively). Fibrinogen concentration and Fibtem amplitude decreased significantly On CPB ( P ≤ .0001) and normalized after cryoprecipitate transfusion. Fibtem A10 > 9.5 mm predicted fibrinogen >200 mg/dL (AUC = 0.817), but it correlated less well with fibrinogen concentration ( R = 0.65). CONCLUSIONS ROTEM analysis during neonatal cardiac surgery is sensitive and specific for thrombocytopenia and hypofibrinogenemia, identifying deficits within 10 minutes. Platelet and cryoprecipitate transfusion during neonatal CPB normalizes platelet count, fibrinogen level, and ROTEM amplitudes.
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Affiliation(s)
- John P Scott
- 1 Section of Pediatric Anesthesiology, Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, USA.,2 Section of Pediatric Critical Care, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Robert A Niebler
- 2 Section of Pediatric Critical Care, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Eckehard A E Stuth
- 1 Section of Pediatric Anesthesiology, Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Debra K Newman
- 3 Blood Research Institute, Blood Center of Southeastern Wisconsin, Milwaukee, WI, USA
| | - James S Tweddell
- 4 Section of Pediatric Cardiothoracic Surgery, Department of Cardiothoracic Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Rachel S Bercovitz
- 5 Section of Pediatric Hematology, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - D Woodrow Benson
- 6 Section of Pediatric Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Regina Cole
- 6 Section of Pediatric Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Pippa M Simpson
- 7 Division of Quantitative Health Sciences, Department of Biostatistics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ke Yan
- 7 Division of Quantitative Health Sciences, Department of Biostatistics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ronald K Woods
- 8 Section of Pediatric Cardiothoracic Surgery, Department of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
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Patregnani JT, Sochet AA, Zurakowski D, Klugman D, Diab Y, Berger JT, Sinha P. Cardiopulmonary Bypass Reduces Early Thrombosis of Systemic-to-Pulmonary Artery Shunts. World J Pediatr Congenit Heart Surg 2018; 9:276-282. [PMID: 29692234 DOI: 10.1177/2150135118755985] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Shunt thrombosis is a significant cause of morbidity and mortality after systemic-to-pulmonary artery shunt (SPS) placement. Concurrent procedures with placement of SPS may require cardiopulmonary bypass (CPB). Cardiopulmonary bypass is known to cause bleeding and platelet dysfunction in infants, which may protect from early shunt thrombosis. We hypothesized that infants undergoing SPS placement on CPB have a lower incidence of early shunt thrombosis. METHODS Retrospective cohort study of infants undergoing SPS placement from January 2008 to December 2014 was performed. Patients with and without early shunt thrombosis and on or off CPB were compared using the Mann-Whitney U test or Fisher exact test. Multivariable regression analysis was performed to identify independent predictors of early shunt thrombosis and to assess effect of CPB independent of other factors. RESULTS Seventy-five infants underwent SPS placement during the study period (on CPB, n = 25; off CPB, n = 50). Operative mortality was 11% (8/75). Nine (12%) patients developed early shunt thrombosis, all of whom had shunt placement off CPB. Independent risk factors for early shunt thrombosis were identified to be SPS placement off CPB ( P = .011), prematurity ( P = .034), and competitive antegrade pulmonary blood flow ( P = .038). CONCLUSION Prematurity, competitive antegrade pulmonary blood flow, and shunt placement off CPB lead to higher risk of early shunt thrombosis. We speculate that the protection offered by use of CPB may be accounted for by the associated complex coagulopathy and platelet dysfunction associated with CPB.
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Affiliation(s)
- Jason T Patregnani
- 1 Division of Cardiac Intensive Care Medicine, Children's National Health System, The George Washington School of Medicine, Washington, DC, USA
| | - Anthony A Sochet
- 2 Division of Critical Care Medicine, Johns Hopkins All Children's Hospital, Johns Hopkins University, St Petersburg, FL, USA
| | - David Zurakowski
- 3 Department of Anesthesia, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,4 Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Darren Klugman
- 1 Division of Cardiac Intensive Care Medicine, Children's National Health System, The George Washington School of Medicine, Washington, DC, USA
| | - Yaser Diab
- 5 Division of Hematology/Oncology, Children's National Health System, The George Washington School of Medicine, Washington, DC, USA
| | - John T Berger
- 1 Division of Cardiac Intensive Care Medicine, Children's National Health System, The George Washington School of Medicine, Washington, DC, USA
| | - Pranava Sinha
- 6 Division of Cardiovascular Surgery, Children's National Health System, The George Washington School of Medicine, Washington, DC, USA
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Hunt R, Hoffman CM, Emani S, Trenor CC, Emani SM, Faraoni D, Kimchi-Sarfaty C, Ibla JC. Elevated preoperative von Willebrand factor is associated with perioperative thrombosis in infants and neonates with congenital heart disease. J Thromb Haemost 2017; 15:2306-2316. [PMID: 28981194 DOI: 10.1111/jth.13860] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Indexed: 01/19/2023]
Abstract
Essentials Perioperative thrombosis is a major cause of morbidity and mortality in congenital heart disease. Neonates and infants undergoing repair of congenital heart lesions were prospectively followed. Elevated von Willebrand factor (VWF) to ADAMTS-13 activity ratios typified the postoperative period. Thrombosis was associated with preoperative VWF activity and cryoprecipitate transfusion SUMMARY: Background The surgical repair of congenital heart malformations is frequently complicated by perioperative thrombosis of unclear etiology. An imbalance between von Willebrand factor (VWF) and ADAMTS-13 is an emerging variable in thrombosis. Objectives To describe perioperative changes to VWF, ADAMTS-13 and NETosis, and evaluate clinical and biochemical associations with postoperative thrombosis. Methods Neonates and infants undergoing palliation or definitive surgical repair of congenital heart malformations were recruited (n = 133). Preoperative and postoperative plasma levels of VWF, ADAMTS-13 and markers of NETosis were determined. Patients were followed for up to 30 days for the occurrence of thrombosis. Univariate and multivariate logistic regression analyses were conducted to identify variables associated with thrombosis. Results We identified significant postoperative increases in VWF activity, VWF level, DNA-histone complexes and cell-free DNA with an overall decrease in ADAMTS-13 activity. Patients experiencing postoperative thrombotic events (9%) were characterized by surgery performed at a lower intraoperative temperature, higher preoperative lactic acid levels, and higher preoperative VWF activity and level. A multivariate logistic regression model identified preoperative VWF activity (odds ratio (OR) 8.39 per IU mL-1 , 95% confidence interval [CI] 1.73-40.55) and transfusion of cryoprecipitate (OR 1.10 per mL kg-1 , 95% CI 1.03-1.17) as being associated with thrombosis. Conclusions Pediatric patients undergoing surgical repair of congenital heart malformations are exposed to high levels of VWF with diminished or minimal change to ADAMTS-13 in the immediate postoperative period. Elevated preoperative VWF activity is associated with postoperative thrombosis in pediatric congenital heart disease.
