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Predicting and treating coagulopathies after cardiopulmonary bypass in children
B E Miller1, T Mochizuki, J H Levy
1Department of Anesthesiology, Emory University School of Medicine and Egleston Children's Hospital at Emory University, Atlanta, Georgia 30322, USA.
Insights
Children under 8 kg experience more bleeding and coagulopathy after cardiopulmonary bypass (CPB). Platelets and cryoprecipitate are effective for hemostasis, while fresh-frozen plasma offers no benefit in pediatric CPB patients.
Area of Science:
- Pediatric Cardiology
- Hematology
- Cardiothoracic Surgery
Background:
- Coagulopathies following cardiopulmonary bypass (CPB) in children are complex.
- Limited data exist correlating coagulation tests with postoperative bleeding in this population.
Purpose of the Study:
- To evaluate coagulation changes after CPB and coagulation product administration in children.
- To identify predictors of postoperative bleeding and guide component therapy.
Main Methods:
- Coagulation tests were performed at baseline, after protamine, after product transfusion, and in the ICU for 75 children.
- Regression analysis was used to identify predictors of bleeding (chest tube drainage).
Main Results:
- No baseline coagulation test predicted postoperative bleeding; weight and CPB duration were the only predictors.
- Children <8 kg had increased bleeding and required more coagulation products.
- Postprotamine platelet count and fibrinogen (for <8 kg) or thrombelastography (for >8 kg) correlated with drainage.
- Platelets effectively restored hemostasis; cryoprecipitate aided ongoing bleeding.
- Fresh-frozen plasma worsened outcomes and was associated with increased bleeding and transfusions.
Conclusions:
- Children <8 kg are at higher risk for severe coagulopathy, bleeding, and require more transfusions post-CPB.
- Platelets and cryoprecipitate are optimal for restoring hemostasis.
- Fresh-frozen plasma provides no benefit for postcardiopulmonary bypass coagulopathies in children.
Unlabelled:
Coagulopathies in children after cardiopulmonary bypass (CPB) are complex. There are very limited data correlating coagulation tests with postoperative bleeding. We evaluated coagulation changes after CPB and after the administration of coagulation products to 75 children. Baseline coagulation tests were obtained and repeated after protamine administration, after transfusion of individual coagulation products, and on arrival in the intensive care unit (ICU). Regression analysis demonstrated no baseline coagulation test to predict postoperative chest tube drainage. Weight and duration of CPB were determined to be the only predictors of bleeding. Further analyses demonstrated that children <8 kg had more bleeding and required more coagulation products than children >8 kg. Postprotamine platelet count and fibrinogen level correlated independently with 24-h chest tube drainage in children <8 kg, whereas postprotamine platelet count and thrombelastographic values did so in patients weighing >8 kg. Platelet administration alone was found to restore effective hemostasis in many patients. With ongoing bleeding, cryoprecipitate improved coagulation parameters and limited blood loss. Fresh-frozen plasma administration after platelets worsened coagulation parameters and was associated with greater chest tube drainage and more coagulation product transfusions in the ICU. Objective data to guide post-CPB component therapy transfusion in children are suggested.
Implications:
Children <8 kg can be expected to have more severe coagulopathies, require more coagulation product transfusions, and bleed more after cardiopulmonary bypass. Correlations between coagulation tests and postoperative chest tube drainage are defined. Platelets and, if necessary, cryoprecipitate optimally restore hemostasis. Fresh-frozen plasma offers no benefits in correcting postcardiopulmonary bypass coagulopathies in children.