Revisiting acute normovolemic hemodilution and blood transfusion during pediatric cardiac surgery: a prospective observational study

Background: Due to the substantial improvement in survival among pediatric patients undergoing congenital heart surgery, reducing early and long-term morbidity is becoming the major focus of care. Blood transfusion is associated with worse postoperative outcomes after cardiac surgery. Acute normovolemic hemodilution (ANH) is a blood conservation strategy that aims to reduce allogenic blood transfusion during cardiac surgery. However, there are scant data regarding its efficacy for pediatric cardiac surgery patients. Methods: We designed a single-center, controlled, randomized, pilot trial in patients between 6 and 36 months old undergoing pediatric heart surgery. Patients were equally assigned to undergo ANH prior to initiation of cardiopulmonary bypass or to be managed per usual care. The primary end point was the amount of blood product transfused perioperatively. Secondary end points were markers of morbidity: postoperative bleeding, hematocrit, inotropic agents use, intensive care unit, and hospital stay. The analysis was by intention-to-treat. Estimates of differences between groups are presented with 95% CIs. Results: Twelve pediatric heart surgery patients were randomized to each group, ANH and usual care. Baseline characteristics were similar between groups. Acute normovolemic hemodilution implementation did not result in a reduction in the administration of blood product transfused (difference between ANH and usual care among patients transfused = −1.4 mL [−29.4 to 26.6], P = .92). Secondary end points were not different between groups. Conclusions: In this small trial of pediatric cardiac surgery patients, ANH as a strategy to reduce blood component therapy was safe; however, the study failed to show a reduction in perioperative transfusion or other postoperative outcomes.

Download Full-text

Absence of Beneficial Effect of Acute Normovolemic Hemodilution Combined with Aprotinin on Allogeneic Blood Transfusion Requirements in Cardiac Surgery

Anesthesiology ◽

10.1097/00000542-200202000-00009 ◽

2002 ◽

Vol 96 (2) ◽

pp. 276-282 ◽

Cited By ~ 30

Author(s):

Laurent Höhn ◽

Alexandre Schweizer ◽

Marc Licker ◽

Denis R. Morel

Keyword(s):

Cardiac Surgery ◽

Cardiopulmonary Bypass ◽

High Risk ◽

Blood Transfusion ◽

Allogeneic Blood ◽

Surgical Patients ◽

Control Group ◽

Acute Normovolemic Hemodilution ◽

Normovolemic Hemodilution ◽

Normal Cardiac Function

Background The efficacy of acute normovolemic hemodilution (ANH) in decreasing allogeneic blood requirements remains controversial during cardiac surgery. Methods In a prospective, randomized study, 80 adult cardiac surgical patients with normal cardiac function and no high risk of ischemic complications were subjected either to ANH, from a mean hematocrit of 43% to 28%, or to a control group. Aprotinin and intraoperative blood cell salvage were used in both groups. Blood (autologous or allogeneic) was transfused when the hematocrit was less than 17% during cardiopulmonary bypass, less than 25% after cardiopulmonary bypass, or whenever clinically indicated. Results The amount of whole blood collected during ANH ranged from 10 to 40% of the patients' estimated blood volume. Intraoperative and postoperative blood losses were not different between control and ANH patients (total blood loss, control: 1,411 +/- 570 ml, n = 41; ANH: 1,326 +/- 509 ml, n = 36). Allogeneic blood was given in 29% of control patients (median, 2; range, 1-3 units of packed erythrocytes) and in 33% of ANH patients (median, 2; range, 1-5 units of packed erythrocytes; P = 0.219). Preoperative and postoperative platelet count, prothrombin time, and partial thromboplastin time were similar between groups. Perioperative morbidity and mortality were not different in both groups, and similar hematocrit values were observed at hospital discharge (33.7 +/- 3.9% in the control group and 32.6 +/- 3.7% in the ANH group; nonsignificant) Conclusions Hemodilution is not an effective means to lower the risk of allogeneic blood transfusion in elective cardiac surgical patients with normal cardiac function and in the absence of high risk for coronary ischemia, provided standard intraoperative cell saving and high-dose aprotinin are used.