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Affiliation(s)
- R Hunt
- Hemostasis Branch, Division of Plasma Protein Therapeutics, Office of Tissues and Advanced Therapeutics, Center for Biologics Evaluation and Research, US FDA, Silver Spring, MD, USA
| | - C M Hoffman
- Hemostasis Branch, Division of Plasma Protein Therapeutics, Office of Tissues and Advanced Therapeutics, Center for Biologics Evaluation and Research, US FDA, Silver Spring, MD, USA
| | - S Emani
- Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - C C Trenor
- Division of Hematology/Oncology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - S M Emani
- Department of Cardiac Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - D Faraoni
- Division of Cardiac Anesthesia, Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - C Kimchi-Sarfaty
- Hemostasis Branch, Division of Plasma Protein Therapeutics, Office of Tissues and Advanced Therapeutics, Center for Biologics Evaluation and Research, US FDA, Silver Spring, MD, USA
| | - J C Ibla
- Department of Anesthesiology Perioperative and Pain Medicine, Division of Cardiac Anesthesia, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
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Downey L, Brown ML, Faraoni D, Zurakowski D, DiNardo JA. Recombinant Factor VIIa Is Associated With Increased Thrombotic Complications in Pediatric Cardiac Surgery Patients. Anesth Analg 2017; 124:1431-1436. [PMID: 28319507 DOI: 10.1213/ane.0000000000001947] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Recombinant factor VIIa (rFVIIa) is routinely used as an off-label hemostatic agent in children undergoing cardiac surgery. Despite evidence that rFVIIa use is associated with an increased incidence of thrombotic complications in adult cardiac surgery, the safety of rFVIIa as a rescue hemostatic agent in the pediatric cardiac surgical population is less definitively delineated. In this retrospective study, we used propensity score matching to compare the incidence of thrombotic complications between children treated with rFVIIa and their matched controls. METHODS We retrospectively reviewed medical records and pharmacy data from all neonates and children who underwent congenital cardiac surgery between May 1, 2011, and October 31, 2013, at Boston Children's Hospital, and identified those who received rFVIIa during the perioperative period. Using existing knowledge, we chose 10 factors associated with bleeding after cardiac surgery to be used in our propensity score: age, sex, body weight, neonates, prematurity, previous sternotomy, cardiopulmonary bypass time, deep hypothermic circulatory arrest time, aortic cross-clamp time, and the operative surgeon. We then used propensity-matched analysis to match children treated with rFVIIa with 2 controls. The primary outcome was thrombotic complications. Secondary outcomes included reexploration for bleeding, length of cardiac intensive care unit stay, length of hospital stay, and 30-day mortality. RESULTS One hundred forty-nine patients received perioperative rFVIIa during the study period. Propensity matching yielded 143 rFVIIa patients matched to 2 control patients each (n = 286). Three control patients were found to have received rFVIIa during the perioperative course and were removed from the analysis, for a total of 283 control patients. The administration of rFVIIa was associated with an increased incidence of thrombotic complications (20% vs 8%; odds ratio [OR]: 3.9 [95% confidence interval {CI}: 2.6-5.9], P < .001). Administration of rFVIIa was associated with a prolonged median length of cardiac intensive care unit stay (8 days [interquartile range {IQR}: 4-24] vs 5 days [IQR: 2-10], P < .001) and prolonged length of hospital stay (20 [IQR: 9-44] vs 11 days [IQR: 7-23], P < .001). No difference in reexploration for bleeding (rFVII = 14% vs controls = 9%; OR: 1.7 [95% CI, 0.92-3.1], P = .12) or 30-day mortality was observed (8% vs 6%; OR 1.3 [95% CI, 0.60-2.89], P = .51). CONCLUSIONS This retrospective analysis confirmed that perioperative administration of rFVIIa is associated with an increased incidence of postoperative thrombotic complications in neonates and children undergoing cardiac surgery, without increase in 30-day mortality. In conclusion, rFVIIa should be used with extreme caution in pediatric patients undergoing cardiac surgery.
