Red Blood Cell Transfusion and Adverse Outcomes in Pediatric Cardiac Surgery Patients: Where Does the Blame Lie?

Abstract

GLOSSARYCCAS = Congenital Cardiac Anesthesia Society; CHSD = Congenital Heart Surgery Database; CPB = cardiopulmonary bypass; DO 2 = oxygen delivery; RBC = red blood cell; STS = Society of Thoracic Surgeons; VO 2 = oxygen consumption P ediatric cardiac patients undergoing cardiac surgery are frequently exposed to red blood cell (RBC) transfusions. Transfusions are usually added into the cardiopulmonary bypass (CPB) to avoid prime-induced hemodilution and are commonly administered after CPB in the context of excessive blood loss or to optimize hemoglobin delivery to vital organs. Although studies have shown that liberal transfusions are not superior to restrictive transfusions in children with cyanotic and noncyanotic heart diseases, 1,2 liberal transfusion strategies are commonly used in the perioperative period of pediatric cardiac surgery despite the published recommendations. 3,4 In this issue of Anesthesia & Analgesia, Long et al 5 published the results of an analysis of the Society of Thoracic Surgeons (STS) and Congenital Cardiac Anesthesia Society (CCAS) database in which the association between postcardiac surgery hematocrit values and postoperative complications or mortality in pediatric cardiac surgical patients was examined. The authors performed a retrospective analysis of data included in the STS-CHSD

Preparing small‐dose red cell concentrates (RCCs) for neonatal and pediatric transfusions: Impact of RCC volume, storage, and irradiation

“…14 Robust randomized controlled trials (RCTs) or retrospective studies that are not confounded by the variations in patient age (0-6 years), disease, or transfused blood volumes, like many prior studies of this nature, are warranted. [14][15][16] It is essential that the "evidence-base" be improved to support all pediatric/neonate-specific practices implemented in blood banks.…”

“…This issue is not specific to RCCs as extensive variability also exists in the preparation and processing of platelet and plasma products for pediatric/neonatal transfusions 14 . Robust randomized controlled trials (RCTs) or retrospective studies that are not confounded by the variations in patient age (0–6 years), disease, or transfused blood volumes, like many prior studies of this nature, are warranted 14–16 . It is essential that the “evidence‐base” be improved to support all pediatric/neonate‐specific practices implemented in blood banks.…”

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

“…A goal-directed erythrocyte transfusion strategy targeting specific physiologic parameters may be a more appropriate approach to transfusion than a specific hemoglobin target. 66 However, without high-quality outcome data on physiologic transfusion thresholds, expert consensus recommends a restrictive approach to transfusion in cardiac children. Current expert consensus recommends a postoperative hemoglobin transfusion threshold in stable, acyanotic cardiac patients with hemoglobin levels greater than 7.0 or 8.0 g/dL in the presence of signs of symptomatic anemia (grade IB evidence).…”

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

“…11 The optimal treatment approach for post-CPB coagulopathy is still debated despite multiple studies. [11][12][13] Many authors have investigated the correlation between postoperative extracardiac complications and total intraoperative blood products, but few have analyzed these correlations by specific blood product type. The largest study to examine specific blood products analyzed retrospective data from 1631 pediatric patients and found RBC transfusion to be associated with postoperative renal failure, fresh frozen plasma (FFP) transfusion to be associated with postoperative respiratory failure, and platelet transfusion to be associated with decreased 30-day mortality.…”

“…The optimal treatment approach for post‐CPB coagulopathy is still debated despite multiple studies 11–13 . Many authors have investigated the correlation between postoperative extracardiac complications and total intraoperative blood products, but few have analyzed these correlations by specific blood product type.…”