Understanding and managing the complex balance between bleeding and thrombosis following cardiopulmonary bypass in paediatric cardiac surgical patients

Abstract Bleeding in the perioperative period of congenital heart surgery with cardiopulmonary bypass is associated with increased morbidity and mortality both from the direct effects of haemorrhage as well as the therapies deployed to restore haemostasis. Perioperative bleeding is complex and multifactorial with both patient and procedural contributions. Moreover, neonates and infants are especially at risk. The objective of this review is to summarise the evidence regarding bleeding management in paediatric surgical patients and identify strategies that might facilitate appropriate bleeding management while minimising the risk of thrombosis. We will address the use of standard and point-of-care tests, and the role of contemporary coagulation factors and other novel drugs.

Download Full-text

Asanguineous Cardiopulmonary Bypass in Infants: Impact on Postoperative Mortality and Morbidity

The Thoracic and Cardiovascular Surgeon ◽

10.1055/s-0038-1676789 ◽

2019 ◽

Vol 68 (01) ◽

pp. 059-067 ◽

Cited By ~ 1

Author(s):

Peter Murin ◽

Wolfgang Boettcher ◽

Shinichi Ozaki ◽

Alexa Wloch ◽

Mi-Young Cho ◽

...

Keyword(s):

Cardiopulmonary Bypass ◽

Heart Surgery ◽

Postoperative Mortality ◽

Hemoglobin Concentration ◽

Congenital Heart Surgery ◽

Mortality And Morbidity ◽

Morbidity Score ◽

Inotropic Score ◽

Group 2 ◽

Neonates And Infants

Background We routinely start cardiopulmonary bypass (CPB) for pediatric congenital heart surgery without homologous blood, due to circuit miniaturization, and blood-saving measures. Blood transfusion is applied if hemoglobin concentration falls under 8 g/dL, or it is postponed to after coming off bypass or after operation. How this strategy impacts on postoperative mortality and morbidity, in infants weighing ≤ 7 kg? Methods Six-hundred fifteen open-heart procedures performed from January 2014 to June 2018 were selected. One-hundred sixty-three patients (26.5%) were transfused on CPB (group 1), while 452 (73.5%) patients were not transfused on CPB (group 2). Operative risk and complexity were similar in both groups. Postoperative mortality and morbidity were compared. Multiple logistic regression was used to detect factors independently associated with outcome. Results Observed mortality in nontransfused group (0.7% = 3/452) was significantly lower than expected (4.2% = 19/452): p = 0.0007, and much lower than in transfused group (6.7% = 11/163): p < 0.0001. CPB transfusion (p = 0.001) was independently associated with mortality, either acting as the sole factor or in combination with the Society of Thoracic Surgeons morbidity score (p = 0.013). Patients not transfused during CPB required less frequently vasoactive inotropic drugs (p = 0.011) and duration of their mechanical ventilation was shorter (93 ± 134 hours) than for transfused patients (142 ± 170 hours): p = 0.0003. CPB transfusion was an independent determinant factor for morbidity (p = 0.05), together with body weight (p < 0.0001), vasoactive inotropic score (p < 0.0001), CPB duration (p = 0.001), and postoperative transfusion (p = 0.009). Conclusion The strategy of transfusion-free CPB course, feasible in most patients ≤ 7kg, was associated with improved outcome. Asanguineous priming of CPB circuit should become standard, even in neonates and infants.

Download Full-text

Low antithrombin levels in neonates and infants undergoing congenital heart surgery result in more red blood cell and plasma transfusion on cardiopulmonary bypass

Transfusion ◽

10.1111/trf.16082 ◽

2020 ◽

Vol 60 (12) ◽

pp. 2841-2848

Author(s):

Zhe Amy Fang ◽

Karen Bruzdoski ◽

Vadim Kostousov ◽

Shiu‐Ki Rocky Hui ◽

David Vener ◽

...