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Affiliation(s)
- Laura Downey
- From the *Department of Anesthesiology, Perioperative and Pain Medicine, Lucile Packard Children's Hospital, Stanford University, Stanford, California; †Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; and ‡Department of Anesthesia and Pain Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Guzzetta NA, Williams GD. Current use of factor concentrates in pediatric cardiac anesthesia. Paediatr Anaesth 2017; 27:678-687. [PMID: 28393462 DOI: 10.1111/pan.13158] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/10/2017] [Indexed: 11/29/2022]
Abstract
Excessive bleeding following pediatric cardiopulmonary bypass is associated with increased morbidity and mortality, both from the effects of hemorrhage and the therapies employed to achieve hemostasis. Neonates and infants are especially at risk because their coagulation systems are immature, surgeries are often complex, and cardiopulmonary bypass technologies are inappropriately matched to patient size and physiology. Consequently, these young children receive substantial amounts of adult-derived blood products to restore adequate hemostasis. Adult and pediatric data demonstrate associations between blood product transfusions and adverse patient outcomes. Thus, efforts to limit bleeding after pediatric cardiopulmonary bypass and minimize allogeneic blood product exposure are warranted. The off-label use of factor concentrates, such as fibrinogen concentrate, recombinant activated factor VII, and prothrombin complex concentrates, is increasing as these hemostatic agents appear to offer several advantages over conventional blood products. However, recognizing that these agents have the potential for both benefit and harm, well-designed studies are needed to enhance our knowledge and to determine the optimal use of these agents. In this review, our primary objective was to examine the evidence regarding the use of factor concentrates to treat bleeding after pediatric CPB and identify where further research is required. PubMed, MEDLINE/OVID, The Cochrane Library and the Cochrane Central Register of Controlled Trials (CENTRAL) were systematically searched to identify existing studies.
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Affiliation(s)
- Nina A Guzzetta
- Department of Anesthesiology, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Glyn D Williams
- Department of Anesthesiology, Stanford University School of Medicine, Lucile Packard Children's Hospital, Palo Alto, CA, USA
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25
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Lopez M, Feng C, Vasilyeva O, Eaton MP. Supplemental Antithrombin Is Effective in Achieving Adequate Anticoagulation in Infants and Children With an Inadequate Response to Heparin. J Cardiothorac Vasc Anesth 2017; 31:896-900. [DOI: 10.1053/j.jvca.2016.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Indexed: 01/19/2023]
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26
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Gertler R, Gruber M, Grassin-Delyle S, Urien S, Martin K, Tassani-Prell P, Braun S, Burg S, Wiesner G. Pharmacokinetics of tranexamic acid in neonates and infants undergoing cardiac surgery. Br J Clin Pharmacol 2017; 83:1745-1757. [PMID: 28245519 DOI: 10.1111/bcp.13274] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 02/15/2017] [Accepted: 02/21/2017] [Indexed: 11/30/2022] Open
Abstract
AIM Tranexamic acid (TXA) continues to be one of the antifibrinolytics of choice during paediatric cardiac surgery. However, in infants less than 1 year of age, the optimal dosing based on pharmacokinetic (PK) considerations is still under discussion. METHODS Forty-three children less than 1 year of age were enrolled, of whom 37 required the use of cardiopulmonary bypass (CPB) and six were operated on without CPB. Administration of 50 mg kg-1 TXA intravenously at the induction of anaesthesia was followed by 50 mg kg-1 into the CPB prime in the CPB group. Plasma concentrations of TXA were analysed by gas chromatography-mass spectrometry. PK data were investigated using nonlinear mixed-effect models. RESULTS A two-compartment model was fitted, with the main covariates being allometrically scaled bodyweight, CPB, postmenstrual age (PMA). Intercompartmental clearance (Q), peripheral volume (V2), systemic clearance, (CL) and the central volume (V1) were calculated. Typical values of the PK parameter estimates were as follows: CL = 3.78 [95 % confidence interval (CI) 2.52, 5.05] l h-1 ; central volume of distribution = 13.6 (CI 11.7, 15.5) l; Q = 16.3 (CI 13.5, 19.2) l h-1 ; V2 = 18.0 (CI 16.1, 19.9) l. Independently of age, 10 mg kg-1 TXA as a bolus, a subsequent infusion of 10 mg kg-1 h-1 , then a 4 mg kg-1 bolus into the prime and a reduced infusion of 4 mg kg-1 h-1 after the start of CPB are required to maintain TXA concentrations continuously above 20 μg ml-1 , the threshold value for an effective inhibition of fibrinolysis and far lower than the usual peak concentrations (the '10-10-4-4 rule'). CONCLUSIONS The introduction of a modified dosing regimen using a starting bolus followed by an infusion and a CPB prime bolus would prohibit the potential risk of seizures caused by high peak concentrations and also maintain therapeutic plasma concentration above 20 μg ml-1 .
