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Transfusion Effects on Pediatric Heart Transplant Patients. Kimberly Howard- Quijano , M.D. Assistant Clinical Professor Department of Anesthesiology David Geffen School of Medicine, UCLA. Disclosures. None. Effects of blood transfusions. Benefits Increased oxygen-carrying capacity

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transfusion effects on pediatric heart transplant patients

Transfusion Effects on Pediatric Heart Transplant Patients

Kimberly Howard-Quijano, M.D.

Assistant Clinical Professor

Department of Anesthesiology

David Geffen School of Medicine, UCLA

effects of blood transfusions
Effects of blood transfusions
  • Benefits
    • Increased oxygen-carrying capacity
    • Tissue oxygenation
    • Replace operative blood loss
    • Improve hemostasis

Guzzetta NA. Benefits and risks of red blood cell transfusion in pediatric patients undergoing cardiac surgery. PediatrAnesth. 2010;21:504–11

effects of blood transfusions1
Effects of blood transfusions
  • Risks
    • Infectious risks
    • Transfusion-related acute lung injury
    • Transfusion-related circulatory overload
    • Hemolytic transfusion reactions
    • Clerical errors
    • Independent risk factor for worsening postoperative outcomes

Guzzetta NA. Benefits and risks of red blood cell transfusion in pediatric patients undergoing cardiac surgery. PediatrAnesth. 2010;21:504–11

pediatric population
Pediatric Population
  • Increased complication risk in children versus adults
    • 10.7 complications per 1000 units transfused in the pediatric population
    • 2.5 complications per 1000 units transfused in adults

Slonin AD, Joseph JG, Turenne WM, et al. Blood transfusions in children; a multi-institutional analysis of practices and complications. Transfusion 2008; 48: 73-80

pediatric population1
Pediatric Population
  • Studies in pediatric ICU patients have shown an association between transfusions and poor outcomes
    • Retrospective
      • Single center study, 295 patients admitted to ICU
      • Independent associations between transfusions and ICU morbidity and mortality
      • Increase in inotrope score, duration of intubation, and length of ICU stay

Kneyber MC, Hersi MI, Twisk JW, Markhorst DG, Plotz FB. Red blood cell transfusion in critically ill children is associated with increased mortality. Intensive Care Med. 2007;33:

1414–22

pediatric population2
Pediatric Population
  • Prospective
    • Non-inferiority trial
    • 637 pts admitted to ICU who were stable but critically ill
    • Randomized to restrictive (Hg 7 g/dl) versus liberal transfusion (Hg 9.5 g/dl) threshold
    • No difference on outcomes, no increase in adverse events

Lacroix J, Hebert P, Hutchison J, et al. Transfusion strategies for patients in pediatric intensive care units. NEJM 2007 356;16. 1609-1619.

congenital cardiac patients
Congenital Cardiac Patients
  • Difficult to study given small numbers and wide heterogeneity in population
  • Increased transfusions in this population due to cardiopulmonary bypass associated hemodilution
  • Majority of studies are performed in ICU and do not take into account the transfusions given in the operating room
congenital cardiac patients1
Congenital Cardiac Patients
  • Prospective
    • 657 pediatric patients undergoing open heart surgery
    • Transfusions during surgery and first 24hrs post-op were calculated
    • Association was found between increasing transfusions and risk of post-operative infection but not mortality

Szekely A, Cserep Z, Sapi E, Breuer T, Nagy CA, Vargha P, Hartyanszky I, Szatmari A, Treszel A. Risks and predictors of blood transfusion in pediatric patients undergoing open heart operations. Ann Thorac Surg. 2009;87:187–97

pediatric heart transplants
Pediatric Heart Transplants
  • Unique patient population:
    • Large percentage of patients undergo transfusions (83% nationally per STS database)
    • Complex immunologic reactions
  • Several theories regarding recipient immune response to donor leukocytes as causative agent in transfusion related outcomes
effect of blood transfusions on pediatric heart transplant
Effect of Blood Transfusions on Pediatric Heart Transplant
  • Retrospectivestudyfor all pediatric patients receiving OHT
    • January 2004 to December 2010
    • Data gathered from paper and electronic records, UNOS database, anesthesia and perfusion records
  • Pre-operative demographics
  • Intra-operative data
      • surgery, CPB, and red blood cell transfusions (ml/kg)
methods
Methods
  • Post-operative data
    • RBC transfusions (ml/kg) first 48hrs after admission to ICU
    • Outcome measures
      • Duration of ICU stay
      • Length of mechanical ventilation
      • Inotrope score for first 48hrs
      • Major adverse events (MAE’s) for first 30 days post-op
      • Mortality
methods1
Methods
  • Clinical transfusion protocol:
    • Intra and post-operative transfusion for
      • Hct< 28%
      • Continued bleeding
      • Evidence of decreased oxygen carrying capacity
  • CPB protocol:
    • PRBC pump prime for pt weight <10kg, or dilutionalHct < 23%
    • Transfusions on pump for expected Hct <28% coming off pump
pre operative diagnosis
Pre-operative Diagnosis