Keyword(s):

Cardiopulmonary Bypass ◽

Blood Cell ◽

Red Blood Cell ◽

Congenital Heart ◽

Heart Surgery ◽

Congenital Heart Surgery ◽

Plasma Transfusion ◽

Blood Cell And Plasma ◽

Neonates And Infants

Download Full-text

Post-operative kinetics of C-reactive protein to distinguish between bacterial infection and systemic inflammation in infants after cardiopulmonary bypass surgery: the early and the late period

Cardiology in the Young ◽

10.1017/s1047951121003231 ◽

2021 ◽

pp. 1-8

Author(s):

Hanna Renk ◽

David Grosse ◽

Sarah Schober ◽

Christian Schlensak ◽

Michael Hofbeck ◽

...

Keyword(s):

Cardiopulmonary Bypass ◽

Bacterial Infection ◽

Congenital Heart ◽

Bypass Surgery ◽

Heart Surgery ◽

Congenital Heart Surgery ◽

C Reactive Protein ◽

Reactive Protein ◽

Post Operative Period ◽

Kinetics Of

Abstract Objectives: Differentiation between post-operative inflammation and bacterial infection remains an important issue in infants following congenital heart surgery. We primarily assessed kinetics and predictive value of C-reactive protein for bacterial infection in the early (days 0–4) and late (days 5–28) period after cardiopulmonary bypass surgery. Secondary objectives were frequency, type, and timing of post-operative infection related to the risk adjustment for congenital heart surgery score. Methods: This 3-year single-centre retrospective cohort study in a paediatric cardiac ICU analysed 191 infants accounting for 235 episodes of CPBP surgery. Primary outcome was kinetics of CRP in the first 28 days after CPBP surgery in infected and non-infected patients. Results: We observed 22 infectious episodes in the early and 34 in the late post-operative period. CRP kinetics in the early post-operative period did not accurately differentiate between infected and non-infected patients. In the late post-operative period, infected infants displayed significantly higher CRP values with a median of 7.91 (1.64–22.02) and 6.92 mg/dl (1.92–19.65) on days 2 and 3 compared to 4.02 (1.99–15.9) and 3.72 mg/dl (1.08–9.72) in the non-infection group. Combining CRP on days 2 and 3 after suspicion of infection revealed a cut-off of 9.47 mg/L with an acceptable predictive accuracy of 76%. Conclusions: In neonates and infants, CRP kinetics is not useful to predict infection in the first 72 hours after CPBP surgery due to the inflammatory response. However, in the late post-operative period, CRP is a valuable adjunctive diagnostic test in conjunction with clinical presentation and microbiological diagnostics.

Download Full-text

Improving respiratory outcomes after pediatric cardiac surgery: new uses for nitric oxide.

10.22541/au.163726568.85602167/v1 ◽

2021 ◽

Author(s):

Jacques Scharoun

Keyword(s):

Nitric Oxide ◽

Respiratory Failure ◽

High Frequency ◽

Heart Surgery ◽

Congenital Heart Surgery ◽

Surgical Patients ◽

Improved Outcomes ◽

Frequency Oscillator ◽

Hypoxic Respiratory Failure ◽

Respiratory Outcomes

Nitric oxide has been used to treat respiratory failure in post-pediatric cardiac surgical patients. High frequency oscillator ventilation is used to rescue infants who have failed conventional ventilation. In this issue a study is presented showing the benefit of combining these two therapies for improved outcomes in infants with hypoxic respiratory failure after congenital heart surgery

Download Full-text

Treatment of systemic inflammatory response syndrome following on-pump pediatric congenital heart surgery

Complex Issues of Cardiovascular Diseases ◽

10.17802/2306-1278-2021-10-2-113-124 ◽

2021 ◽

Vol 10 (2) ◽

pp. 113-124

Author(s):

D. V. Borisenko ◽

A. A. Ivkin ◽

D. L. Shukevich

Keyword(s):

