Association of Blood Products Administration During Cardiopulmonary Bypass and Excessive Post-operative Bleeding in Pediatric Cardiac Surgery

Abstract

Our objectives were to study risk factors and post-operative outcomes associated with excessive post-operative bleeding in pediatric cardiac surgeries performed using cardiopulmonary bypass (CPB) support. A retrospective observational study was undertaken, and all consecutive pediatric heart surgeries over 1 year period were studied. Excessive post-operative bleeding was defined as 10 ml/kg/h of chest tube output for 1 h or 5 ml/kg/h for three consecutive hours in the first 12 h of pediatric cardiac intensive care unit (PCICU) stay. Risk factors including demographics, complexity of cardiac defect, CPB parameters, hematological studies, and post-operative morbidity and mortality were evaluated for excessive bleeding. 253 patients were studied, and 107 (42 %) met the criteria for excessive bleeding. Bayesian model averaging revealed that greater volume of blood products transfusion during CPB was significantly associated with excessive bleeding. Multiple logistic regression analysis of blood products transfusion revealed that increased volume of packed red blood cells (PRBCs) administration for CPB prime and during CPB was significantly associated with excessive bleeding (p = 0.028 and p = 0.0012, respectively). Proportional odds logistic regression revealed that excessive bleeding was associated with greater time to achieve negative fluid balance, prolonged mechanical ventilation, and duration of PCICU stay (p < 0.001) after adjusting for multiple parameters. A greater volume of blood products administration, especially PRBCs transfusion for CPB prime, and during the CPB period is associated with excessive post-operative bleeding. Excessive bleeding is associated with worse post-operative outcomes.

Effect of 22q11.2 deletion on bleeding and transfusion utilization in children with congenital heart disease undergoing cardiac surgery

“…Numerous factors have previously been shown to contribute to the need for transfusion support and/or incidence of significant bleeding in these children. These factors include conditions associated with CPB, such as contact of blood with the artificial surfaces of the bypass unit (34), hemodilution of platelets and coagulation factors (7,33,35,36), hypothermia induced during surgery (33,37), and length of time on bypass (33,37). Patient-specific factors such as age and weight have also been found to contribute to bleeding in children following cardiac surgery (33,37).…”

“…These factors include conditions associated with CPB, such as contact of blood with the artificial surfaces of the bypass unit (34), hemodilution of platelets and coagulation factors (7,33,35,36), hypothermia induced during surgery (33,37), and length of time on bypass (33,37). Patient-specific factors such as age and weight have also been found to contribute to bleeding in children following cardiac surgery (33,37). The case-control design of this study, which enabled patients with 22q11.2 DS to be matched with control patients on the basis of age, cardiac anatomy, and surgical procedure, eradicated significant differences between patient populations with respect to weight, volume of blood products used to prime the bypass pump (which determines the extent of hemodilution), the lowest temperature achieved during surgery, and the length of time on bypass.…”

Intraoperative Red Blood Cell Transfusion in Infant Heart Transplant Patients Is Not Associated with Worsened Outcomes

“…excessive postoperative bleeding and worsened outcomes following pediatric cardiac surgery. 25 Those investigators reported notable risk factors for excessive postoperative bleeding included age and weight. Those with excessive bleeding averaged 138 days age and 5.3 kg weight compared to 657 days and 10.3 kg weight in those without excessive bleeding.…”

“…Those with excessive bleeding averaged 138 days age and 5.3 kg weight compared to 657 days and 10.3 kg weight in those without excessive bleeding. 25 Similarly, infants that required intraoperative and postoperative transfusions despite undergoing a bloodsparing approach to pediatric cardiac surgery had worsened outcomes (increased ventilator days and ICU LOS) compared with non-transfused infants. 26,27 However, considering the uniform intraoperative transfusion protocol and maximal blood-sparing approach (including miniaturized CPB circuit down to 95 ml priming volume), it is possible that the need for RBC transfusion is a marker for rather than the cause of patient morbidity.…”

Audit of transfusion of blood products in paediatric congenital heart surgery on cardiopulmonary bypass

“…5 In paediatric cardiac surgery on CPB, transfusion of blood products has been associated with cardiovascular instability, acute kidney injury, 6 delayed extubation time, 7 prolonged mechanical ventilation, infection, 6,8,9 and increased risk of postoperative bleeding. 10 The World Health Organisation (WHO) recommends the provision of disease-free blood products, and promotion of appropriate usage of blood products by healthcare providers. 11 The implementation of blood-conservation strategies to reduce rates of transfusion of blood products in paediatric cardiac surgery is recognised by the WHO.…”