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Affiliation(s)
- Ralph Gertler
- Klinik für Anaesthesie, operative und allgemeine Intensivmedizin, Notfallmedizin, Klinikum Links der Weser, University Medical Center Hamburg-Eppendorf, Bremen, Germany.,Institute of Anaesthesiology, German Heart Centre Munich, Technical University Munich, Munich, Germany
| | - Michael Gruber
- Department of Anesthesia, University Hospital Regensburg, Regensburg, Germany
| | - Stanislas Grassin-Delyle
- Département des Maladies des Voies Respiratoires, Hôpital Foch, Université Versailles Saint Quentin en Yvelines, Université Paris Saclay, F-92150, Suresnes, France.,Plateforme de spectrométrie de masse et INSERM UMR1173, UFR Sciences de la Santé Simone Veil, Université Versailles Saint Quentin en Yvelines, Université Paris Saclay, F-78180, Montigny-le-Bretonneux, France
| | - Saïk Urien
- CIC1419 Inserm Necker-Cochin, URC Paris Descartes Necker Cochin, AP-HP, Paris, France.,EAU7323, Université Paris Descartes, Sorbonne Paris Cité, France
| | - Klaus Martin
- Institute of Anaesthesiology, German Heart Centre Munich, Technical University Munich, Munich, Germany
| | - Peter Tassani-Prell
- Institute of Anaesthesiology, German Heart Centre Munich, Technical University Munich, Munich, Germany
| | - Siegmund Braun
- Institute of Laboratory Medicine, German Heart Centre Munich, Technical University Munich, Munich, Germany
| | - Simon Burg
- Institute of Anaesthesiology, German Heart Centre Munich, Technical University Munich, Munich, Germany
| | - Gunther Wiesner
- Institute of Anaesthesiology, German Heart Centre Munich, Technical University Munich, Munich, Germany
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27
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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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28
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Topical and low-dose intravenous tranexamic acid in cyanotic cardiac surgery. Asian Cardiovasc Thorac Ann 2017; 25:118-122. [DOI: 10.1177/0218492316688416] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Coagulopathy is a major problem in surgery for cyanotic congenital heart disease. Tranexamic acid has been used both topically and systemically and plays a vital role in pediatric cardiac surgery by reducing blood loss and blood product requirement. We aimed to determine the anti-fibrinolytic effectiveness of low-dose systemic or topical tranexamic acid or a combination of both. Methods Seventy-five patients were divided in 3 groups of 25. Group A patients were given tranexamic acid 20 mg kg−1 intravenously after sternotomy and 20 mg kg−1 after heparin reversal. Group B patients were given tranexamic acid 50 mg kg−1 in 20 mL of saline intrapericardially before sternal closure, with the drain clamped for 20 min. Group C patients were given tranexamic acid 20 mg kg−1 intravenously after sternotomy and 50 mg kg−1 intrapericardially before sternal closure. A number of clinical variables were recorded in the first 3 postoperative days. Ventilator time, intensive care unit stay, and outcome were also recorded. Results Chest tube drainage and blood product requirements were lowest in group C. Blood urea and serum creatinine levels were higher in groups A and C ( p < 0.05). Intensive care unit stay and ventilator time were similar in all 3 groups. No patient died and none had a seizure or other neurological event or thromboembolic complication postoperatively. Conclusion The combination of low-dose intravenous and topical tranexamic acid reduces postoperative blood loss and blood product requirement without incurring neurological, renal or thromboembolic complications. We recommend the routine use of topical and low-dose systemic tranexamic acid in cyanotic pediatric cardiac surgery.
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29
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Friesen RH. Landmark papers in pediatric cardiac anesthesia: documenting the history of the specialty. Paediatr Anaesth 2016; 26:1047-1052. [PMID: 27734558 DOI: 10.1111/pan.13011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/19/2016] [Indexed: 11/30/2022]
Abstract
Pediatric cardiac anesthesia has developed over the past eight decades into a specialty delivering complex clinical care and contributing remarkable scientific progress. The history of this development can be traced through journal articles that mark the strides of the specialty. This article discusses journal articles, chosen by the author, that he considers had a significant impact on the practice of pediatric cardiac anesthesia or are of historical interest.
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Affiliation(s)
- Robert H Friesen
- Department of Anesthesiology, Children's Hospital Colorado and University of Colorado School of Medicine, Denver, CO, USA.
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30
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Kim E, Shim HS, Kim WH, Lee SY, Park SK, Yang JH, Jun TG, Kim CS. Predictive Value of Intraoperative Thromboelastometry for the Risk of Perioperative Excessive Blood Loss in Infants and Children Undergoing Congenital Cardiac Surgery: A Retrospective Analysis. J Cardiothorac Vasc Anesth 2016; 30:1172-8. [DOI: 10.1053/j.jvca.2016.03.132] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Indexed: 11/11/2022]
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Mossad EB, Machado S, Apostolakis J. Bleeding Following Deep Hypothermia and Circulatory Arrest in Children. Semin Cardiothorac Vasc Anesth 2016; 11:34-46. [PMID: 17484172 DOI: 10.1177/1089253206297413] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Deep hypothermic circulatory arrest (DHCA) is a technique of extracorporeal circulation commonly used in children with complex congenital heart defects undergoing surgical repairs. The use of profound cooling (20°C) and complete cessation of circulation allow adequate exposure and correction of these complex lesions, with enhanced cerebral protection. However, the profound physiologic state of DHCA results in significant derangement of the coagulation system and a high incidence of postoperative bleeding. This review examines the impact of DHCA on bleeding and transfusion requirements in children and the pathophysiology of DHCA-induced platelet dysfunction. It also focuses on possible pharmacologic interventions to decrease bleeding following DHCA in children.
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Affiliation(s)
- Emad B Mossad
- Department of Cardiothoracic Anesthesia-G3, Cleveland Clinic, Cleveland, OH 44195, USA.
