Reply to “No evidence to support a priming strategy with FFP in infants”

Abstract

To the editor: We would like to thank Faraoni et al. for their letter in response to our paper [5]. The letter is a good opportunity to provide additional information on the rational use of fresh frozen plasma (FFP) as well as fibrinogen concentrate in the pediatric population. We agree with their comments on the following two aspects.For one, there is no evidence to support the systematic administration of FFP in pediatric patients, especially in children older than 6 months. However, the addition of FFP in the priming solution is still a common practice during pediatric cardiopulmonary bypass (CPB) today, may be not just in our country. In addition to the blood shortage, the inappropriate use of FFP could lead to unnecessary donor exposure and cause a variety of adverse clinical consequences. Thus, more specific researches focus upon this kind of patients, including children older than 6 months, are still in urgent need. For neonates and infants aged between 1 and 6 months, the evidence of using FFP is poor and we also not support to use FFP in the pump prime. Indeed, neonates undergoing arterial switch operation with CPB in our institution had been just primed with red blood cell, albumin, and artificial colloid solution (20 ml/kg) in recent 2 years. No safety concerns, such as abnormal bleeding, increased transfusion requirements, and mortality, were observed during our almost 2 years of clinical practice. The suggestion of defining the benefit-to-risk balance of a priming strategy with FFP in neonates will be included in our ongoing studies. We will further evaluate the coagulation function in these patients by using thromboelastography (TEG). Moreover, the more extensive study across a larger cohort of patients should be carried out in order to supply acceptable level of evidence regarding priming with FFP in neonates.For the other, we agree with Faraoni and colleagues that fibrinogen concentrate supplementation could be effective in preventing and treating postoperative blood loss. In our previous studies, we had observed that fibrinogen concentrate could be an effective substitute for FFP and its administration guided by TEG was associated with decreased postoperative blood loss and improved prognosis for severe cyanotic patients with complex congenital heart disease [1, 2]. Faraoni and colleagues study supplied an important finding that a cut-off value of 1.50 g l −1 for plasma fibrinogen concentration measured by the Clauss method or a cut-off of 3 mm for MCF on FIBTEM was predictive of significantly postoperative bleeding [3,4]. Our study also showed that the preoperative FLEV value was independently associated with postoperative blood loss. The administration of fibrinogen concentrate during closure time in our institution was mainly based upon the discretion of surgeon and anesthesiologist for patients with severe cyanosis or whom undergoing complex surgery with prolonged CPB. After returning to ICU, fibrinogen concentrate was administered either independently to the patients with moderate bleeding o...