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

Abstract

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.

Red cell transfusion practices after stage 1 palliation: a survey of practitioners from the Pediatric Cardiac Intensive Care Society

“…The survey used 4 case-based scenarios and 11 transfusion indicators. 23 Providers were more likely to transfuse cyanotic and unstable patients. 23 Among cyanotic patients, providers exhibited substantial transfusion threshold variability, with treatment thresholds ranging from 7 to 14 g/dl.…”

“…23 Providers were more likely to transfuse cyanotic and unstable patients. 23 Among cyanotic patients, providers exhibited substantial transfusion threshold variability, with treatment thresholds ranging from 7 to 14 g/dl. 23 In comparison, our survey was focused on a narrower cohort of neonates undergoing stage 1 palliation.…”

“…23 Among cyanotic patients, providers exhibited substantial transfusion threshold variability, with treatment thresholds ranging from 7 to 14 g/dl. 23 In comparison, our survey was focused on a narrower cohort of neonates undergoing stage 1 palliation. It is well known that neonates after stage 1 palliation receive substantial post-operative Figure 1.…”

“…A recent survey of Canadian ICU providers attempted to understand factors affecting red cell transfusion decisionmaking after congenital heart surgery; haemodynamic instability and cyanotic heart disease were identified as influencing transfusion decision-making. 23 Of note, providers chose a widely ranging haemoglobin threshold (ranging from <7 to 14 g/dl) to transfuse after surgery, illustrating the complete lack of consensus around red cell transfusion decision-making. 23 In clinical practice, the decision to transfuse after stage 1 palliation depends on a complex interplay of institutional, provider, and patient factors.…”

“…23 Of note, providers chose a widely ranging haemoglobin threshold (ranging from <7 to 14 g/dl) to transfuse after surgery, illustrating the complete lack of consensus around red cell transfusion decision-making. 23 In clinical practice, the decision to transfuse after stage 1 palliation depends on a complex interplay of institutional, provider, and patient factors. In an effort to characterise decision-making around red cell transfusion after stage 1 palliation, we sought to explore ICU providers' red cell transfusion practices and to identify factors affecting the decision with a case-based survey instrument.…”