Cardiopulmonary Bypass ◽

Systemic Inflammatory Response Syndrome ◽

Inflammatory Response ◽

Congenital Heart ◽

Heart Surgery ◽

Heart Defects ◽

Surgical Techniques ◽

Congenital Heart Surgery ◽

Systemic Inflammatory Response ◽

Preventive Strategies

Highlights. The article discusses the pathophysiological aspects of cardiopulmonary bypass and the mechanisms underlying the development of the systemic inflammatory response in children following congenital heart surgery. We summarize and report the most relevant preventive strategies aimed at reducing the systemic inflammatory response, including both, CPB-related methods and pharmacological ones.The growing number of children with congenital heart defects requires the development of more advanced technologies for their surgical treatment. However, cardiopulmonary bypass is required in almost all surgical techniques. Despite the tremendous progress and recent advances in cardiopulmonary bypass techniques, the systemic inflammatory response syndrome associated with these surgeries remains unresolved. The review summarizes the causes and mechanisms underlying its development. The most commonly used preventive strategies are reported, including standard and modified ultrafiltration, leukocyte filters, and pharmacological agents (systemic glucocorticoids, aprotinin, and antioxidants).The role of cardioplegia and hypothermia in the reduction of systemic inflammation is defined. Cardiac surgery centers around the world use a variety of techniques and pharmacological approaches, drawing on the results of randomized clinical studies. However, there are no clear and definite clinical guidelines aimed at reducing the systemic inflammatory response during cardiopulmonary bypass in children. It remains a significant problem for pediatric intensive care by aggravating their postoperative status, prolonging the length of the in-hospital stay, and reducing the survival rates.

Download Full-text

The Correlation of Two Cerebral Saturation Monitors With Jugular Bulb Oxygen Saturation in Children Undergoing Cardiopulmonary Bypass for Congenital Heart Surgery

Journal of Intensive Care Medicine ◽

10.1177/0885066616663649 ◽

2016 ◽

Vol 32 (10) ◽

pp. 603-608 ◽

Cited By ~ 5

Author(s):

Aymen N. Naguib ◽

Peter D. Winch ◽

Roby Sebastian ◽

Daniel Gomez ◽

Luisa Guzman ◽

...

Keyword(s):

Infrared Spectroscopy ◽

Cardiopulmonary Bypass ◽

Oxygen Saturation ◽

Congenital Heart ◽

Heart Surgery ◽

Near Infrared ◽

Jugular Bulb ◽

Congenital Heart Surgery ◽

Cerebral Oxygen ◽

Cerebral Saturation

Background: Near-infrared spectroscopy (NIRS) is a noninvasive monitoring technique that measures regional cerebral oxygen saturation (rSO2). Objectives: The primary aim was to compare the output of 2 NIRS-based cerebral oximetry devices, FORESIGHT (CAS Medical Systems Inc, Branford, Connecticut) and INVOS (Covidien, Boulder, Colorado), to venous oxygen saturations from the jugular venous bulb at cannulation and decannulation of the superior vena cava (SVC). Secondary objectives included evaluating correlations of cerebral saturation, as measured by the NIRS devices, with mean arterial blood pressure (MAP), measured by an invasive arterial line, and end-tidal CO2 (ETCO2). Methods: Near-infrared spectroscopy, MAP, and ETCO2 data were collected at 13 defined events during each case when hemodynamic instability was expected. At SVC cannulation and decannulation, a 0.1 mL sample of blood was collected from the jugular bulb by the surgeon using a long angiocatheter. The oxygen saturation of these blood samples was measured using an AVOX device and compared with contemporaneous readings from the NIRS probes. Mixed-effects linear regression was used to correlate MAP or ETCO2 with cerebral oxygen saturation (by NIRS) at each time point. Results: Children undergoing cardiopulmonary bypass for congenital heart surgery (n = 34) were enrolled in the study. At SVC cannulation, both INVOS ( r = .78) and FORESIGHT ( r = .59) were correlated with AVOX data at P < .001, although the correlation with INVOS was significantly stronger ( P = .003). At SVC decannulation, INVOS ( r = .68; P < .001) and FORESIGHT ( r = .60; P < .001) were similarly correlated with jugular venous rSO2. Correlations of rSO2 (by NIRS) with MAP and ETCO2 levels were stronger than correlations between rSO2 change and change in MAP or ETCO2. Conclusion: INVOS correlated more strongly than FORESIGHT with the jugular bulb rSO2 at SVC cannulation but may have underestimated oxygen saturation at low rSO2 values. Data from both NIRS devices were correlated with MAP and ETCO2 over the case duration.