*Complex congenital heart disease: cyanotic (n=8) andacyanotic (n=20)

transfusion amount
Transfusion Amount
  • Largest amount transfused was in infants and patients weigh less than 10 kg
  • Infants: 95 cc/kg, children: 30 cc/kg, and adolescents: 9cc/kg
  • Weight < 10kg: 94 cc/kg versus >60 kg: 3cc/kg
major adverse events
Major Adverse Events
  • MAE found in 20 pts:
    • ECMO (8), Sepsis (5), Open Chest (10), AKI (6), Graft failure (3)
roc for prediction of mae
ROC for Prediction of MAE
  • Threshold of 60 ml/kg increased likelihood for MAE.
    • Sensitivity 80%, Specificity 72%, Accuracy 76%
    • Area under ROC curve 0.77
multivariate analysis
Multivariate Analysis
  • Red blood cell transfusions were independently associated with:
    • Increased length of ICU stay
    • Increased duration of intubation and mechanical ventilation
    • Inotrope score in the 1st 24hrs post-op
significant findings
Significant Findings
  • Red blood cell transfusions are associated with dose dependent worsening clinical outcomes in pediatric heart transplant patients
    • Other pre-operative factors such as age, UNOS status, and ischemia time were not independent risk factors
  • Patients receiving > 60ml/kg are more likely to suffer from major adverse events
limitations
Limitations
  • Retrospective study design
    • Can determine associations but not causality
    • Which is truly changing outcomes; bleeding or blood transfusions
  • Sample size
  • Age of blood transfused
conclusions
Conclusions
  • Proper blood management is of utmost importance, blood transfusions are necessary but not benign
    • Must be able to determine who really needs transfusions
    • Blood utilization and conservation protocols
    • Increased research with strong randomized controlled trials
intraop blood conservation protocol
Intraop Blood Conservation Protocol
  • Indications for red cell transfusion:
    • Hematocrit< 30% for cyanotic and acyanotic patients AND/OR:
    • AVO2 > 40
    • NIRS decrease > 20%
    • Lactate > 20 x 2 values
    • Hematocrit20-30% is acceptable if patient is hemodynamically stable with nosign of poor tissue perfusion and oxygenation
  • Indications for FFP, platelet or cryoprecipitate transfusion
    • If bleeding (> 5cc/kg/hr):
    • Platelet transfusion for platelets < 60,000
    • Cryoprecipitate for fibrinogen < 150
    • Fresh frozen plasma for INR > 1.7
postop blood conservation protocol
PostopBlood Conservation Protocol
  • Indications for red cell transfusion:
    • Hct(< 30 for cyanotic patients, < 20 for acyanotic) AND/OR:
    • AVO2 >30-40
    • NIRS decrease > 20%
    • Lactate >20 x 2 values
  • Indications for FFP, platelet or cryoprecipitate transfusion:

If bleeding > 10 cc/kg/hr:

    • FFP if INR > 1.7, Platelets transfusion for platelets < 60, Cryoprecipitate for fibrinogen < 150

If bleeding 5-10 cc/kg/hr:

    • FFP if INR > 2.0, Platelets for count < 50, Cryoprecipitate for fibrinogen < 120
bloodless surgery protocol
Bloodless Surgery Protocol
  • Formulated for our Jehovah’s witness patients
  • Created by collaboration of surgeons, intensivists, hematology, anesthesia, perfusion, and blood bank
    • With input from religious elders and patients
  • Pediatric patients however, are always allowed transfusions in life threatening situations
    • Regardless of parents religious beliefs
bloodless surgery protocol1
Bloodless Surgery Protocol

Preoperatively

  • HIGH RISK patients (cyanotic 10-14kg, acyanotic 8-12kg and any patient < 12 kg)
    • Iron and folate supplementation if hematocrit < 40
    • Hct >35, proceed with surgery.
    • Hct < 35, refer to pediatric hematology. Surgery should be delayed, if possible, until hematocrit is near 40.
  • For LOW RISK patients (cyanotic > 14kg, acyanotic> 12kg):
    • Iron and folate supplementation for all
    • CBC drawn day prior to surgery
    • If hematocrit < 25, surgery should be postponed
bloodless surgery protocol2
Bloodless Surgery Protocol

Intraoperatively

  • Anesthesia
    • Minimize crystalloid administration
    • Acute normovolemichemodilution
  • Perfusion
    • Retrograde autologous priming (available for patients 20-40kg)
    • Circuit miniaturization
    • Modified ultrafiltration
bloodless surgery protocol3
Bloodless Surgery Protocol

Postoperatively

  • Minimize blood draws
  • First PT/INR, PTT, fibrinogen after surgery to OR lab for faster processing
  • Consider use of additional protamine, aminocaproic acid, factor VIIa to control bleeding
  • Consider erythropoietin, iron supplementation
  • Blood conservation protocol
questions
Questions

Thank you