Perioperative Pediatric Erythrocyte Transfusions: Incorporating Hemoglobin Thresholds and Physiologic Parameters in Decision-making

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.

Section: Discussionmentioning

confidence: 48%

Section: Con Clus Ionsmentioning

confidence: 68%

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

Busack¹,

Rana²,

Beidas

et al. 2023

“…Increased use of POC testing such as VET may also aid in intraoperative hemostatic management decisions. Other evolving tools for continuous PBM monitoring include noninvasive hemoglobin monitoring, somatic end organ near infrared spectrometry (to monitor end organ oxygen supply, demand, and saturation), and continuous base deficit and lactate monitors 42 …”

Section: Discussionmentioning

confidence: 99%

Perioperative management of pediatric patients undergoing juvenile angiofibroma resection. A case series and educational review highlighting patient blood management

Longacre

Seshadri

Adil

et al. 2023

Background: Juvenile nasopharyngeal angiofibromas are one of the most enigmatic, bloody tumors encountered by otorhinolarygnologists, head and neck surgeons, neurosurgeons, and anesthesiologists. Juvenile nasopharyngeal angiofibromas are rare, benign, highly vascular tumors with a propensity towards aggressive local invasion. Surgery, open or endoscopic, to remove the growth is the primary treatment of choice for Juvenile nasopharyngeal angiofibromas. Historically, surgical resection was associated with massive, rapid blood loss, traditionally managed by blood product transfusion and deliberate hypotension. Preventative management employing multimodal blood conservation strategies should be an essential standard of perioperative care for patients with Juvenile nasopharyngeal angiofibromas. Methods:We describe a contemporary and comprehensive approach in the management of patients with high grade Juvenile nasopharyngeal angiofibromas. This includes surgical strategies such as preemptive external carotid artery embolization, endoscopic surgical approach, and staged operations, as well as anesthetic strategies including antifibrinolytic therapy and acute normovolemic hemodilution. These surgeries, once synonymous with massive transfusion, may potentially be performed without allogeneic blood transfusion, or deliberate hypotension.Aims: Using a case series, the authors introduce a contemporary approach to multimodal, multidisciplinary blood conservation strategies for Juvenile nasopharyngeal angiofibromas surgery. Results:Here in the authors report on an updated contemporary perioperative clinical approach to patients with Juvenile nasopharyngeal angiofibromas. From an anesthetic perspective, we describe the successful use of normal hemodynamic goals, restrictive transfusion strategy, antifibrinolytic therapy, autologous normovolemic hemodilution, and early extubation in the care of three adolescent males with highly invasive tumors. We demonstrate that new surgical and anesthetic strategies have yielded a significant decrease in intraoperative blood loss and eliminated the need for transfusion of autologous red blood cells, which enable improved outcomes. Conclusions:The perioperative approach to elective surgery for Juvenile nasopharyngeal angiofibromas management is presented from a multidisciplinary patient blood management perspective.

“…However, the solution lies not in a Hb number but in incorporating recommended restrictive hemoglobin transfusion thresholds with emerging data on physiologic parameters to define optimal decision‐making strategies for perioperative erythrocyte transfusions 60 . Choosing Wisely Pediatric and Neonatal Medicine recommends: “Avoid dependence on standard laboratory values for transfusion decisions; Consideration of the patient's clinical status is requisite.” 12 As such a novel individualized goal‐directed approach harnessing real‐time physiological parameters has been suggested.…”

Section: Error Trap 5: Failure To Prevent Unnecessary Transfusion And...mentioning

confidence: 99%

Error traps in Pediatric Patient Blood Management in the Perioperative Period

Tan

Murto

Downey

et al. 2023

Self Cite

Pediatric patients with severe anemia, coagulopathy or clinically significant blood loss are frequently encountered in the perioperative environment. Appropriate management is most effective and safest when harnessing the patient's own hematopoietic system if time permits. In some situations, allogeneic blood component transfusion is necessary to preserve limb and/or life. While necessary to treat anemia, clotting disorders, or improve oxygen delivery, allogeneic blood transfusions can place pediatric patients at risk for respiratory complications, infection, alloimmunization, prolonged hospital stays, multi-organ failure, and death. 1 Therefore, finding ways to reduce unnecessary allogeneic blood transfusions may improve pediatric patient outcomes.Patient Blood Management (PBM) is a patient-centered, systematic, evidence-based approach to improve patient outcomes by managing and preserving the patient's own blood, while promoting patient safety and empowerment. 2 In adult surgical patients, PBM has reduced overall transfusions, hospital costs, and adverse events.PBM is a new standard of care to optimize blood health. 3 This report focuses on providing insight and guidance to the pediatric anesthesiologists regarding evidence-based recommended clinical care considerations for pediatric PBM (pPBM).