The Never-Ending Quest To Miminize Postbypass Bleeding While Minimizing Donor Exposure
James DiNardo, Viviane Nasr, Lindsey Loveland Baptist, Susan Nicolson
Original article
Jill M Cholette; Jennifer A Muszynski; Juan C Ibla; Sitaram Emani; Marie E Steiner; Adam M Vogel; Robert I Parker; Marianne E Nellis; Melania M Bembea: Plasma and Platelet Transfusions Strategies in Neonates and Children Undergoing Cardiac Surgery with Cardiopulmonary Bypass or Neonates and Children Supported by Extracorporeal Membrane Oxygenation: From the Transfusion and Anemia EXpertise Initiative–Control/Avoidance of Bleeding. Pediatr Crit Care Me 23, e25–e36 (2022). PMID: 34989703
Previous PAADs from this group of authors have addressed the potential association of “un-necessary” red cell transfusions with adverse outcomes in pediatric cardiac surgical patients. Similarly, strategies, such as use of antifibrinolytics, to limit the blood loss associated with cardiac surgery have been addressed. While a great deal of attention has been paid to the consequences of red cell transfusion and strategies to mitigate blood loss very little attention has been paid to the consequences of platelet and plasma transfusions and to the triggers for transfusion of these products.
Recently published in Pediatric Critical Care Medicine is a series of articles summarizing recommendations and expert consensus for plasma and platelet transfusion practice in critically ill children. This effort is the work of the Transfusion and Anemia EXpertise Initiative–Control/Avoidance of Bleeding (TAXI-CAB) experts.1 This group comprised of 29 experts in methodology, transfusion, and implementation science from five countries and nine pediatric subspecialties focused on eight subpopulations of critical illness:
· severe trauma, intracranial hemorrhage, or traumatic brain injury
· cardiopulmonary bypass surgery (CPB)
· extracorporeal membrane oxygenation (ECMO)
· oncologic diagnosis or hematopoietic stem cell transplantation,
· acute liver failure or liver transplantation
· noncardiac surgery
· invasive procedures outside the operating room
· sepsis and/ or disseminated intravascular coagulation
In addition, the group addressed laboratory assays and physiologic triggers for transfusion of plasma and platelet components.
While we recommend that every pediatric anesthesiologist read the entire series of articles (several will be reviewed in upcoming PAADs) our intent here is to specially summarize the recommendations for patients following CPB. A subgroup of nine experts developed evidence-based and, when evidence was insufficient, expert-based statements for plasma and platelet transfusions in critically ill neonates and children following CPB or supported by ECMO. The recommendations as regards CPB are summarized as follows:
In neonatal and pediatric patients undergoing cardiac surgery with CPB, viscoelastic testing (VET) might be considered as an adjunct to standard hemostatic testing (in the operating room after rewarming and protamine, and in the intensive care unit (ICU)) to inform decisions regarding prophylactic and therapeutic transfusions of plasma and/or platelets.
In neonatal and pediatric patients undergoing cardiac surgery with CPB, the development of institution-specific transfusion algorithms for post-CPB (after rewarming and protamine and in ICU) transfusion management might be considered to reduce individual case and global overall blood product usage.
In neonatal and pediatric patients undergoing cardiac surgery, there is insufficient evidence to make a recommendation regarding specific indications or transfusion strategies to direct plasma or platelet transfusion.
What are we to take from this as there is very little in the way of definitive guidance provided here? There is no doubt that VET can be used to assess coagulation status in cardiac surgical patients. However, unless the data obtained from this assessment is incorporated in an algorithm it is of little use. Algorithms are a force function for critical analysis of data and subsequent decision making. Initiation of a VET guided transfusion algorithm may result in a reduction in transfusion of coagulation products but it will most certainly change the pattern of transfusion with reduction in transfusion of one component (plasma) often associated with an increase in transfusion of another component (platelets). 2,3 The important point is that each institution must develop their own individualized approach to post-CPB hemostasis in the neonate and infant based on careful analysis of important variables, such as pump prime volumes and composition, temperature management, operative duration, and surgical attention to hemostasis combined with an objective measure of coagulation status.
References
Nellis, M. E. et al. Executive Summary of Recommendations and Expert Consensus for Plasma and Platelet Transfusion Practice in Critically Ill Children: From the Transfusion and Anemia EXpertise Initiative—Control/Avoidance of Bleeding (TAXI-CAB). Pediatr Crit Care Me 23, 34–51 (2022).
Machovec, K. A. & Jooste, E. H. Pediatric Transfusion Algorithms: Coming to a Cardiac Operating Room Near You. Journal of cardiothoracic and vascular anesthesia 33, 2017–2029 (2019).
Whiting, D. & DiNardo, J. A. TEG and ROTEM: technology and clinical applications. Am J Hematol 89, 228–232 (2014).