Safety and effects of two red blood cell transfusion strategies in pediatric cardiac surgery patients: a randomized controlled trial

Gast-Bakker, Dana-Anne H de; Wilde, R. B. P. de; Hazekamp, Mark G.; Soják, Vladimír; Zwaginga, Jaap Jan; Wolterbeek, Ron; Jonge, Evert de; Veer, Birthe J. Gesink-van der

doi:10.1007/s00134-013-3085-7

Cited by 91 publications

(98 citation statements)

References 36 publications

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“…In contrast to previous work, the interventions were applied during anesthesia and surgery and not just postoperative ICU care. In the restrictive group less blood was used, costs were lower, and, most importantly, the length of hospital stay was reduced [restrictive median 8 (IQR 7-11) vs. liberal 9 (IQR 7-14) days, p = 0.047] [43]. The accompanying editorial reminds us once again of the central importance of primum non nocere [44].…”

Section: Primum Non Nocerementioning

confidence: 93%

Year in review in Intensive Care Medicine 2013: III. Sepsis, infections, respiratory diseases, pediatrics

et al. 2014

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Section: Primum Non Nocerementioning

confidence: 93%

Year in review in Intensive Care Medicine 2013: III. Sepsis, infections, respiratory diseases, pediatrics

et al. 2014

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“…Animals in which the hemoglobin level declined to less than 8 g/dL at any point were excluded from the study. In general, when the hemoglobin becames 7-8 g/dL in clinical site, we consider blood transfusion [5,6]. In this study, the purpose was to perform extracorporeal circulation without blood transfusion.…”

Section: Anesthesia Surgical Preparation and Extracorporeal Circulamentioning

confidence: 99%

A novel small animal extracorporeal circulation model for studying pathophysiology of cardiopulmonary bypass

et al. 2014

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Extracorporeal circulation (ECC) is indispensable for cardiac surgery. Despite the fact that ECCcauses damage to blood components and is non-physiologic, its pathophysiology has not been fully elucidated. This is because difficulty in clinical research and animal experiments keeps the knowledge insufficient. Therefore, it is desirable to have a miniature ECC model for small animals, which enables repetitive experiments, to study the mechanism of pathophysiological changes during ECC. We developed a miniature ECC system and applied it to the rat. We measured changes in hemodynamics, blood gases and hemoglobin (Hb) concentration, serum cytokines (TNF-α, IL-6, IL-10), biochemical markers (LDH, AST, ALT), and the wet-to-dry weight (W/D) ratio of the lung for assessing whether the rat ECC model is comparable to the human ECC. The ECC system consisted of a membranous oxygenator (polypropylene, 0.03 m(2)), tubing line (polyvinyl chloride), and roller pump. Priming volume of this system is only 8 ml. Rats (400-450 g) were divided into the SHAM group (n = 7) and the ECC group (n = 7). Blood samples were collected before, 60 and 120 min after initiation of ECC. During ECC, blood pressure and Hb were maintained around 80 mmHg and 10 g/dL, respectively. The levels of the inflammatory and biochemical markers and the W/D ratio were significantly elevated in the ECC group, indicating some organ damages and systemic inflammatory responses during ECC. We successfully established the ECC for the rat. This miniature ECC model could be a useful approach for studying the mechanism of pathophysiology during ECC and basic assessment of the ECC devices.

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“…Most cardiac children (range: 46-79 %) receive at least one RBC transfusion during their ICU stay after a cardiac surgery [15,16]. However, recent data suggest that a restrictive transfusion strategy might be as safe, if not safer than a liberal transfusion strategy.…”

mentioning

confidence: 99%

“…In this issue, de Gast-Bakker et al [15] published a randomised clinical trial where they compared the outcomes of children allocated to receive an RBC transfusion if their Hb level dropped below 8 g/dl (restrictive group) or below 10.8 g/dl (liberal group) in the operating room and in the ICU. All children older than 6 weeks with a planned cardiac surgery were considered for inclusion; cyanotic cases were excluded.…”

mentioning

confidence: 99%

“…It must be recognised that the threshold Hb level below which there are more benefits than harms administrating an RBC transfusion is not well characterised during and after paediatric cardiac surgery. The study by de Gast-Bakker et al [15] suggests that, in both the operating room and ICU, a threshold of 8 g/dl is safe in infants with non-cyanotic cardiac disease if the RACHS score is B3 and if their severity of illness is low; however, a large multicentre clinical trial is required before any strong recommendation can be made in this population. Moreover, it must be underlined that these data are not applicable to surgery with RACHS scores [3, to cardiac neonates and to children with cyanotic cardiac disease.…”

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confidence: 99%

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Do cardiac children need more red blood cell transfusions than other critically ill children?

