Transfusion Strategies for Pediatric Cardiac Surgery: A Meta-Analysis and Trial Sequential Analysis

Abstract

This study aimed to compare the effects of restrictive and liberal red blood cell (RBC) transfusion strategies on pediatric patients undergoing cardiac surgery, including cyanotic and non-cyanotic children. A literature search of the MEDLINE, EMBASE, PubMed, and the Cochrane Library database was conducted. Meta-analyses were carried out comparing restrictive and liberal transfusion strategies. Subgroup analyses were performed based on the basis of cyanotic status. Five randomized controlled trials with a total of 497 children were included. There was no significant difference in the risk of in-hospital mortality between the two transfusion strategies (risk ratio 1.21; 95% confidence interval 0.49 to 2.99; P = 0.68). The trial sequential analysis suggested that the current meta-analysis had an absence of evidence for in-hospital mortality, and the data were insufficient. Moreover, no significant differences existed between groups in terms of risk of infection, blood loss, duration of mechanical ventilation, pediatric intensive care unit (PICU) stay duration, or hospital stay duration. Cyanotic children treated with a liberal transfusion strategy had a shorter ventilator duration, but the transfusion strategy did not affect in-hospital mortality, infection, hospital stay, or PICU stay duration. On the basis of the available data, our analysis indicates that a liberal transfusion strategy did not lead to a better outcomes, but the data are extremely sparse, which highlights the need for clearer transfusion guidelines specific to this specific population. Trial registration number CRD42018102283.

Current hemoglobin thresholds in pediatric anesthesia - guidelines and studies

“…No clinical trials investigating the impact of Hb triggers on clinical outcome in pediatric cardiac surgery have been published in the past 18 months. However, a recent meta-analysis [8] analyzed four older randomized controlled trials (RCTs) [9][10][11][12] and one abstract involving a total of 497 cyanotic and noncyanotic children on the effects of restrictive and liberal RBC transfusion strategies in pediatric patients undergoing cardiac surgery. Only one of these RCTs [9] compared perioperative thresholds, whereas the remaining three RCTs [10][11][12] and the abstract examined postoperative thresholds.…”

Analysis of haemodynamics surrounding blood transfusions after the arterial switch operation: a pilot study utilising real-time telemetry high-frequency data capture

“…10,14,15 However, two subsequent meta-analyses comparing "restrictive" and "liberal" packed red blood cell transfusion strategies during paediatric cardiac surgery found no significant difference in risk of in-hospital mortality, infection, blood loss, duration of mechanical ventilation, or length of stay. 16,17 Furthermore, subgroup analysis of patients with cyanotic CHD treated with "liberal" transfusion strategy demonstrated a significantly shorter duration of post-operative mechanical ventilation. 16 Regarding efficacy, outcome measures focusing on oxygen delivery biomarkers such as lactate and mixed venous oxygen saturation (SvO 2 ) have failed to find consistent benefit from packed red blood cell transfusion transfusion after paediatric cardiac surgery.…”

“…16,17 Furthermore, subgroup analysis of patients with cyanotic CHD treated with "liberal" transfusion strategy demonstrated a significantly shorter duration of post-operative mechanical ventilation. 16 Regarding efficacy, outcome measures focusing on oxygen delivery biomarkers such as lactate and mixed venous oxygen saturation (SvO 2 ) have failed to find consistent benefit from packed red blood cell transfusion transfusion after paediatric cardiac surgery. Reasons for this are likely multifactorial, including high baseline Hb levels at time of transfusion and failing to account for the concomitant effects supplemental oxygen, mechanical ventilation, vasoactive support, analgesics, and neuromuscular blockade have on overall oxygen balance.…”

Analysis of Hemodynamics During Blood Transfusion Utilizing High-Fidelity Realtime Telemetry After the Arterial Switch Operation

“…While they recommended considering the overall clinical context and not exclusively hemoglobin concentration, no speci c hemodynamic parameters were outlined or recommended 5 . Other publications investigating hemodynamic changes are limited to retrospective studies of hourly vital signs and binary pre/post-pRBCTx data variables, which are prone to errors, omissions, and outliers 1,[6][7][8][9][10][11] . With Sickbay™ (Medical Informatics Corp, Houston, TX), a surveillance and analytics platform that collects high-delity, continuous hemodynamic data from routinely-used bedside devices 12 , we can analyze second-to-second changes in vital signs.…”