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Prediction of Bleeding in Pediatric Cardiac Surgery Using Clinical Characteristics and Prospective Coagulation Test
Jessica M Harris1, Karen Sheehan2, Chris A Rogers1
1Bristol Trials Centre, Faculty of Health Sciences, University of Bristol, Bristol, UK.
Insights
Prospective coagulation testing slightly improves prediction of bleeding concerns (CCB) in pediatric cardiac surgery patients. However, the clinical impact is minimal compared to using clinical factors alone.
Area of Science:
- Pediatric Cardiac Surgery
- Coagulation Medicine
- Clinical Prediction Modeling
Background:
- Bleeding due to coagulopathy is a frequent complication in pediatric cardiac surgery, leading to adverse outcomes.
- The predictive role of coagulation testing for bleeding risk in this population remains uncertain.
Purpose of the Study:
- To compare the predictive accuracy of prospective coagulation testing versus clinical characteristics alone for excessive bleeding during and after pediatric cardiac surgery.
Main Methods:
- A single-center, prospective cohort study involving 225 children undergoing cardiac surgery.
- Coagulation testing was performed at anesthetic induction and post-cardiopulmonary bypass.
- Clinical Concern about Bleeding (CCB) was the primary outcome, defined by prohemostatic treatment or high chest drain volume.
Main Results:
- CCB occurred in 12% during and 30% after surgery.
- Clinical characteristics alone predicted CCB with c-statistics of 0.64 (during) and 0.74 (after).
- Incorporating coagulation tests improved prediction (c-statistics 0.79 and 0.80) but with only a marginal increase in correct classification (0.9% and 0.4%).
Conclusions:
- Prospective coagulation testing offers a marginal improvement in predicting bleeding concerns in pediatric cardiac surgery.
- The clinical utility of adding coagulation testing to predictive models is limited when compared to clinical factors alone.
Abstract:
Bleeding caused by coagulopathy is common in children undergoing cardiac surgery and causes adverse outcomes. Coagulation testing assists selection of treatments to stop bleeding but has an uncertain role for predicting bleeding. We aimed to evaluate how well prospective coagulation testing predicted excessive bleeding during and after cardiac surgery compared to prediction using clinical characteristics alone. The study was a single-center, prospective cohort study in children having a range of cardiac surgery procedures with coagulation testing at anesthetic induction and immediately after cardiopulmonary bypass. The primary outcome was clinical concern about bleeding (CCB), a composite of either administration of prohemostatic treatments in response to bleeding or a high chest drain volume after surgery. In 225 children, CCB occurred in 26 (12%) during surgery and in 68 (30%) after surgery. Multivariable fractional polynomial models using the clinical characteristics of the children alone predicted CCB during surgery (c-statistic 0.64; 95% confidence interval 0.53, 0.76) and after surgery (0.74; 0.67, 0.82). Incorporating coagulation test results into these models improved prediction (c-statistics 0.79; 0.70, 0.87, and 0.80; 0.74, 0.87, respectively). However, this increased the overall proportion of children classified correctly as CCB or not CCB during surgery by only 0.9% and after surgery by only 0.4%. Incorporating coagulation test results into predictive models had no effect on prediction of blood transfusion or postoperative complications. Prospective coagulation testing marginally improves prediction of CCB during and after cardiac surgery but the clinical impact of this is small when compared to prediction using clinical characteristics.
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