Download Full-text

Room I, 10/17/2000 2: 00 PM - 4: 00 PM (PS) Effect of Acute Normovolemic Hemodilution on Allogeneic Blood Transfusion and Surgical Blood Loss during Cardiac Surgery; A Meta-Analysis

Anesthesiology ◽

10.1097/00000542-200009001-01181 ◽

2000 ◽

Vol 93 (3A) ◽

pp. A-1181

Author(s):

Paul G. Loubser ◽

Jay Herson ◽

Nila Patel

Keyword(s):

Cardiac Surgery ◽

Blood Transfusion ◽

Blood Loss ◽

Meta Analysis ◽

Allogeneic Blood Transfusion ◽

Allogeneic Blood ◽

Acute Normovolemic Hemodilution ◽

Surgical Blood Loss ◽

Normovolemic Hemodilution

Download Full-text

Prevention of postoperative bleeding after complex pediatric cardiac surgery by early administration of fibrinogen, prothrombin complex and platelets: a prospective observational study

BMC Anesthesiology ◽

10.1186/s12871-020-01217-1 ◽

2020 ◽

Vol 20 (1) ◽

Author(s):

Nils Dennhardt ◽

Robert Sümpelmann ◽

Alexander Horke ◽

Oliver Keil ◽

Katja Nickel ◽

...

Keyword(s):

Cardiac Surgery ◽

Observational Study ◽

Blood Volume ◽

Prospective Observational Study ◽

Postoperative Bleeding ◽

Maximum Amplitude ◽

Mean Value ◽

Pediatric Cardiac Surgery ◽

Early Administration ◽

Coagulation Parameters

Abstract Background Postoperative bleeding is a major problem in children undergoing complex pediatric cardiac surgery. The primary aim of this prospective observational study was to evaluate the effect of an institutional approach consisting of early preventive fibrinogen, prothrombin complex and platelets administration on coagulation parameters and postoperative bleeding in children. The secondary aim was to study the rate of re-intervention and postoperative transfusion, the occurrence of thrombosis, length of mechanical ventilation, ICU stay and mortality. Methods In fifty children (age 0–6 years) with one or more predefined risk factors for bleeding after cardiopulmonary bypass (CPB), thrombelastography (TEG) and standard coagulation parameters were measured at baseline (T1), after CPB and reversal of heparin (T2), at sternal closure (T3) and after 12 h in the ICU (T4). Clinical bleeding was evaluated by the surgeon at T2 and T3 using a numeric rating scale (NRS, 0–10). Results After CPB and early administration of fibrinogen, prothrombin complex and platelets, the clinical bleeding evaluation score decreased from a mean value of 6.2 ± 1.9 (NRS) at T2 to a mean value of 2.1 ± 0.8 at T3 (NRS; P < 0.001). Reaction time (R), kinetic time (K), maximum amplitude (MA) and maximum amplitude of fibrinogen (MA-fib) improved significantly (P < 0.001 for all), and MA-fib correlated significantly with the clinical bleeding evaluation (r = 0.70, P < 0.001). The administered total amount of fibrinogen (mg kg− 1) correlated significantly with weight (r = − 0.42, P = 0.002), priming volume as percentage of estimated blood volume (r = 0.30, P = 0.034), minimum CPB temperature (r = − 0.30, P = 0.033) and the change in clinical bleeding evaluation from T2 to T3 (r = 0.71, P < 0.001). The incidence of postoperative bleeding (> 10% of estimated blood volume) was 8%. No child required a surgical re-intervention, and no cases of thrombosis were observed. Hospital mortality was 0%. Conclusion In this observational study of children with an increased risk of bleeding after CPB, an early preventive therapy with fibrinogen, prothrombin complex and platelets guided by clinical bleeding evaluation and TEG reduced bleeding and improved TEG and standard coagulation parameters significantly, with no occurrence of thrombosis or need for re-operation. Trial registration German Clinical Trials Register DRKS00018109 (retrospectively registered 27th August 2019).

Download Full-text