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32
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Oliver WC. Overview of Heparin and Protamine Management and Dosing Regimens in Pediatric Cardiac Surgical Patients. Semin Cardiothorac Vasc Anesth 2016. [DOI: 10.1177/108925320300700404] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Compared with adults, infants and children who undergo cardiopulmonary bypass for cardiac surgery present with a myriad of anticoagulation considerations. Inadequate anticoagulation during cardiopulmonary bypass may cause “subclinical” or “overt” thrombosis, while effective anticoagulation decreases excessive bleeding and transfusions. Current strategies for heparinization and its neutralization in pediatric patients undergoing congenital heart repair requiring cardiopulmonary bypass are examined. The coagulation system of the neonate and infant is immature and is further weakened by congenital heart disease. Changes in coagulation and fibrinolytic activity occur during cardiopulmonary bypass as a result of hemodilution and exposure of the blood to the extracorporeal circuit. Adequate anticoagulation is essential to minimize the thrombin generation that will result. The extent of excessive thrombin formation in pediatric patients undergoing cardiopulmonary bypass is better appreciated today than in the past, but no controlled study defines the optimal dose or technique for heparin dosing in these patients. Heparin concentration may even fall to 1.5 U/mL during cardiopulmonary bypass. However, the activated clotting time and heparin concentration correlate poorly. The ideal method to achieve adequate thrombin inhibition is unknown. Additionally, the dangers of excessive protamine are becoming more apparent. Heparin continues to be the most effective agent to achieve anticoagulation and protamine the most effective agent to neutralize it. A technique for heparin and protamine dosing with determination of heparin concentrations, may remove many variables associated with pediatric cardiac surgery that requires cardiopulmonary bypass and may provide clinicians with new therapies to achieve better anticoagulation for patients and consequently better outcomes.
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33
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Curi-Curi PJ, Springall del Villar MR, Gómez-García L, González Vergara B, Calderón-Colmenero J, Ramírez-Marroquín S, Cervantes-Salazar JL. Impacto intraoperatorio de la ultrafiltración modificada en pacientes pediátricos sometidos a cirugía cardíaca con circulación extracorpórea. CIRUGIA CARDIOVASCULAR 2016. [DOI: 10.1016/j.circv.2016.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Chew MS, Brix-Christensen V, Ravn HB, Brandslund I, Ditlevsen E, Pedersen J, Hjortholm K, Hansen OK, Tønnesen E, Hjortdal VE. Effect of modified ultrafiltration on the inflammatory response in paediatric open-heart surgery: a prospective, randomized study. Perfusion 2016; 17:327-33. [PMID: 12243435 DOI: 10.1191/0267659102pf595oa] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Modified ultrafiltration (MUF) is often used in conjunction with paediatric cardiac surgery with cardiopulmonary bypass (CPB) and is thought to improve clinical outcome. It is unclear whether these improvements (if any) are due to the removal of inflammatory mediators. In this prospective study, 18 children aged 12-24 months undergoing uncomplicated cardiac surgery with methylprednisolone added in the pump prime were randomized to receive CPB with ( n= 10) and without ( n= 8) MUF. Cytokines (TNFα, IL-6, IL- 1β, IL-10, IL-1ra), complement split products (C3d, C4d) and coagulation system activation (F1+ 2, ATIII) were measured pre-, peri- and up to 48 h postoperatively. For clinical outcome, the alveolar-arterial oxygen (A-a) gradient, transfusion requirement, drain loss, mean blood pressure and requirement for inotropic support were registered up to 24 h postoperatively. Our results show an improvement in postoperative oxygenation as well as a tendency towards decreased drain loss and improved haemodynamics in the MUF group. There were no intergroup differences detectable for TNFα, IL-1β, IL-1ra, complement and coagulation markers. We conclude that MUF in itself does not significantly influence TNFα, IL-1β, IL-1ra and the complement and coagulation profiles in children undergoing cardiac surgerywith CPB. Despite this, there was some evidence for improved clinical outcome. Our results do not support that MUF improves postoperative organ function by modulation of the measured markers of inflammation.
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Affiliation(s)
- Michelle S Chew
- Department of Anaesthesia and Intensive Care, Institute of Experimental Clinical Research, Aarhus University Hospital, Denmark.
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35
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Raja SG, Yousufuddin S, Rasool F, Nubi A, Danton M, Pollock J. Impact of Modified Ultrafiltration on Morbidity after Pediatric Cardiac Surgery. Asian Cardiovasc Thorac Ann 2016; 14:341-50. [PMID: 16868113 DOI: 10.1177/021849230601400417] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Cardiopulmonary bypass is a double-edged sword. Without it, corrective cardiac surgery would not be possible in the majority of children with congenital heart disease. However, much of the perioperative morbidity that occurs after cardiac surgery can be attributed to a large extent to pathophysiologic processes engendered by extracorporeal circulation. One of the challenges that has confronted pediatric cardiac surgeons has been to minimize the consequences of cardiopulmonary bypass. Ultrafiltration is a strategy that has been used for many years in an effort to attenuate the effects of hemodilution that occur when small children undergo surgery with cardiopulmonary bypass. Over the past several years, a modified technique of ultrafiltration, commonly known as modified ultrafiltration, has been used with increasing enthusiasm. Multiple studies have been undertaken to assess the effects of modified ultrafiltration on organ function and postoperative morbidity following repair of congenital heart defects. This review attempts to evaluate current available scientific evidence on the impact of modified ultrafiltration on organ function and morbidity after pediatric cardiac surgery.
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Affiliation(s)
- Shahzad G Raja
- Department of Cardiac Surgery, Royal Hospital for Sick Children, Yorkhill NHS Trust, Dalnair Street, Glasgow G3 8SJ, United Kingdom.
