Hemostasis in Pediatric Cardiac Surgery

Abstract

The majority of children undergoing pediatric cardiac surgery with cardiopulmonary bypass require transfusion of blood products. The management of hemostasis in the pediatric population is challenging, partly due to pronounced alterations in several hemostatic parameters following cardiopulmonary bypass. Despite these marked changes being seen quite often, they are not necessarily an indication for hemostatic interventions. This review summarizes and discusses the available monitoring tests of hemostatic impairment during and following pediatric cardiac surgery. It covers standard laboratory tests, viscoelastic test, evaluation of platelet function, fibrinolysis, and the management of anticoagulation including its reversal. Interpretation of hemostatic measurements is done with due respect to the concept of developmental hemostasis, but also cyanotic heart disease, which are considered by some to be associated with an increased risk of bleeding.

Evaluation of Thromboelastography 6s prognostication of fibrinogen supplementation in pediatric cardiac surgery

“…with cryoprecipitate transfusion, including low age and longer CPB duration. [2][3][4]11 Due to the retrospective study design, we cannot conclude whether young age on its own is an independent risk factor for transfusion, or simply associated with higher RACHS-1 categories.…”

“…2 Other risk factors for increased perioperative bleeding in pediatric patients include an immature coagulation system, as well as hypothermia, and extensive, complex surgery leading to increased CPB duration, too. 3,4 Due to surgery and perioperative coagulopathy, the vast majority of infants require transfusion of blood products during and after surgery. Consequently, transfusion management has become an increasingly bigger part of the perioperative optimization during pediatric congenital heart surgery.…”

“…Other risk factors for increased perioperative bleeding in pediatric patients include an immature coagulation system, as well as hypothermia, and extensive, complex surgery leading to increased CPB duration, too. 3 , 4 …”

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“…Ravn therefore summarizes and discusses studies evaluating viscoelastic tests such as ROTEM and TEG as well as platelet function tests in children undergoing cardiac surgery. 6 Moreover, the review provides valuable information on heparin use and reversal in pediatric cardiopulmonary bypass, and finally, the potential use of antifibrinolytics in the pediatric population is challenged. 6 A new class of non-vitamin K oral anticoagulants (NOACs), also called direct oral anticoagulants (DOACs), and comprising direct anti-thrombin and anti-Xa agents, has now become available worldwide and is increasingly being used.…”

“…6 Moreover, the review provides valuable information on heparin use and reversal in pediatric cardiopulmonary bypass, and finally, the potential use of antifibrinolytics in the pediatric population is challenged. 6 A new class of non-vitamin K oral anticoagulants (NOACs), also called direct oral anticoagulants (DOACs), and comprising direct anti-thrombin and anti-Xa agents, has now become available worldwide and is increasingly being used. One of the advantages of NOACs is that no regular laboratory monitoring is needed, but in case of emergency surgery anticoagulant assessment is warranted.…”