Patient Blood Management in Pediatric Cardiac Surgery: A Review

Cholette, Jill M.; Faraoni, David; Goobie, Susan M.; Ferraris, Victor A.; Hassan, Nabil

doi:10.1213/ane.0000000000002504

Cited by 59 publications

(72 citation statements)

References 157 publications

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“…Since the availability of a suitable donor heart can present at any time, VAD‐supported patients are frequently brought to the operating room with full therapeutic anticoagulation, predisposing them to significant perioperative bleeding at the time of cardiac transplant. Children with VADs undergoing heart transplant have additional risk factors for significant perioperative bleeding, including the following: age‐dependent changes on procoagulant and anticoagulant protein factor concentrations and function, congenital heart disease‐related coagulation abnormalities such as decreased vitamin K dependent clotting factors, abnormal platelet adhesion, and accelerated fibrinolysis, and bleeding risks associated with multiple sternotomies, chronic anticoagulation, and acquired von Willebrand syndrome in VAD‐supported patients …”

Section: Introductionmentioning

confidence: 99%

The use of prothrombin complex concentrate as a warfarin reversal agent in pediatric patients undergoing orthotopic heart transplantation

Sisti

Williams²,

Ding

et al. 2020

Pediatric Anesthesia

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Background Patients supported with a ventricular assist device are predisposed to severe bleeding at the time of orthotopic heart transplant due to several risk factors including anticoagulation with vitamin K antagonists. Kcentra, a four‐factor prothrombin complex concentrate, has been approved by the FDA for warfarin reversal in adults prior to urgent surgery. There is a lack of published data on the preoperative use of four‐factor prothrombin complex concentrates in pediatric patients undergoing cardiacsurgery. Methods This is a single‐center retrospective analysis of pediatric patients with a continuous‐flow ventricular assist device who underwent heart transplant, comparing patients who received Kcentra for anticoagulation reversal with a historical patient cohort who did not. Consecutive patients from January 2013 to December 2017 were analyzed. The primary outcome was volume of blood product transfusion prior to cardiopulmonary bypass initiation. Secondary outcomes include blood product transfusion after cardiopulmonary bypass intraoperatively and up to 24 hours postoperatively, chest tube output within 24 hours of surgery, time to extubation, incidence of thromboembolism, and post‐transplant length ofstay. Results From 2013 to 2017, 31 patients with continuous‐flow ventricular assist devices underwent heart transplant, with 27 patients included in the analysis. Fifteen patients received Kcentra compared with 12 patients who received fresh‐frozen plasma for anticoagulation reversal. Compared with the control group, patients who received Kcentra had less packed red blood cells, fresh‐frozen plasma, and platelets transfused prior to cardiopulmonary bypass initiation. The Kcentra group also received less packed red blood cells on bypass and less packed red blood cells after cardiopulmonary bypass termination. There were no differences in chest tube output, time to extubation, intensive care unit length of stay, or overall hospital length of stay. Neither group had thromboembolic complications detected during the first seven postoperative days. Conclusion This small retrospective study indicates that preoperative warfarin reversal with Kcentra reduces blood product exposure in pediatric patients with ventricular assist devices undergoing heart transplant.

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Section: Introductionmentioning

confidence: 99%

The use of prothrombin complex concentrate as a warfarin reversal agent in pediatric patients undergoing orthotopic heart transplantation

Sisti

Williams²,

Ding

et al. 2020

Pediatric Anesthesia

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“…Adopting a conservative RBC transfusion approach (transfusing a hemoglobin less than 7.0 g/dL for biventricular repairs or less than 9.0 g/dL for palliative procedures plus clinical indication) has been shown to be effective in reducing RBC transfusion while showing no significant differences in lactate, avO 2 diff, or clinical outcomes (33).…”

Section: The Need and Problems Of Rbc Transfusion During Neonatal Carmentioning

confidence: 99%

Recent innovations in perfusion and cardiopulmonary bypass for neonatal and infant cardiac surgery

Sturmer¹,

Beaty²,

Clingan³

et al. 2018

Transl Pediatr

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Abstract:The development and refinement of cardiopulmonary bypass (CPB) has made the repair of complex congenital heart defects possible in neonates and infants. In the past, the primary goal for these procedures was patient survival. Now that substantial survival rates have been achieved for even the most complex of repairs in these patients, focus has been given to the reduction of morbidity. Although a necessity for these complex neonatal and infant heart defect repairs, CPB can also be an important source of perioperative complications. Recent innovations have been developed to mitigate these risks and is the topic of this review. Specifically, we will discuss improvements in minimizing blood transfusions, CPB circuit design, monitoring, perfusion techniques, temperature management, and myocardial protection, and then conclude with a brief discussion of how further systematic improvements can be made in these areas.

