Randomized trial of hematocrit 25% versus 35% during hypothermic cardiopulmonary bypass in infant heart surgery

Newburger, Jane W.; Jonas, Richard A.; Soul, Janet S.; Kussman, Barry D.; Bellinger, David C.; Laussen, Peter C.; Robertson, Richard L.; Mayer, John E.; Nido, Pedro J. del; Bacha, Emile A.; Forbess, Joseph M.; Pigula, Frank A.; Roth, Stephen J.; Visconti, Karen J.; Plessis, Adré J. du; Farrell, David M.; McGrath, Ellen; Rappaport, Leonard; Wypij, David

doi:10.1016/j.jtcvs.2007.01.051

Cited by 136 publications

(100 citation statements)

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“…This observation was previously reported in preterm infants by our group [38]. These findings support the importance of maintaining HGB levels in the perioperative period [70]. In addition, these data underscore the need for not only further research, but also new devices, to fully investigate neurodevelopmental outcomes and cerebral physiology in CHD patients.…”

Section: Discussionsupporting

confidence: 89%

Perioperative cerebral hemodynamics and oxygen metabolism in neonates with single-ventricle physiology

Dehaes

Cheng

Buckley

et al. 2015

Biomed. Opt. Express

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Abstract:Congenital heart disease (CHD) patients are at risk for neurodevelopmental delay. The etiology of these delays is unclear, but abnormal prenatal cerebral maturation and postoperative hemodynamic instability likely play a role. A better understanding of these factors is needed to improve neurodevelopmental outcome. In this study, we used bedside frequency-domain near infrared spectroscopy (FDNIRS) and diffuse correlation spectroscopy (DCS) to assess cerebral hemodynamics and oxygen metabolism in neonates with single-ventricle (SV) CHD undergoing surgery and compared them to controls. Our goals were 1) to compare cerebral hemodynamics between unanesthetized SV and healthy neonates, and 2) to determine if FDNIRS-DCS could detect alterations in cerebral hemodynamics beyond cerebral hemoglobin oxygen saturation (SO 2 ). Eleven SV neonates were recruited and compared to 13 controls. Preoperatively, SV patients showed decreased cerebral blood flow (CBF i ), cerebral oxygen metabolism (CMRO 2i ) and SO 2 ; and increased oxygen extraction fraction (OEF) compared to controls. Compared to preoperative values, unstable postoperative SV patients had decreased CMRO 2i and CBF i , which returned to baseline when stable. However, SO 2 showed no difference between unstable and stable states. Preoperative SV neonates are flow-limited and show signs of impaired cerebral development compared to controls. FDNIRS-DCS shows potential to improve assessment of cerebral development and postoperative hemodynamics compared to SO 2 alone. References and links 1. J. I. E. Hoffman and S. Kaplan, "The incidence of congenital heart disease," J. Am. Coll. Cardiol. 39, 1890-1900 A. Rappaport, and D. Wypij, "Randomized trial of hematocrit 25% versus 35% during hypothermic cardiopulmonary bypass in infant heart surgery," J. Thorac. Cardiovasc. Surg. 135, 347-54, 354.e1-4 (2008).

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Section: Discussionsupporting

confidence: 89%

Perioperative cerebral hemodynamics and oxygen metabolism in neonates with single-ventricle physiology

Dehaes

Cheng

Buckley

et al. 2015

Biomed. Opt. Express

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“…All invited investigators agreed to submit data for this analysis. 8,9,[15][16][17][18][19][20][21][22][23][24] …”