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Abstract
In a prospective randomized study, aprotinin was assessed in cyanotic children with tetralogy of Fallot undergoing total correction utilizing cardiopulmonary bypass. In group A (n = 25), 20,000 kallikrein inhibiting units of aprotinin per kilogram of body weight was administered before cardiopulmonary bypass and the same amount was added to the pump prime. In group B (n = 25), only a single dose of aprotinin was given before cardiopulmonary bypass. Blood loss and blood product requirements were compared with those in a control group of 25 patients who did not receive aprotinin. Blood loss and blood products used in groups A and B did not differ but the control group had significantly more bleeding and transfusion requirements. A single dose of aprotinin before cardiopulmonary bypass is recommended in cyanotic patients undergoing intracardiac repair.
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Brenner MK, Clarke S, Mahnke DK, Simpson P, Bercovitz RS, Tomita-Mitchell A, Mitchell ME, Newman DK. Effect of 22q11.2 deletion on bleeding and transfusion utilization in children with congenital heart disease undergoing cardiac surgery. Pediatr Res 2016; 79:318-24. [PMID: 26492284 PMCID: PMC5114022 DOI: 10.1038/pr.2015.216] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Accepted: 07/31/2015] [Indexed: 01/10/2023]
Abstract
BACKGROUND Postsurgical bleeding causes significant morbidity and mortality in children undergoing surgery for congenital heart defects (CHD). 22q11.2 deletion syndrome (DS) is the second most common genetic risk factor for CHD. The deleted segment of chromosome 22q11.2 encompasses the gene encoding glycoprotein (GP) Ibβ, which is required for expression of the GPIb-V-IX complex on the platelet surface, where it functions as the receptor for von Willebrand factor (VWF). Binding of GPIb-V-IX to VWF is important for platelets to initiate hemostasis. It is not known whether hemizygosity for the gene encoding GPIbβ increases the risk for bleeding following cardiac surgery for patients with 22q11.2 DS. METHODS We performed a case-control study of 91 pediatric patients who underwent cardiac surgery with cardiopulmonary bypass from 2004 to 2012 at Children's Hospital of Wisconsin. RESULTS Patients with 22q11.2 DS had larger platelets and lower platelet counts, bled more excessively, and received more transfusion support with packed red blood cells in the early postoperative period relative to control patients. CONCLUSION Presurgical genetic testing for 22q11.2 DS may help to identify a subset of pediatric cardiac surgery patients who are at increased risk for excessive bleeding and who may require more transfusion support in the postoperative period.
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Affiliation(s)
- Michelle K Brenner
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, Wisconsin
| | - Shanelle Clarke
- Department of Pediatrics, Division of Critical Care and Cardiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Donna K Mahnke
- Department of Surgery, Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Pippa Simpson
- Department of Pediatrics, Division of Quantitative Health Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Rachel S Bercovitz
- Medical Sciences Institute, BloodCenter of Wisconsin, Milwaukee, Wisconsin
| | - Aoy Tomita-Mitchell
- Department of Surgery, Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Michael E Mitchell
- Department of Surgery, Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
- Department of Cardiothoracic Surgery, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Debra K Newman
- Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, Wisconsin
- Department of Pharmacology and Toxicology, Medical College of Wisconsin, Milwaukee, Wisconsin
- Department of Microbiology and Molecular Genetics, Medical College of Wisconsin, Milwaukee, Wisconsin
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Burke CR, McMullan DM. Extracorporeal Life Support for Pediatric Heart Failure. Front Pediatr 2016; 4:115. [PMID: 27812522 PMCID: PMC5071357 DOI: 10.3389/fped.2016.00115] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 10/05/2016] [Indexed: 11/15/2022] Open
Abstract
Extracorporeal life support (ECLS) represents an essential component in the treatment of the pediatric patient with refractory heart failure. Defined as the use of an extracorporeal system to provide cardiopulmonary support, ECLS provides hemodynamic support to facilitate end-organ recovery and can be used as a salvage therapy during acute cardiorespiratory failure. Support strategies employed in pediatric cardiac patients include bridge to recovery, bridge to therapy, and bridge to transplant. Advances in extracorporeal technology and refinements in patient selection have allowed wider application of this therapy in pediatric heart failure patients.
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Affiliation(s)
- Christopher R Burke
- Division of Cardiac Surgery, Seattle Children's Hospital , Seattle, WA , USA
| | - D Michael McMullan
- Division of Cardiac Surgery, Seattle Children's Hospital , Seattle, WA , USA
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Abstract
In pediatric cardiac surgery, there is a substantial gap between published recommendations or guidelines for blood product use and clinical practice. The drawbacks of blood transfusion are well acknowledged though. The aim of this paper is to present the rationale for packed red blood cells, fresh frozen plasma (FFP), and platelets used in pediatric patients. Blood hemoglobin level is the current trigger used for packed red blood cells transfusion, though commonly admitted to be suboptimal. An increase in hemoglobin level is likely to be associated with an increase in blood oxygen content and blood oxygen delivery. However, above a critical level of hemoglobin, normovolemic anemia is well tolerated, and any increase in hemoglobin will fail to increase oxygen consumption and therefore to improve end-organ oxygen supply. FFP is one way to address the coagulation factors deficiency induced by hemodilution, consumption, or hepatic insufficiency. The volume needed to increase these factors is not negligible. To avoid dilution and/or fluid overload, the use of clotting factor concentrate is recommended. The same remark can be made regarding the treatment of antithrombin III deficiency. Platelets infusion should be restricted to bleeding patients with thrombocytopenia and without surgical bleeding. In clinical studies, the prevention of bleeding through prophylactic infusion of platelets proved to be useless. Optimizing the use of blood products (avoiding overuse, underuse, and inappropriate use) is a challenging task in pediatric cardiac surgery. Data or guidelines cannot replace clinical judgment and the decision to transfuse is left to individual discretion, but the medical community needs to optimize its transfusion practice, otherwise policy-makers without similar expertise may step in to regulate the use of blood products.
