Blood conservation strategies in cardiac surgery

Despite the continuous efforts to increase the safety of blood components, red blood cell transfusions remain associated with some risks and side effects. Therefore, numerous techniques have been developed to decrease blood use, but they also carry risks and bear costs. Most of them are frequently used in cardiac surgery, which still consumes a large part of the available blood supply. Among western countries the use of alternative techniques, but also transfusion practice, has been shown to vary markedly. 'Blood conservation' is a global concept engulfing all possible strategies aimed at reducing patients' exposure to allogeneic blood components. The development of the 'best strategy' consists of the selection of those techniques that are most appropriate to the local specific situation. It implies the establishment of a reliable system, collecting data both at the surgical team and at the medical level.     

Blood conservation pediatric cardiac surgery in all ages and complexity levels

AIM To demonstrate the feasibility of blood conservation methods and practice across all ages and risk categories in congenital cardiac surgery.METHODS We retrospectively analyzed a collected database of 356 patients who underwent cardiac surgery using cardiopulmonary bypass(CPB) from 2010-2015. The patients were grouped into blood conservation(n = 138) and nonconservation(n = 218) groups and sub-grouped based on their ages and procedural complexity scores. RESULTS There were no statistical differences in gender,weight,pre-operative and pre-CPB hematocrit levels in both groups. Despite equivalent hematocrit levels during and after CPB for both groups,there was significantly less operative homologous blood utilized in blood conservation group across all ages and complexity levels. CONCLUSION Blood conservation surgery can be performed in con-genital patients needing cardiac surgery in all age groups and complexity categories. The above findings in addition to attendant risks and side effects of blood transfusion and the rising cost of safer blood products justify blood conservation in congenital cardiac surgery.     

Evaluation of Epsilon amino-caproic acid (EACA) and autologous blood as blood conservation strategies in patients undergoing cardiac surgery

BACKGROUND: To evaluate the effects of autologous blood and Epsilon amino-caproic acid on intra-operative and post-operative blood loss and homologous blood product requirements in patients undergoing cardiac surgery. METHODS: Patients were randomly allocated to two groups of 30 each. In the Epsilon amino-caproic acid (EACA) group, the drug was administered in a loading dose of 100 mg/kg before skin incision followed by an infusion of 1/5 th the loading dose hourly and terminated 3 h after heparin neutralization. In the autologous transfusion (AT) group, 10% of the calculated whole blood volume was collected intra-operatively before cardiopulmonary bypass and re-infused after its termination. RESULTS: Haemoglobin values were comparable pre-operatively, on cardiopulmonary bypass, off cardiopulmonary bypass and post-operatively on day two in both groups. Intra-operative blood loss was not significantly different (643.3+/-129.14 ml in group EACA versus 710+/-145.5 ml in group AT, p = 0.66). Although the chest drainage was more in group AT during 0-3 h (71.3+/-54.3 ml versus 112.6+/-79.3.6 ml, p = 0.006) it was comparable amongst in the first 24 h (231.1+/-98.3 ml in group AT versus 235+/-101.4 ml in group EACA, p = 0.88). Homologous blood product requirements were similar in both groups. CONCLUSION: Autologous blood is as efficacious as Epsilon amino-caproic acid for blood conservation in cardiac surgery.     

法乐四联症根治术术中血液保护策略

探讨法洛四联症心内直视手术中的血液保护方法。方法 分析2010年1月至2014年5月我院75例法洛四联症根治术患者资料,按我院开始行血液保护措施时间将患者分为两组,对照组（31例）和血液保护组（44例）,两组患者采用常规预充方法。血液保护组预计体外循环（ECC）转流中红细胞压积（HCT）大于30%时,经腔静脉插管放血,转流中维持HCT 25%,停机后给予改良超滤提高HCT至30%,并保持体温35 ℃～36 ℃;对照组HCT大于30%不予处理,停机后HCT低于30%给予输注红细胞悬液。比较两组患者体外循环预充用血量和预充用血浆量、血红蛋白（Hb）、胶体渗透压（COP）、乳酸值（Lac）、尿液颜色等。结果 所有患者均痊愈出院,无严重脏器损害。预充用血量对照组明显高于血液保护组（180.0ml/121.4ml）（P<0.05）,但预充用血浆量两组患者比较未见统计学差异（P>0.05）。转中Hb、COP以及转后Hb两组患者比较未见统计学差异（115.5ml/121.5ml）（P>0.05）,转后血液保护组COP高于对照组（P<0.05）,但转后Lac血液保护组明显低于对照组（P<0.05）,对照组出现血红蛋白尿比例高于血液保护组（P<0.05）。结论 法洛四联症手术中综合应用血液保护措施安全可行,能有效减少围术期用血量,有利于患者恢复。     

