Perfusion techniques toward bloodless pediatric open heart surgery

There continues to be evidence regarding the negative impact of blood transfusion on morbidity and mortality in the adult literature, including infection risk, increased hospital and intensive care length of stay, and costs. More effort has been put into reducing the use of blood components in adult surgical centers but blood transfusions continue to be used frequently in pediatric centers. From 2002 through 2005, we embarked on a mission of reduced prime volume in an effort toward bloodless cardiac surgery to meet the needs of the Jehovah's Witness patient. The same bloodless surgical and perfusion techniques were applied to all patients undergoing cardiopulmonary bypass beginning in 2006. Circuit size was minimized and acute normovolemic hemodilution (ANH) was considered and attempted more often, especially if a re-operation. Retrograde arterial prime (RAP) and venous antegrade prime (VAP), dilutional or balanced ultrafiltration during cardiopulmonary bypass, modified arteriovenous ultrafiltration post bypass, and cell salvage of remaining circuit contents after flushing with crystalloid were recorded. ANH, RAP, and VAP, separately or in combination, were used less than 1% of the time prior to 2006. From 2006-2008 ANH was performed on 42% of the patients and RAP/ VAP was performed on 70% of the patients. From 2006-2008, 43% (287 of 662) of the open heart surgeries were performed bloodless in the operating room versus 30% (193 of 633) from 2003-2005. Bloodless surgery more than doubled for the 0-6, 6-15, and 15-20 kg groups from 3.5%, 23%, and 23% respectively in 2003-2005 to 9%, 44%, and 58%, respectively in 2006-2008. With the cooperation of the entire cardiac surgical team, bloodless open heart surgery is achievable in a pediatric cardiac surgical center, including neonates.