Anemia after Pediatric Congenital Heart Surgery

Abstract

The postoperative course of infants following congenital heart surgery is associated with significant blood loss and anemia. Optimal transfusion thresholds for cardiac surgery patients while in pediatric intensive care unit (PICU) remain a subject of debate. The goal of this study is to describe the epidemiology of anemia and the transfusion practices during the PICU stay of infants undergoing congenital heart surgery. A retrospective cohort study was performed in a PICU of a tertiary university-affiliated center. Infants undergoing surgery for congenital heart disease (CDH) before 6 weeks of age between February 2013 and June 2019 and who were subsequently admitted to the PICU were included. We identified 119 eligible patients. Mean age at surgery was 11 ± 7 days. Most common cardiac diagnoses were d-Transposition of the Great Arteries (55%), coarctation of the aorta (12.6%), and tetralogy of Fallot (11.8%). Mean hemoglobin level was 14.3 g/dL prior to surgery versus 12.1 g/dL at the PICU admission. Hemoglobin prior to surgery was systematically higher than hemoglobin at the PICU entry, except in infants with Hypoplastic Left Heart Syndrome. The average hemoglobin at PICU discharge was 11.7 ± 1.9 g/dL. Thirty-three (27.7%) patients were anemic at PICU discharge. Fifty-eight percent of patients received at least one red blood cell (RBC) transfusion during PICU stay. This study is the first to describe the epidemiology of anemia at PICU discharge in infants following cardiac surgery. Blood management of this distinctive and vulnerable population requires further investigation as anemia is a known risk factor for adverse neurodevelopment delays in otherwise healthy young children.

Keywords

critical care illness - pediatric intensive care unit - congenital heart disease - anemia

^* These authors contributed equally to this work.