体外循环心脏手术中单种和联合血液保护效果比较

目的比较多种联合措施及单种措施对血液的保护作用效果。方法对辽宁医学院附属第一医院2009年1月～2011年12月间行体外循环心脏直视手术的84例患者的血液保护措施(氨甲环酸、止血颗粒、去氨加压素及冷沉淀)资料进行收集和整理,用SPSS17.0软件进行统计分析。结果氨甲环酸加用止血颗粒可降低胸腔引流量,再加去氨加压素不仅减少胸腔引流量,还减少部分血细胞丢失及血液制品的输入量。加用冷沉淀之后的联合血液保护措施可明显提高术后血细胞计数、减少术后引流量(P均<0.05),而且明显减少新鲜冰冻血浆和浓缩红细胞的输入量(P均<0.05)。结论多种联合措施比单种措施对血液的保护作用效果显著。     

Vacuum-assisted closure for mediastinitis after pediatric cardiac surgery

Two children, aged 1 and 14 years with methicillin-resistant Staphylococcus aureus mediastinitis after pediatric open-heart surgery, were fitted with a vacuum-assisted closure system. Complete healing was achieved in both cases, and primary wound closure could be carried out without an omental flap after 6 and 16 days.     

Infection risk factors in pediatric cardiac surgery

Cardiac operations were preformed in 499 children from January 1998 through December 1999. Their median age was 263 days. A positive culture from blood, bronchoalveolar lavage, wound, or central catheter was obtained in 110 patients (22%). Age, sex, presence of pulmonary hypertension, body surface area, ratio of body surface area to oxygenator surface area, whether heart surgery was open or closed, and the duration of the operation, cardiopulmonary bypass, intubation, and intensive care were analyzed. Patients who developed infections were significantly younger, with smaller body surface areas and disparity with the oxygenator surface area, longer operative and bypass times, extended intubation, and prolonged intensive care. There was a significant correlation between infection and pulmonary hypertension. Sex and type of operation were not predictors of infection.     

Critical illness hyperglycemia in pediatric cardiac surgery

Critical illness hyperglycemia (CIH) is common in pediatric and adult intensive care units (ICUs). Children undergoing surgical repair or palliation of congenital cardiac defects are particularly at risk for CIH and its occurrence has been associated with increased morbidity and mortality in this population. Strict glycemic control through the use of intensive insulin therapy (IIT) has been shown to improve outcomes in some adult and pediatric studies, yet these findings have sparked controversy. The practice of strict glycemic control has been slow in extending to pediatric ICUs because of the documented increase in the incidence of hypoglycemia in patients treated with IIT. Protocol driven approaches with more liberal glycemic targets have been successfully validated in general and cardiac critical care pediatric patients with low rates of hypoglycemia. It is unknown whether a therapeutic benefit is obtained by keeping patients in this more liberal glycemic control target. Definitive randomized controlled trials of IIT utilizing these targets in critically ill children are ongoing.     

小儿心脏手术脑保护的研究

随着心脏大血管手术技术的迅速发展,小儿先天性心脏病术后并发症及死亡率显著下降,但术后脑功能紊乱发生率仍很高,脑保护问题已日益引起人们的关注.近年来国内外学者的研究主要集中于体外循环灌注技术、血气稳态管理方式以及药物脑保护等方面,并取得了重大进展.     

