Early postoperative bleeding is independently associated with increased surgical mortality in infants after cardiopulmonary bypass

Wolf, Michael; Maher, Kevin; Kanter, Kirk R.; Kogon, Brian; Guzzetta, Nina A.; Mahle, William T.

doi:10.1016/j.jtcvs.2013.10.050

Cited by 40 publications

(20 citation statements)

References 30 publications

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“…In these patients, bleeding is currently addressed through the transfusion of adult blood products, including platelets and cryoprecipitate (fibrinogen component), and multiple transfusions are often required to restore hemostasis. However, transfusion of allogeneic blood products is associated with substantial morbidity and mortality . Moreover, our recent studies show that neonatal and adult fibrin networks are structurally distinct and do not fully integrate with each other, resulting in an incomplete fibrin matrix structure .…”

Section: Introductionmentioning

confidence: 88%

Analysis of the structural and mechanical effects of procoagulant agents on neonatal fibrin networks following cardiopulmonary bypass

Nellenbach

Guzzetta

Brown

2018

Journal of Thrombosis and Haemostasis

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To cite this article: Nellenbach K, Guzzetta NA, Brown AC. Analysis of the structural and mechanical effects of procoagulant agents on neonatal fibrin networks following cardiopulmonary bypass. J Thromb Haemost 2018; 16: 2159-67. Essentials• The standard of care (SOC) for treating neonatal bleeding is transfusion of adult blood products. • We compared neonatal clots formed with cryoprecipitate (SOC) to two procoagulant therapies. • The current SOC resulted in clots with increased stiffness and decreased fibrinolytic properties. • Procoagulant therapies may be a viable alternative to SOC treatment for neonatal bleeding.Summary. Background: Bleeding is a serious complication of neonates undergoing cardiopulmonary bypass (CPB) and associated with substantial morbidity and mortality. Bleeding is addressed through the transfusion of adult blood products, including platelets and cryoprecipitate. However, significant differences exist between neonatal and adult clotting components, specifically fibrinogen. Our recent ex vivo studies have shown that neonatal fibrinogen does not fully integrate with adult fibrinogen, leading to decreased susceptibility to fibrinolysis. These differences may contribute to ineffective clot formation and/or an increased risk of thrombosis. A need exists to identify more effective and safer methods to promote clotting in neonates. Objectives: Procoagulant agents, such as prothrombin complex concentrates (PCCs) and recombinant activated factor VII (rFVIIa), are being used off-label to treat excessive bleeding in neonates after CPB. Because these agents stimulate endogenous fibrin formation, we hypothesize that their addition to post-CPB neonatal plasma will better recapitulate native clot properties than cryoprecipitate. Methods: We analyze the structural, mechanical and degradation properties of fibrin matrices formed by neonatal plasma collected after CPB in the presence of an activated four-factor (F) PCC (FEIBA), rFVIIa, or cryoprecipitate using confocal microscopy, atomic force microscopy and a fluidics-based degradation assay. Results: The ex vivo addition of FEIBA and rFVIIa to post-CPB neonatal plasma resulted in enhanced clot networks with differences in fibrin alignment, mechanics and degradation properties. Conclusions: Our results suggest that these procoagulant agents could be used as an alternative to the transfusion of adult fibrinogen for the treatment of bleeding after CPB in neonates.

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Section: Introductionmentioning

confidence: 88%

Analysis of the structural and mechanical effects of procoagulant agents on neonatal fibrin networks following cardiopulmonary bypass

Nellenbach

Guzzetta

Brown

2018

Journal of Thrombosis and Haemostasis

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“…The etiology is often multifactorial and includes prior congenital heart surgery requiring extensive dissection, aggressive anticoagulation, and antiplatelet use while on VAD, coagulopathy of CPB, and poor preoperative nutritional status. Early post‐CPB bleeding is more common in pediatric patients compared to adults and is associated with increased morbidity and mortality .…”

Section: Pediatric Heart Transplantationmentioning

confidence: 99%

Pediatric transplantation: managing bleeding

Raffini

Witmer

2015

Journal of Thrombosis and Haemostasis

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Summary. There has been extraordinary progress over the last half-century in the field of medical transplantation in which tissue, organs, or body parts from one human are placed into another. Solid organ transplants have allowed thousands of children with otherwise devastating inherited or acquired disorders to survive. Depending upon the clinical situation, there are many specific peri-transplant issues that must be carefully addressed to optimize outcomes. Although surgical, immunologic, and infectious concerns are usually in the forefront, important aspects regarding hemostasis frequently arise. The number of solid organs that can be successfully transplanted in children has expanded over the last decades and includes kidney, liver, heart, lung, intestine, pancreas, and thymus. Bleeding complications may occur in the setting of organ failure prior to transplantation, during the surgical procedure, or in the post-transplant setting, and can results in significant morbidity. This report will focus on preventing and managing non-surgical-related bleeding complications in children undergoing liver, heart, kidney transplantation, in whom there are often unique aspects of coagulation to be considered.

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“…Satisfactory hemostasis is an important imperative for the intraoperative team because persistent bleeding after pediatric heart surgery is associated with increased mortality . Most anesthesiologists choose a hemostasis strategy that usually works and then reassess, understanding that a minority will continue to bleed excessively or, conversely, become overtly prothrombotic.…”

Section: Why Transfuse Blood Products?mentioning

confidence: 99%

Editorial comment on paper by Naguib, et al. ‘A single‐center strategy to minimize blood transfusion in neonates and children undergoing cardiac surgery’

Williams

Ramamoorthy

2015

Pediatric Anesthesia

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Early postoperative bleeding is independently associated with increased surgical mortality in infants after cardiopulmonary bypass

Cited by 40 publications

References 30 publications

Analysis of the structural and mechanical effects of procoagulant agents on neonatal fibrin networks following cardiopulmonary bypass

Analysis of the structural and mechanical effects of procoagulant agents on neonatal fibrin networks following cardiopulmonary bypass

Pediatric transplantation: managing bleeding

Editorial comment on paper by Naguib, et al. ‘A single‐center strategy to minimize blood transfusion in neonates and children undergoing cardiac surgery’

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