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Quantitative and functional changes in platelets and fibrinogen following cardiopulmonary by-pass in children
Margherita Plebani1, David Longchamp2, Pauline Lauwers2
1Pediatric Infectious Diseases and Vaccinology Unit, Department Women-Mother-Child, Lausanne University Hospital and University of Lausanne, Laussanne, Switzerland.
Insights
Cardiopulmonary bypass (CPB) surgery in children with congenital heart disease (CHD) significantly reduces platelet and fibrinogen levels and function. Prolonged CPB and hypothermia worsen this coagulopathy, particularly in younger children.
Area of Science:
- Cardiovascular Surgery
- Hematology
- Pediatric Cardiology
Background:
- Cardiopulmonary bypass (CPB) is associated with coagulopathy, increasing risks of bleeding and mortality in patients with congenital heart diseases (CHD).
- The precise mechanisms and contributing factors to post-CPB coagulopathy remain incompletely understood, necessitating further investigation.
Purpose of the Study:
- To assess changes in platelet and fibrinogen concentration and function following CPB in pediatric patients with CHD.
- To identify factors associated with the occurrence and severity of post-CPB coagulopathy.
Main Methods:
- Prospective analysis of 104 pediatric patients (0-16 years) undergoing CPB for CHD.
- Collection of blood samples pre-surgery and post-CPB for standard coagulation tests.
- Functional coagulation analysis using point-of-care thromboelastometry and impedance aggregometry.
Main Results:
- Significant post-CPB decreases in platelet count, fibrinogen concentration, and their respective functional activities were observed.
- CPB duration correlated with reduced platelet count and fibrinogen levels, but not functional activity.
- Patients avoiding hypothermia had higher postoperative platelet and fibrinogen levels; younger age was linked to greater decreases in platelet count and fibrinogen function.
Conclusions:
- Post-CPB coagulopathy in pediatric CHD patients is multifactorial, involving both dilution and functional impairment of coagulation components.
- Thromboelastometry and impedance aggregometry are valuable tools for assessing these functional changes.
- Younger children, longer CPB duration, and intraoperative hypothermia are significant risk factors for developing post-CPB coagulopathy.
Introduction:
Cardiopulmonary bypass (CPB) causes coagulopathy, increasing the risk of postoperative bleeding and mortality. The underlying causes of post-CPB coagulopathy and the factors associated with its occurrence are not yet fully understood. This study assesses platelet and fibrinogen concentration and function following CPB in children with congenital heart diseases (CHD).
Methods:
We analyzed prospective data from 104 patients aged 0-16 years who underwent CPB surgery for CHD. Blood samples were collected before surgery and within 30 min of CPB completion. In addition to usual coagulation tests, functional analyses were performed using point of care systems with thromboelastometry and impedance aggregometry.
Results:
Platelet count, fibrinogen concentration, and platelet and fibrinogen activities significantly decreased after CPB. The duration of CPB was directly associated with a reduction in platelet count and fibrinogen level (r = -0.38, p < 0.001; r = -0.21, p = 0.03, respectively), but not with their measured activity. Postoperative percentages of baseline values for platelet count (58.36% [43.34-74.44] vs. 37.44% [29.81-54.17], p < 0.001) and fibrinogen concentration (73.68% [66.67-82.35] vs. 65.22% [57.89-70.83], p < 0.001) were significantly higher in patients who did not experience hypothermia during surgery. Age was inversely associated with the decrease in platelet count (r = 0.63, p < 0.001), TRAPTEM AUC (r = 0.43, p < 0.001), fibrinogen concentration (r = 0.44, p < 0.001) and FIBTEM MCF (r = 0.57, p < 0.001).
Conclusion:
Post-CPB coagulopathy is multifactorial and not solely attributed to hemodilution. It also involves functional changes in coagulation cascade components, which can be demonstrated by thromboelastometry and impedance aggregometry. Young children, patients requiring prolonged CPB surgery, or those experiencing hypothermia are particularly affected.