Outcomes of emergent cardiac catheterization following pediatric cardiac surgery

Background: Although there is agreement of the importance of cardiac catheterization, especially interventional procedures, cardiac catheterization in postoperative critical care unit (CCU) period is often debated. The focus of this study was to explore the indications for and determinants of outcome after cardiac catheterization in this setting. Methods: Between March 2004 and October 2006, 49 children (2.8% of cardiac surgeries) underwent 62 catheterizations before discharge from the CCU. Morphological, surgical, and catheterization data were accrued and analyzed using parametric competing risks models and multivariable risk‐hazard analysis. Results: Median age at surgery was 167 days (0–13.5 years) and time to catheterization was 8.5 (0–84) days following surgery. Catheterization procedures were either interventional (n = 35) or noninterventional (n = 27). Children who required a more urgent investigation following initial surgery more often had deployment of a stent at catheterization (P = 0.01) or subsequent surgical pulmonary artery augmentation (P < 0.01). Surgical reoperation was required following 23 (37%) catheterizations and was more common following index surgery involving a cavopulmonary shunt. Overall mortality was high (43%). Delayed invasive investigation beyond 2–3 weeks (P = 0.04) or a splinted sternum (P < 0.001) were risk factors for death. In addition, reoperation after a noninterventional catheterization predicted worse survival (P < 0.001). Conclusions: The need for invasive investigation in the immediate CCU period is associated with a poor outcome, especially when the investigation is delayed or an intervention is not possible. Identification of at‐risk patients may improve outcomes. Best outcomes follow expedient catheterization with definitive management (often stent deployment or pulmonary artery augmentation). © 2009 Wiley‐Liss, Inc.     

先天性心脏病外科手术后的血糖控制

目的:观察先天性心脏病外科术后血糖控制对并发症发生率及预后的影响。方法: 156例先天性心脏病患儿被随机分为加强控制组（A组）,积极控制组（B组）,一般控制组（C组）。患儿入ICU后每2 h查静脉血糖,A组、B组、C组分别在血糖超过8.3 mmol/L、10.0 mmol/L、15.0 mmol/L静脉给予胰岛素治疗。比较3组患儿术后72 h血白细胞计数、呼吸道感染发生率、伤口感染发生率、低血糖发生率、手术死亡率、ICU滞留时间、住院时间。结果: A组的低血糖发生率明显高于B组和C组,A组和B组的72 h血白细胞计数、肺部感染发生率、伤口感染发生率、手术死亡率、ICU滞留时间、住院时间均无统计学差异。C组的72 h血白细胞计数、肺部感染发生率明显高于A组和B组。结论: 术后过高的血糖能增加患儿的白细胞计数及肺部感染发生率。 但过于积极的控制血糖并不能改善患者的疗效,反而会增加低血糖的发生率。     

Conservation of blood in cardiac surgery

The rising costs of surgical care and decreasing third-party reimbursement mandate conservation of surgical resources and supplies whenever possible. One such resource is autologous blood. Its conservation has the added benefit of protecting the patient from the potential dangers of homologous blood and its products. This article presents conservation techniques found to be feasible in open-heart surgery.     

Preoperative autologous blood donation for cardiac surgery in children

Preoperative autologous blood donation has been shown to reduce homologous blood transfusion in cardiac operations, but there have been few reports of its use in children. Of 50 children aged 6 months to 5 years (weight, 6.1-14.8 kg) undergoing primary cardiac surgery for simple anomalies, 23 donated autologous blood before surgery, the other 27 were age and weight-matched controls. Two donations of 10 mL x kg(-1) each were collected via the femoral vein under mild general anesthesia 12 +/- 5 and 19 +/- 7 days preoperatively. No complications related to autologous blood collection were observed. Homologous blood use was significantly less in the group given autologous blood (4.3%) compared to the control group (44.4%). There was no significant difference in hemoglobin levels between groups before, during or after the operation. Preoperative autologous blood donation appears to be safe and effective in reducing homologous transfusions, even in children weighing less than 15 kg.