Intraoperative blood product transfusion in pediatric cardiac surgery patients: A retrospective review of adverse outcomes

Abstract

Background:Resuscitation with blood products is often required for pediatric cardiac surgery patients following cardiopulmonary bypass. However, data suggest that blood product transfusion is an independent predictor of adverse outcomes. Most studies have specifically found detrimental effects of overall transfusion of red blood cells in particular, but few have analyzed outcomes by the other specific blood product components. Aims:The objective of this study is to analyze adverse outcomes associated with intraoperative transfusion of specific blood product components. Methods:A retrospective review was performed on 643 pediatric patients who underwent cardiac surgery requiring cardiopulmonary bypass to evaluate the risk of selected adverse outcomes associated with intraoperative blood product transfusion. Adverse outcomes included thrombotic complications, stroke, acute kidney injury, prolonged mechanical ventilation, and death. Univariate logistic and linear regression analyses were performed to explore the association between various blood products and the occurrence of postoperative complications.Multiple logistic and linear regression analyses were performed adjusting for age, cyanotic status, The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Score (STAT score), and cardiopulmonary bypass time.Results: Unadjusted analysis using univariate logistic and linear regressions showed statistically significant associations of almost all blood components (per 10 mL/kg dose increments) with multiple postoperative complications, including mortality, thrombotic complications, stroke, and days of mechanical ventilation. After adjusting for patient age, cyanotic status, STAT score, and cardiopulmonary bypass time, multivariable logistic and linear regression analyses revealed no association between transfusion of blood products with acute kidney injury and stroke. Administration of red blood cells was the only category significantly correlated with increased days of mechanical ventilation (0.5 days increase in mechanical ventilation per 10 mL/kg transfusion of red blood cells). The only blood product to show complete lack of a statistically significant association with any of the studied outcomes was cryoprecipitate. Conclusions:Transfusion of blood products following cardiopulmonary bypass is associated with postoperative adverse outcomes. Future studies aimed at strategies to reduce intraoperative bleeding and decrease the amount of blood products administered are warranted.

Reply

“…Our final paragraph concludes that "there are significant postoperative adverse outcomes associated with intraoperative administration of all blood products," and the goal for anesthesiologists should be to find strategies to reduce amounts of blood products transfused. 1 However, in our retrospective review, we were unable to find any statistically significant associations between cryoprecipitate and our selected adverse outcomes after adjusted multivariate analysis. This finding, along with the mortality benefit of cryoprecipitate and platelets found by…”

“…Butt, et al for their knowledgeable comments regarding our study, "Intraoperative blood product transfusion in pediatric cardiac surgery patients: A retrospective review of adverse outcomes." 1 This further commentary regarding our study shows the pediatric cardiac anesthesiology community's commitment to better understanding the multifactorial coagulopathy following cardiopulmonary bypass and to developing strategies to reduce adverse outcomes for our patients. In our response below, we hope to address some of the analytical concerns raised by Dr.…”

Circulation, far from an innocent bystander in pediatric cardiac surgical research

“…To the Editor, Busack et al 1 are congratulated for their research report featuring a diligent retrospective review of adverse outcomes following intraoperative blood transfusion in a pediatric cardiac surgical cohort. While the merit of investigating the links between transfusion practices and post-cardiotomy outcomes is undeniable, there remain additional points in the matter necessitating deliberation.…”

“…First, the tissue oxygen delivery (DO 2 ) is, in addition to the oxygen carrying capacity of the blood, fundamentally affected by cardiac output (CO), where DO 2 = CO × ([Hemoglobin × arterial oxygen saturation × 1.34] + [partial pressure of oxygen in the arterial blood × 0.003]). 2 Withstanding, the lack of account of postoperative low cardiac output syndrome (LCOS) in the Busack et al 1 analysis focusing morbid end-organ outcomes deserves attention. A recent meta-analysis by Wang et al outlined an overall 13.95% incidence of postoperative LCOS in 12 048 patients from a total of 18 (11 prospective and 7 retrospective) pediatric cardiac surgical studies.…”

“…6 Finally, alongside the role of circulatory disturbances in modulating pediatric cardiac surgical outcomes, details on the use of modified ultrafiltration are particularly important to consider in the context of the modern-day conduct of pediatric cardiac anesthesia. 1,7…”