Section: Identification Of Participating Institutionsmentioning

confidence: 99%

Neurodevelopmental Outcomes After Cardiac Surgery in Infancy

et al. 2015

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, for the International Cardiac Collaborative on Neurodevelopment (ICCON) Investigators abstract BACKGROUND: Neurodevelopmental disability is the most common complication for survivors of surgery for congenital heart disease (CHD). METHODS:We analyzed individual participant data from studies of children evaluated with the Bayley Scales of Infant Development, second edition, after cardiac surgery between 1996 and 2009. The primary outcome was Psychomotor Development Index (PDI), and the secondary outcome was Mental Development Index (MDI).RESULTS: Among 1770 subjects from 22 institutions, assessed at age 14.5 6 3.7 months, PDIs and MDIs (77.6 6 18.8 and 88.2 6 16.7, respectively) were lower than normative means (each P , .001). Later calendar year of birth was associated with an increased proportion of high-risk infants (complexity of CHD and prevalence of genetic/extracardiac anomalies). After adjustment for center and type of CHD, later year of birth was not significantly associated with better PDI or MDI. Risk factors for lower PDI were lower birth weight, white race, and presence of a genetic/extracardiac anomaly (all P # .01). After adjustment for these factors, PDIs improved over time (0.39 points/year, 95% confidence interval 0.01 to 0.78; P = .045). Risk factors for lower MDI were lower birth weight, male gender, less maternal education, and presence of a genetic/extracardiac anomaly (all P , .001). After adjustment for these factors, MDIs improved over time (0.38 points/year, 95% confidence interval 0.05 to 0.71; P = .02).CONCLUSIONS: Early neurodevelopmental outcomes for survivors of cardiac surgery in infancy have improved modestly over time, but only after adjustment for innate patient risk factors. As more high-risk CHD infants undergo cardiac surgery and survive, a growing population will require significant societal resources.

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“…The first study showed in 113 children younger than 9 months that hemodilution during CPB to hematocrit of 21.5 % (Hb & 7.5 g/dL) compared to 27.8 % (Hb & 9.3 g/dL) was associated with lower Bayley Psychomotor Development index at 1 year of age (81.9 ± 15.7 vs. 89.7 ± 14.7, p = 0.008) [20]. However, in a different study of 124 patients, the same psychomotor development index was similar at 1 year of age in subjects with hematocrits of 24.8 % (Hb & 8.3 g/dL) and 32.6 % (Hb & 10.9 g/dL) during CPB [21]. A subgroup analysis of 125 infants enrolled in the TRIPICU study after cardiac surgery [12] showed no significant difference in incidence of multiple organ dysfunction syndrome and death (12.7 vs. 6.3 %; p = 0.36) when comparing restrictive and liberal transfusion groups (Hb: 7.0 vs. 9.5 g/dL); however, neonates and patients with cyanotic heart disease were excluded from this trial [14].…”

Section: Discussionmentioning

confidence: 88%

Red Blood Cell Transfusion in the Postoperative Care of Pediatric Cardiac Surgery: Survey on Stated Practice

et al. 2016

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The optimal red blood cell transfusion threshold for postoperative pediatric cardiac surgery patients is unknown. This study describes the stated red blood cell transfusion practice of physicians who treat postoperative pediatric cardiac surgery patients in intensive care units. A scenario-based survey was sent to physicians involved in postoperative intensive care of pediatric cardiac surgery patients in all Canadian centers that perform such surgery. Respondents reported their red blood cell transfusion practice in four postoperative scenarios: acyanotic or cyanotic cardiac lesion, in a neonate or an infant. In part A of each scenario, the patient was critically ill, but stabilized; in part B, the patient became unstable. Response rate was 58 % (71 of 123), with 45 respondents indicating direct involvement in postoperative intensive care. There was a wide variability in stated transfusion threshold, ranging from <7.0-14.0 g/dL for stabilized cases. There was no significant difference between neonates and infants in stated transfusion threshold. The mean hemoglobin level below which respondents would transfuse a stabilized patient was 9 g/dL for acyanotic and 11.2 g/dL for cyanotic patients, a statistically significant difference (2.2 ± 0.9 g/dL, p < 0.001). All clinical determinants of instability significantly increased transfusion threshold. Hemodynamic instability increased transfusion threshold by 2.3 ± 1.3 g/dL in acyanotic patients and by 1.3 ± 1.1 g/dL in cyanotic patients. Cyanotic lesion and clinical instability, but not patient age, increased stated red blood cell transfusion threshold. Significant variation in reported red blood cell transfusion practice exists among physicians treating pediatric patients in intensive care following cardiac surgery.

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Randomized trial of hematocrit 25% versus 35% during hypothermic cardiopulmonary bypass in infant heart surgery

Abstract: Hemodilution to hematocrit levels of 35% compared with those of 25% had no major benefits or risks overall among infants undergoing 2-ventricle repair. Developmental outcomes at age 1 year in both randomized groups were below those in the normative population.

Cited by 136 publications

References 20 publications

Perioperative cerebral hemodynamics and oxygen metabolism in neonates with single-ventricle physiology

Perioperative cerebral hemodynamics and oxygen metabolism in neonates with single-ventricle physiology

Neurodevelopmental Outcomes After Cardiac Surgery in Infancy

Red Blood Cell Transfusion in the Postoperative Care of Pediatric Cardiac Surgery: Survey on Stated Practice

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