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“…While evidence‐based criteria and expert consensus guidelines for clinically appropriate transfusion have been published, practitioners continue to transfuse patients outside these recommended criteria and best practice guidelines without sufficient demonstration of benefit to the recipient. The implementation of a comprehensive PBM program has been shown to decrease blood transfusion, decrease morbidity and mortality and decrease hospital costs …”

Section: Introductionmentioning

confidence: 99%

“…The implementation of a comprehensive PBM program has been shown to decrease blood transfusion, decrease morbidity and mortality and decrease hospital costs. 4,6,10 Therefore, comprehensive multimodal PBM is the new standard of care to manage anemia and hemostasis and has been recommended by the World Health Organization, the American Society of Anesthesiologists, the European Society of Anaesthesiology, and the Australian National Blood Authority. 1,21,26,34 Management of pediatric bleeding and blood product transfusion presents distinctive considerations.…”

mentioning

confidence: 99%

“…23 Uniquely challenging settings are those of cardiopulmonary bypass, extracorporeal membrane oxygenation or exchange transfusion; situations analogous to a massive transfusion. 4,5 Due to the small blood volume of neonates and infants, multiple blood components are usually indicated. Prematurity and immaturity contribute to sub-optimal coagulation in many patients.…”

mentioning

confidence: 99%

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Society for the advancement of blood management administrative and clinical standards for patient blood management programs. 4th edition (pediatric version)

Goobie¹,

Gallagher²,

Gross

et al. 2019

Pediatric Anesthesia

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Summary Patient Blood Management is the timely application of evidence‐based medical and surgical concepts designed to maintain hemoglobin concentration, optimize hemostasis, and minimize blood loss to improve patient outcomes. Conceptually similar to a “bundle” strategy, it is designed to improve clinical care using comprehensive evidence‐based treatment strategies to manage patients with potential or ongoing critical bleeding, bleeding diathesis, critical anemia, and/ or a coagulopathy. Patient Blood Management includes multimodal strategies to screen, diagnose and properly treat anemia, coagulopathies and minimize bleeding, using goal‐directed therapy and leverages a patient's physiologic ability to adapt to anemia while definitive treatment is undertaken. Allogeneic blood component transfusion is one traditional therapeutic modality out of many for managing blood loss and anemia and, while it may be the best choice in certain situations, other effective and more appropriate options are available and should be used in conjunction or alone. Therefore, comprehensive Patient Blood Management is the new standard of care to prevent and manage anemia and optimize hemostasis and has been recommended by the World Health Organization, the American Society of Anesthesiologists, the European Society of Anaesthesiology and the Australian National Blood Authority. While there is a plethora of expert consensus and good practice guidelines published for blood component transfusion from multiple professional organizations and societies, there remains a need for more comprehensive and broader standards of patient medical management to proactively reduce the risk of exposure to allogeneic transfusions. In 2010, the Society for Advancement of Blood Management published the first comprehensive standards to address the administrative and clinical components of an effective, patient‐centered Patient Blood Management program. Recognizing the need to reduce inappropriate transfusions, some professional organizations have placed their emphasis on transfusion guidelines. In contrast, the focus of the Society for Advancement of Blood Management Standard is on the centrality of the patient and the full spectrum of therapeutic strategies needed to improve clinical outcomes in patients at risk for blood loss or anemia, thereby reducing avoidable transfusions as well. The Standards are meant not to replace, but to complement transfusion guidelines by more completely addressing the need for a multi‐modal clinical approach with the goal to improve patient outcomes. Compared to adult programs, Pediatric Patient Blood Management programs are currently not commonly accepted as standard of care for pediatric patients. This is partly due to the fact that, until recently, there was a paucity of robust evidence‐based literature and expert consensus guidelines on pediatric PBM. Managing pediatric bleeding and blood product transfusion presents a unique set of challenges. The main goal of transfusion is to correct or avoid imminent inadequate oxygen c...

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Patient Blood Management in Pediatric Cardiac Surgery: A Review

Cited by 59 publications

References 157 publications

The use of prothrombin complex concentrate as a warfarin reversal agent in pediatric patients undergoing orthotopic heart transplantation

The use of prothrombin complex concentrate as a warfarin reversal agent in pediatric patients undergoing orthotopic heart transplantation

Recent innovations in perfusion and cardiopulmonary bypass for neonatal and infant cardiac surgery

Society for the advancement of blood management administrative and clinical standards for patient blood management programs. 4th edition (pediatric version)

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