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Affiliation(s)
- Yves Durandy
- Intensive Care Department, Pediatric Cardiac Surgery, CCML, Le Plessis-Robinson, France; Perfusion Department, Pediatric Cardiac Surgery, CCML, Le Plessis-Robinson, France
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40
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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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Ismail SR, Elbarbary M, Kabbani MS. Successful use of recombinant tissue plasminogen activator (r-TPA) for management of chylothorax associated with central venous thrombosis after neonatal cardiac surgery. Egypt Heart J 2015. [DOI: 10.1016/j.ehj.2015.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Machovec KA, Jooste EH, Walczak RJ, Homi HM, Jaquiss RDB, Lodge AJ, Ames WA. A change in anticoagulation monitoring improves safety, reduces transfusion, and reduces costs in infants on cardiopulmonary bypass. Paediatr Anaesth 2015; 25:580-6. [PMID: 25530420 DOI: 10.1111/pan.12591] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/06/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND An immature coagulation system coupled with the hypothermia and hemodilution associated with cardiopulmonary bypass (CPB) in infants makes the activated clotting time (ACT) an ineffective monitor for anticoagulation in this population. The Medtronic HMS Plus Hemostasis Management System (HMS; Medtronic, Inc., Minneapolis, MN, USA) is shown to decrease thrombin generation and blood product requirements. AIM We conducted a quality improvement initiative to test our hypothesis that the use of HMS results in reduced incidence of subtherapeutic ACT values, blood product usage, and operating room time for infants undergoing cardiac surgery. METHODS Fifty consecutive patients weighing <10 kg having cardiac surgery requiring CPB had anticoagulation managed by the HMS. Data were compared to that of 50 consecutive patients weighing <10 kg having cardiac surgery who had their anticoagulation monitored by the ACT alone. Comparisons between categorical variables were performed with chi-square tests. Comparisons between continuous variables were performed with the Wilcoxon rank-sum test. Statistical significance was defined as two-tailed P value < 0.05. RESULTS The HMS group had a 61% decrease in incidence of ACT values <480 s and elimination of ACT values < 400 s at any time on bypass. The HMS group received fewer blood products and spent fewer minutes in the operating room after protamine administration, translating to fewer donor exposures and a savings of $403 in transfusion costs and $440 in operating room time costs. CONCLUSION Our findings highlight the benefits of individualized heparinization for pediatric patients undergoing CPB with a monitored heparinization system.
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Affiliation(s)
- Kelly A Machovec
- Division of Pediatric Anesthesia, Department of Anesthesiology, Duke University Hospital, Durham, NC, USA
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Mir A, Frank S, Journeycake J, Wolovits J, Guleserian K, Heistein L, Lemler M. Aspirin Resistance in Single-Ventricle Physiology: Aspirin Prophylaxis Is Not Adequate to Inhibit Platelets in the Immediate Postoperative Period. Ann Thorac Surg 2015; 99:2158-64. [DOI: 10.1016/j.athoracsur.2015.02.026] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Revised: 01/27/2015] [Accepted: 02/10/2015] [Indexed: 01/19/2023]
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Lin CY, Shuhaiber JH, Loyola H, Liu H, del Nido P, DiNardo JA, Pigula FA. The safety and efficacy of antifibrinolytic therapy in neonatal cardiac surgery. PLoS One 2015; 10:e0126514. [PMID: 25954976 PMCID: PMC4425500 DOI: 10.1371/journal.pone.0126514] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Accepted: 04/02/2015] [Indexed: 11/27/2022] Open
Abstract
Background Neonates undergoing open-heart surgery are particularly at risk of postoperative bleeding requiring blood transfusion. Aprotinin has attained high efficacy in reducing the requirement for a blood transfusion following a cardiopulmonary bypass, but is seldom studied in the neonatal age group. The aim of this study was to compare the efficacy and adverse effects of aprotinin and tranexamic acid in neonates undergoing open-heart surgery at a single centre. Methods Between October 2003 and March 2008, perioperative data of 552 consecutive neonatal patients undergoing open-heart surgery in Children’s Hospital Boston were reviewed. Among them, 177 did not receive antifibrinolytic therapy (Group A); 100 were treated with tranexamic acid only (Group B); and 275 patients received aprotinin with or without tranexamic acid (Group C). Except for antifibrinolytic therapy, the anaesthesiological and surgical protocols remained identical. Postoperative complications and in-hospital mortality were the primary study endpoints. Results Body weight and Risk Adjustment for Congenital Heart Surgery (RACHS-1) scores were statistically comparable among the three groups. No statistically significant differences were observed between the duration of hospitalization, chest tube drainage, reexploration for bleeding, and kidney function impairment. In Group C, less blood was transfused within 24 hours than in GroupB. Operative mortality was similar among the three groups. Conclusion No further risk and kidney injury were observed in the use of aprotinin in neonatal cardiac surgery, aprotinin demonstrated a reduced requirement for blood transfusion compared with tranexamic acid. Our data provide reasonable evidence that aprotinin and tranexamic acid are safe and efficacious as antifibrinolytic modalities in neonatal patients undergoing cardiac surgery.