Publikationsverlauf

Eingereicht: 05. November 2020

Angenommen: 23. Januar 2021

Artikel online veröffentlicht:
23. März 2021

• References

• 1 Bateman ST, Lacroix J, Boven K. et al; Pediatric Acute Lung Injury and Sepsis Investigators Network. Anemia, blood loss, and blood transfusions in North American children in the intensive care unit. Am J Respir Crit Care Med 2008; 178 (01) 26-33
• 2 Iyengar A, Scipione CN, Sheth P. et al. Association of complications with blood transfusions in pediatric cardiac surgery patients. Ann Thorac Surg 2013; 96 (03) 910-916
• 3 Kneyber MC, Hersi MI, Twisk JW, Markhorst DG, Plötz FB. Red blood cell transfusion in critically ill children is independently associated with increased mortality. Intensive Care Med 2007; 33 (08) 1414-1422
• 4 Kipps AK, Wypij D, Thiagarajan RR, Bacha EA, Newburger JW. Blood transfusion is associated with prolonged duration of mechanical ventilation in infants undergoing reparative cardiac surgery. Pediatr Crit Care Med 2011; 12 (01) 52-56
• 5 Salvin JW, Scheurer MA, Laussen PC. et al. Blood transfusion after pediatric cardiac surgery is associated with prolonged hospital stay. Ann Thorac Surg 2011; 91 (01) 204-210
• 6 Cholette JM, Swartz MF, Rubenstein J. et al. Outcomes using a conservative versus liberal red blood cell transfusion strategy in infants requiring cardiac operation. Ann Thorac Surg 2017; 103 (01) 206-214
• 7 Cholette JM, Rubenstein JS, Alfieris GM, Powers KS, Eaton M, Lerner NB. Children with single-ventricle physiology do not benefit from higher hemoglobin levels post cavopulmonary connection: results of a prospective, randomized, controlled trial of a restrictive versus liberal red-cell transfusion strategy. Pediatr Crit Care Med 2011; 12 (01) 39-45
• 8 de Gast-Bakker DH, de Wilde RB, Hazekamp MG. et al. Safety and effects of two red blood cell transfusion strategies in pediatric cardiac surgery patients: a randomized controlled trial. Intensive Care Med 2013; 39 (11) 2011-2019
• 9 Willems A, Harrington K, Lacroix J. et al; TRIPICU investigators, Canadian Critical Care Trials Group, Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network. Comparison of two red-cell transfusion strategies after pediatric cardiac surgery: a subgroup analysis. Crit Care Med 2010; 38 (02) 649-656
• 10 Doctor A, Cholette JM, Remy KE. et al. Recommendations on RBC Transfusion in general critically ill children based on hemoglobin and/or physiologic thresholds from the pediatric critical care transfusion and anemia expertise initiative. Pediatr Crit Care Med 2018; 19 (9S suppl 1): S98-S113
• 11 Cholette JM, Willems A, Valentine SL. et al. Recommendations on RBC transfusion in infants and children with acquired and congenital heart disease from the pediatric critical care transfusion and anemia expertise initiative. Pediatr Crit Care Med 2018; 19 (9S suppl 1): S137-S148
• 12 Snookes SH, Gunn JK, Eldridge BJ. et al. A systematic review of motor and cognitive outcomes after early surgery for congenital heart disease. Pediatrics 2010; 125 (04) e818-e827
• 13 Schaefer C, von Rhein M, Knirsch W. et al. Neurodevelopmental outcome, psychological adjustment, and quality of life in adolescents with congenital heart disease. Dev Med Child Neurol 2013; 55 (12) 1143-1149
• 14 Jacobs JP, O'Brien SM, Pasquali SK. et al. Variation in outcomes for risk-stratified pediatric cardiac surgical operations: an analysis of the STS Congenital Heart Surgery Database. Ann Thorac Surg 2012; 94 (02) 564-571 , discussion 571–572
• 15 Lau W. Neonatal and Pediatric Transfusion. Clinical Guide to Transfusion. Canadian Blood Services. 2017. . Available at: https://professionaleducation.blood.ca/en/neonatal-and-pediatric-transfusion
• 16 Demaret P, Karam O, Tucci M. et al. Anemia at pediatric intensive care unit discharge: prevalence and risk markers. Ann Intensive Care 2017; 7 (01) 107
• 17 Demaret P, Valla FV, Behal H. et al. Anemia at discharge from the PICU: a bicenter descriptive study. Pediatr Crit Care Med 2019; 20 (09) e400-e409
• 18 Leteurtre S, Martinot A, Duhamel A. et al. Validation of the paediatric logistic organ dysfunction (PELOD) score: prospective, observational, multicentre study. Lancet 2003; 362 (9379): 192-197
• 19 Rendy L, Sapan HB, Kalesaran LTB. Multiple organ dysfunction syndrome (MODS) prediction score in multi-trauma patients. Int J Surg Open 2017; 8: 1-6
• 20 Pollack MM, Patel KM, Ruttimann UE. PRISM III: an updated pediatric risk of mortality score. Crit Care Med 1996; 24 (05) 743-752
• 21 Jenkins KJ. Risk adjustment for congenital heart surgery: the RACHS-1 method. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2004; 7: 180-184
• 22 Gaies MG, Gurney JG, Yen AH. et al. Vasoactive-inotropic score as a predictor of morbidity and mortality in infants after cardiopulmonary bypass. Pediatr Crit Care Med 2010; 11 (02) 234-238
• 23 Davidson J, Tong S, Hancock H, Hauck A, da Cruz E, Kaufman J. Prospective validation of the vasoactive-inotropic score and correlation to short-term outcomes in neonates and infants after cardiothoracic surgery. Intensive Care Med 2012; 38 (07) 1184-1190
• 24 Jutras C, Sauthier M, Tucci M. et al. Incidence of anemia at discharge of 4890 consecutive pediatric intensive care survivors. Vox Sang 2018;113(S1)
• 25 Radlowski EC, Johnson RW. Perinatal iron deficiency and neurocognitive development. Front Hum Neurosci 2013; 7: 585
• 26 Yager JY, Hartfield DS. Neurologic manifestations of iron deficiency in childhood. Pediatr Neurol 2002; 27 (02) 85-92
• 27 Ji X, Cui N, Liu J. Neurocognitive function is associated with serum iron status in early adolescents. Biol Res Nurs 2017; 19 (03) 269-277
• 28 Kohli-Kumar M. Screening for anemia in children: AAP recommendations—a critique. Pediatrics 2001; 108 (03) E56
• 29 Muñoz M, Breymann C, García-Erce JA, Gómez-Ramírez S, Comin J, Bisbe E. Efficacy and safety of intravenous iron therapy as an alternative/adjunct to allogeneic blood transfusion. Vox Sang 2008; 94 (03) 172-183
• 30 Corwin HL, Gettinger A, Pearl RG. et al; EPO Critical Care Trials Group. Efficacy of recombinant human erythropoietin in critically ill patients: a randomized controlled trial. JAMA 2002; 288 (22) 2827-2835
• 31 Corwin HL, Gettinger A, Fabian TC. et al; EPO Critical Care Trials Group. Efficacy and safety of epoetin alfa in critically ill patients. N Engl J Med 2007; 357 (10) 965-976
• 32 Zabala LM, Guzzetta NA. Cyanotic congenital heart disease (CCHD): focus on hypoxemia, secondary erythrocytosis, and coagulation alterations. Paediatr Anaesth 2015; 25 (10) 981-989
• 33 Hogervorst E, Rosseel P, van der Bom J. et al. Tolerance of intraoperative hemoglobin decrease during cardiac surgery. Transfusion 2014; 54 (10 Pt 2): 2696-2704
• 34 Mazine A, Rached-D'Astous S, Ducruet T, Lacroix J, Poirier N. Pediatric Acute Lung Injury and Sepsis Investigators Network. Blood transfusions after pediatric cardiac operations: A North American Multicenter Prospective Study. Ann Thorac Surg 2015; 100 (02) 671-677
• 35 Du Pont-Thibodeau G, Tucci M, Ducruet T, Lacroix J. Survey on stated transfusion practices in PICUs*. Pediatr Crit Care Med 2014; 15 (05) 409-416