Pont‐Thibodeau

Lacroix

2013

Intensive Care Med

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Anaemia is associated with a higher risk of mortality in cardiac adults [1,2] and children [3]. Only a red blood cell (RBC) transfusion can rapidly increase a low haemoglobin (Hb) concentration. However, there is no such thing as a perfectly safe RBC transfusion: both transfusion-transmitted infections and non-infectious serious hazards of transfusion (NISHOT) can occur [4]. RBC transfusions are associated with a higher mortality rate in cardiac adults [5] and with more morbidity in cardiac children [6][7][8][9]. An association between RBC transfusions and worse outcomes does not mean that there is a cause-effect relationship; it means only that such a cause-effect relationship is possible, and it questions the assertion that RBC transfusions are actually more useful than harmful in patients with cardiovascular disease.In clinical practice, cardiac patients receive more RBC transfusions than other critically ill children [9][10][11]. The question is what prompts physicians to prescribe an RBC transfusion. According to a self-administered survey, determinants in cardiac children include Hb level, patient's stability, active bleeding, inadequate O 2 delivery (low ScvO 2 , high lactate level, low SaO 2 /FiO 2 ratio) and low blood pressure [10]. However, the Hb level remains the most important determinant of RBC transfusion [10,11]. Therefore, it makes sense to ask ourselves the following questions: in cardiac children, how much anaemia can we tolerate and when do the benefits of RBC transfusions overcome their harms?RBC transfusions are given during the perioperative care of paediatric cardiac surgery in the operating room and in the intensive care unit (ICU). While cardiac surgery accounts for only 5 % of anaesthesia episodes, it represents 58 % of perioperative RBC use and 24 % of total hospital RBC use [12]. The lowest Hb level below which an RBC transfusion must be given during a cardiopulmonary bypass (CPB) is not well characterised. Jonas et al. [13] reported that infants randomised at CPB onset to an haematocrit of 20 % (Hb level: about 7 g/dl) had worse 1-year Bayley psychomotor development scores than those allocated to 30 % (10 g/dl); this suggests that the Hb level should be maintained over 7 during a CPB, but it does not tell us what is the best and safest threshold Hb level for transfusion over 7 g/dl.The uncertainty about the threshold Hb level with the best risk/benefits ratio also arises in the ICU after surgery. Most cardiac children (range: 46-79 %) receive at least one RBC transfusion during their ICU stay after a cardiac surgery [15,16]. However, recent data suggest that a restrictive transfusion strategy might be as safe, if not safer than a liberal transfusion strategy. A subgroup analysis that focussed on 125 cardiac children enrolled in the Transfusion Requirements in Pediatric ICU (TRIPI-CU) randomised clinical trial reported that a threshold Hb level of 7 was as safe as 9.5 g/dl in stable non-cyanotic cardiac infants [14].In this issue, de Gast-Bakker et al.[15] published a randomised clin...

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Safety and effects of two red blood cell transfusion strategies in pediatric cardiac surgery patients: a randomized controlled trial

Abstract: For patients with a non-cyanotic congenital heart defect undergoing elective cardiac surgery, a restrictive RBC transfusion policy (threshold of Hb 8.0 g/dl) during the entire perioperative period is safe, leads to a shorter hospital stay and is less expensive.

Cited by 91 publications

References 36 publications

Year in review in Intensive Care Medicine 2013: III. Sepsis, infections, respiratory diseases, pediatrics

Year in review in Intensive Care Medicine 2013: III. Sepsis, infections, respiratory diseases, pediatrics

A novel small animal extracorporeal circulation model for studying pathophysiology of cardiopulmonary bypass

Do cardiac children need more red blood cell transfusions than other critically ill children?

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