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Affiliation(s)
- Chih-Yuan Lin
- Department of Cardiac Surgery, Children’s Hospital Boston, Harvard Medical School, Boston, Massachusetts, United States of America
- Division of Cardiovascular Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Jeffery H. Shuhaiber
- Department of Cardiac Surgery, Children’s Hospital Boston, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Hugo Loyola
- Department of Cardiac Surgery, Children’s Hospital Boston, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Hua Liu
- Department of Cardiac Surgery, Children’s Hospital Boston, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Pedro del Nido
- Department of Cardiac Surgery, Children’s Hospital Boston, Harvard Medical School, Boston, Massachusetts, United States of America
| | - James A. DiNardo
- Department of Anaesthesia, Children’s Hospital Boston, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Frank A. Pigula
- Department of Cardiac Surgery, Children’s Hospital Boston, Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
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Jobes DR, Sesok-Pizzini D, Friedman D. Reduced Transfusion Requirement With Use of Fresh Whole Blood in Pediatric Cardiac Surgical Procedures. Ann Thorac Surg 2015; 99:1706-11. [DOI: 10.1016/j.athoracsur.2014.12.070] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Revised: 12/19/2014] [Accepted: 12/30/2014] [Indexed: 11/29/2022]
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Continuous or discontinuous tranexamic acid effectively inhibits fibrinolysis in children undergoing cardiac surgery with cardiopulmonary bypass. Blood Coagul Fibrinolysis 2015; 25:259-65. [PMID: 24418941 DOI: 10.1097/mbc.0000000000000051] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Tranexamic acid is given continuously or discontinuously as an anti-fibrinolytic therapy during cardiac surgery, but the effects on fibrinolysis parameters remain poorly investigated. We sought to assess the effects of continuous and discontinuous tranexamic acid on fibrinolysis parameters in children undergoing cardiac surgery with cardiopulmonary bypass (CPB). Children requiring cardiac surgery or repeat surgery by sternotomy with CPB for congenital heart disease were randomized to receive either continuous or discontinuous tranexamic acid. Blood tranexamic acid, D-dimers, tissue plasminogen activator (tPA), tPA-plasminogen activator inhibitor 1 (tPA-PAI1) complexes, fibrinogen and fibrin monomers were measured and compared to values obtained from children who did not receive tranexamic acid. Tranexamic acid inhibited the CPB-induced increase in D-dimers, with a similar potency between continuous and discontinuous regimens. Time courses for tPA, fibrin monomers, and fibrinogen were also similar for both regimen, and there was a significant difference in tPA-PAI1 complex concentrations at the end of surgery, which may be related to a significantly higher tranexamic acid concentration. Continuous and discontinuous regimen are suitable for an effective inhibition of fibrinolysis in children undergoing cardiac surgery with CPB, but the continuous regimen was previously shown to be more effective to maintain stable tranexamic acid concentrations.
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Nakayama Y, Nakajima Y, Tanaka K, Sessler D, Maeda S, Iida J, Ogawa S, Mizobe T. Thromboelastometry-guided intraoperative haemostatic management reduces bleeding and red cell transfusion after paediatric cardiac surgery. Br J Anaesth 2015; 114:91-102. [DOI: 10.1093/bja/aeu339] [Citation(s) in RCA: 117] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Wolf MJ, Maher KO, Kanter KR, Kogon BE, Guzzetta NA, Mahle WT. Early postoperative bleeding is independently associated with increased surgical mortality in infants after cardiopulmonary bypass. J Thorac Cardiovasc Surg 2014; 148:631-6.e1. [DOI: 10.1016/j.jtcvs.2013.10.050] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2013] [Revised: 09/12/2013] [Accepted: 10/29/2013] [Indexed: 12/18/2022]
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Limitations of early serum creatinine variations for the assessment of kidney injury in neonates and infants with cardiac surgery. PLoS One 2013; 8:e79308. [PMID: 24244476 PMCID: PMC3823616 DOI: 10.1371/journal.pone.0079308] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Accepted: 09/23/2013] [Indexed: 01/11/2023] Open
Abstract
Background Changes in kidney function, as assessed by early and even small variations in serum creatinine (ΔsCr), affect survival in adults following cardiac surgery but such associations have not been reported in infants. This raises the question of the adequate assessment of kidney function by early ΔsCr in infants undergoing cardiac surgery. Methodology The ability of ΔsCr within 2 days of surgery to assess the severity of kidney injury, accounted for by the risk of 30-day mortality, was explored retrospectively in 1019 consecutive neonates and infants. Patients aged ≤ 10 days were analyzed separately because of the physiological improvement in glomerular filtration early after birth. The Kml algorithm, an implementation of k-means for longitudinal data, was used to describe creatinine kinetics, and the receiver operating characteristic and the reclassification methodology to assess discrimination and the predictive ability of the risk of death. Results Three clusters of ΔsCr were identified: in 50% of all patients creatinine decreased, in 41.4% it increased slightly, and in 8.6% it rose abruptly. Mortality rates were not significantly different between the first and second clusters, 1.6% [0.0–4.1] vs 5.9% [1.9–10.9], respectively, in patients aged ≤ 10 days, and 1.6% [0.5–3.0] vs 3.8% [1.9–6.0] in older ones. Mortality rates were significantly higher when creatinine rose abruptly, 30.3% [15.1–46.2] in patients aged ≤ 10 days, and 15.1% [5.9–25.5] in older ones. However, only 41.3% of all patients who died had an abrupt increase in creatinine. ΔsCr improved prediction in survivors, but not in patients who died, and did not improve discrimination over a clinical mortality model. Conclusions The present results suggest that a postoperative decrease in creatinine represents the normal course in neonates and infants with cardiac surgery, and that early creatinine variations lack sensitivity for the assessment of the severity of kidney injury.
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