Bloodless priming of the cardiopulmonary bypass circuit: determinants of successful transfusion-free operation in neonates and infants with a maximum body weight of 7 kg

Abstract

We currently perform open-heart procedures using bloodless priming of cardiopulmonary bypass circuits regardless of a patient's body weight. This study presents results of this blood-saving approach in neonates and infants with a body weight of up to 7 kg. It tests with multivariate analysis factors that affect perioperative transfusion. A total of 498 open-heart procedures were carried out in the period 2014-2016 and were analysed. Priming volume ranged from 73 ml for patients weighing up to 2.5 kg to 110 ml for those weighing over 5 kg. Transfusion threshold during cardiopulmonary bypass was 8 g/dl of haemoglobin concentration. Transfusion factors were first analysed individually. Variables with a p-value lower than 0.2 underwent logistic regression. Extracorporeal circulation was conducted without transfusion of blood in 335 procedures - that is, 67% of cases. Transfusion-free operation was achieved in 136 patients (27%) and was more frequently observed after arterial switch operation and ventricular septal defect repair (12/18=66.7%). It was never observed after Norwood procedure (0/33=0%). Lower mortality score (p=0.001), anaesthesia provided by a certain physician (p=0.006), first chest entry (p=0.013), and higher haemoglobin concentration before going on bypass (p=0.013) supported transfusion-free operation. Early postoperative mortality was 4.4% (22/498). It was lower than expected (6.4%: 32/498). In conclusion, by adjusting the circuit, cardiopulmonary bypass could be conducted without donor blood in majority of patients, regardless of body weight. Transfusion-free open-heart surgery in neonates and infants requires team cooperation. It was more often achieved in procedures with lower mortality score.

Asanguineous Cardiopulmonary Bypass in Infants: Impact on Postoperative Mortality and Morbidity

“…These have to be accepted by the whole operation team to become effective. In particular, adherence of the anesthetic team is crucial as outlined by Wloch et al 1 Currently, the vast majority of pediatric cardiac surgical units usually add homologous blood in the CPB circuit before starting the extracorporeal circulation in low-weight patients. 18 Our message is that it is worth to commit oneself to a bloodless CPB course, as this strategy is prone to improve outcome, in particular to reduce postoperative mortality (up to 10 times in this series).…”

“…We utilized Sorin Dideco D100 and Terumo Capiox oxygenators and tubings with 1/8-3/16 inner diameters. Details of weight-adjusted CPB circuit are provided by Wloch et al 1 The CPB console was positioned as close as possible to the sterile field and tubings were cut as short as possible.…”

“…Any major decline of regional oxygen saturation was responded to, first by controlling correct position of venous and arterial cannulas, by augmenting the extracorporeal circulation flow rate and, only if these interventions were insufficient, by adding donor blood to the bypass circuit. 1 In cases of palliative surgery with ongoing cyanosis, the minimal target Hb for weaning from CPB was 13 g/dL.…”

“…It has been deemed, for a long time, indispensable in newborns and low-weight patients, to fill CPB circuit with homologous blood to avoid excessive hemodilution at the beginning of the extracorporeal circulation. As recently reported, 1 we currently perform all open-heart procedures using priming solutions without donor blood for all patients, even in those weighing less than 2.5 kg. 2 We try to postpone inevitable transfusion toward after coming off bypass.…”

Cardiopulmonary Bypass Strategy to Facilitate Transfusion-Free Congenital Heart Surgery in Neonates and Infants

“…Before operation, unnecessary blood sampling due to routine medical standards should be avoided. 28 Medication leading to vasoplegia triggers the need for fluid application to counteract the resulting hypotension, tachycardia, and low cardiac output. Continuous application of vasodilating drugs leads to more amount of fluid administration.…”