The Use of Hemostatic Blood Products in Children Following Cardiopulmonary Bypass and Associated Outcomes

Abstract

Objectives: To describe the use of hemostatic transfusions in children following cardiac surgery with cardiopulmonary bypass and the association of hemostatic transfusions postoperatively with clinical outcomes. Design: A retrospective cohort study. Setting: PICU of a tertiary care center from 2011 to 2017. Patients: Children 0–18 years old undergoing cardiac surgery with cardiopulmonary bypass. Interventions: None. Measurements and Main Results: Four-hundred twenty children underwent cardiac surgery with cardiopulmonary bypass. The median (interquartile range) age was 0.8 years (0.3–5 yr) and 243 (58%) were male. The majority of cases were classified as Risk Adjustment for Congenital Heart Surgery 2 (223, 54%) or Risk Adjustment for Congenital Heart Surgery 3 (124, 30%). Twenty-four percent of children (102/420) received at least one hemostatic transfusion with the most common first product being platelet transfusions (47/102), followed by plasma (44/102), and cryoprecipitate (11/102). The children who received hemostatic transfusions were younger ( p = 0.006), had lower body weights ( p = 0.004), less likely to be their initial operation with cardiopulmonary bypass ( p = 0.003), underwent more complex surgeries ( p = 0.001) with longer bypass runs ( p < 0.001), and had more use of hypothermic circulatory arrest ( p = 0.014). The receipt of hemostatic blood products postoperatively was independently associated with more days of mechanical ventilation ( p < 0.001) and longer PICU lengths of stay ( p = 0.001) but not with time receiving vasoactive mediations ( p = 0.113) or nosocomial infections ( p = 0.299). Conclusions: Nearly one-quarter of children undergoing cardiac repair with cardiopulmonary bypass receive hemostatic transfusions postoperatively. These blood products are independently associated with worse clinical outcomes. Larger studies should be performed to determine the hemostatic efficacy of these products, as well as to clarify associated morbidities, in order to inform proper blood management.

Transfusion Strategies for Hemostatic Blood Products in Critically Ill Children: A Narrative Review and Update on Expert Consensus Guidelines

“…Literature indicates that transfusion of hemostatic blood products in pediatric cardiac surgery is associated with worse clinical outcomes. [106][107][108] Complexity of cardiac morphology, surgical procedure, patient comorbid condition, CPB strategy, and perioperative management complicate trial design and limit adoption of single-center experiences broadly.…”

Bleeding in Critically Ill Children—Review of Literature, Knowledge Gaps, and Suggestions for Future Investigation

“…Post-operative bleeding is a common complication in pediatric patients undergoing cardiopulmonary bypass (CPB) and is associated with increased morbidity and mortality ( 46 – 48 ). The receipt of post-operative blood products is independently associated with longer lengths of mechanical ventilation and length of PICU stay ( 49 ). Post-operative bleeding may be predicted by several factors including thrombocytopenia and hypofibrinogenemia ( 6 , 8 ).…”

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

“…Coagulopathy occurs for multiple reasons including, but not limited to, the necessary anticoagulation for the bypass circuit, inflammatory response to foreign bypass cannulas, mechanical destruction of clotting factors from the pump, hemodilution, and induced hypothermia. 1 Recent investigations suggest that blood product transfusion represents an independent predictor of adverse outcomes. [2][3][4][5][6] Reported adverse outcomes include lung injury, renal failure, low cardiac output, thrombotic complications, prolonged hospital stay, infections, and increased mortality.…”