Download Full-text

A Retrospective Analysis of the Use of 3-Factor Prothrombin Complex Concentrates for Refractory Bleeding After Cardiopulmonary Bypass in Children Undergoing Heart Surgery: A Matched Case-Control Study

Seminars in Cardiothoracic and Vascular Anesthesia ◽

10.1177/1089253219899255 ◽

2020 ◽

Vol 24 (3) ◽

pp. 227-231 ◽

Cited By ~ 2

Author(s):

Andrea D. Harris ◽

Richard M. Hubbard ◽

Rebecca M. Sam ◽

Xu Zhang ◽

Jorge Salazar ◽

...

Keyword(s):

Cardiopulmonary Bypass ◽

Prothrombin Complex Concentrate ◽

Heart Surgery ◽

Propensity Scores ◽

Congenital Heart Surgery ◽

Clinical Complications ◽

Increased Risk ◽

Matched Case ◽

Matched Case Control Study ◽

Control Study

The 3-factor prothrombin complex concentrate (3FPCC) may be used off-label to treat refractory bleeding during cardiac surgery in children. This retrospective study examined the rate of clinical complications following the use of 3FPCC. Patients treated with 3FPCC were matched to controls for age, gender, prematurity, weight, cardiopulmonary bypass times, and cross-clamp times. Fifty-nine cases were individually matched to 59 controls based on propensity scores. 3FPCC was not associated with an increased risk of thromboembolic events, mortality, or need for postoperative extracorporeal membrane oxygenator support. These results suggest the safety of 3FPCC when used for refractory bleeding after cardiopulmonary bypass in children undergoing congenital heart surgery.

Download Full-text

Prevalence and predictors of postoperative peritoneal dialysis in infants

Asian Cardiovascular and Thoracic Annals ◽

10.1177/0218492320947543 ◽

2020 ◽

Vol 28 (8) ◽

pp. 476-481

Author(s):

Michael Caesario ◽

Dicky Fakhri ◽

Pribadi Wiranda Busro ◽

Salomo Purba ◽

Liza Fitria ◽

...

Keyword(s):

Body Weight ◽

Peritoneal Dialysis ◽

Cardiopulmonary Bypass ◽

Risk Adjustment ◽

Heart Surgery ◽

Congenital Heart Surgery ◽

Lower Body ◽

Cardiopulmonary Bypass Time ◽

Lower Body Weight ◽

Younger Age

Background Data regarding predictors of the eventual need for postoperative peritoneal dialysis in infants undergoing open heart surgery is still limited. We aimed to determine whether prolonged cardiopulmonary bypass time, surgical complexity classified according to Risk Adjustment for Congenital Heart Surgery category, younger age, and lower body weight increase the probability of requiring postoperative peritoneal dialysis. Methods We retrospectively analyzed data of 181 infants who underwent open heart surgery at our institution from January 1 to December 31, 2018. Cardiopulmonary bypass time, Risk Adjustment for Congenital Heart Surgery category, age, body weight, and the need for postoperative peritoneal dialysis were recorded and analyzed. Results Thirteen (7.2%) of the 181 patients required postoperative peritoneal dialysis. This group was found to have a longer cardiopulmonary bypass time, younger age, and lower body weight. Longer cardiopulmonary bypass time ( p = 0.001), higher Risk Adjustment for Congenital Heart Surgery category ( p = 0.018), younger age ( p < 0.001), and lower body weight ( p < 0.001) significantly increased the risk of postoperative peritoneal dialysis. Conclusion Longer cardiopulmonary bypass time, more complex surgery, younger age, and lower body weight increase the probability of requiring postoperative peritoneal dialysis in infants undergoing open heart surgery.

Download Full-text