Use of autologous umbilical cord blood transfusion in neonates undergoing surgical correction of congenital cardiac defects: A pilot study

Background: Blood transfusion requirement during neonatal open heart surgeries is universal. Homologous blood transfusion (HBT) in pediatric cardiac surgery is used most commonly for priming of cardiopulmonary bypass (CPB) system and for postoperative transfusion. To avoid the risks associated with HBT in neonates undergoing cardiac surgery, use of autologous umbilical cord blood (AUCB) transfusion has been described. We present our experience with the use of AUCB for neonatal cardiac surgery. Designs and Methods: Consecutive neonates scheduled to undergo cardiac surgery for various cardiac diseases who had a prenatal diagnosis made on the basis of a fetal echocardiography were included in this prospective observational study. After a vaginal delivery or a cesarean section, UCB was collected from the placenta in a 150-mL bag containing 5 mL of citrate–phosphate–dextrose–adenine-1 solution. The collected bag with 70–75 mL cord blood was stored at 2°C–6°C and tested for blood grouping and infections after proper labeling. The neonate's autologous cord blood was used for postcardiac surgery blood transfusion to replace postoperative blood loss. Results: AUCB has been used so far at our institute in 10 neonates undergoing cardiac surgery. The donor exposure in age and type of cardiac surgery-matched controls showed that the neonates not receiving autologous cord blood had a donor exposure to 5 donors (2 packed red blood cells [PRBCs], including 1 for CPB prime and 1 for postoperative loss, 1 fresh frozen plasma, 1 cryoprecipitate, and 1 platelet concentrate) compared to 1 donor for the AUCB neonate (1 PRBC for the CPB prime). Postoperative blood loss was similar in both the groups of matched controls and study group. Values of hemoglobin, total leukocyte count, platelet counts, and blood gas parameters were also similar. Conclusions: Use of AUCB for replacement of postoperative blood loss after neonatal cardiac surgery is feasible and reduces donor exposure to the neonate. Its use, however, requires a prenatal diagnosis of a cardiac defect by fetal echo and adequate logistic and psychological support from involved clinicians and the blood bank.

Management of pulmonary alveolar proteinosis with whole lung lavage using extracorporeal membrane oxygenation support in a postrenal transplant patient with graft failure.

Pulmonary alveolar proteinosis (PAP) is a rare lung disease characterized by accumulation of excessive lung surfactant in the alveoli leading to restrictive lung functions and impaired gas exchange. Whole lung lavage (WLL) is the treatment modality of choice, which is usually performed using double lumen endobronchial tube insertion under general anesthesia and alternating unilateral lung ventilation and washing with normal saline. It may be difficult to perform WLL in patients with severe hypoxemia wherein patients do not tolerate single lung ventilation. Extracorporeal membrane oxygenation support (ECMO) has been used in such patients. We report a patient with autoimmune PAP following renal transplant who presented with marked hypoxemia and was managed by WLL under ECMO support.

Surgical repair of D-TGA with an aortopulmonary window and ventricular septal defects / Correção cirúrgica da transposição das grandes artérias com janela aortopulmonar e defeitos do septo ventricular

D-Transposition of great arteries with an aortopulmonary window is a rare congenital anomaly. We describe a case of D-Transposition of great arteries with an aortopulmonary window and multiple ventricular septal defects in a 5-month boy who underwent successful surgical repair.

A transposição das grandes artérias com uma janela aortopulmonar é uma anomalia congênita rara. Descrevemos um caso de transposição das grandes artérias com janela aortopulmonar e múltiplos defeitos do septo ventricular em um menino de 5 meses submetido a tratamento cirúrgico com sucesso.

Comparison of three dose regimens of aprotinin in infants undergoing the arterial switch operation.

To determine the most effective dose regimen of aprotinin for infants undergoing arterial switch operation for transposition of the great arteries in reducing blood loss and postoperative packed red blood cell (PRBC) requirements. A total of 24 infants scheduled for arterial switch operation for transposition of the great arteries were included in the study. The infants were randomly assigned to one of the three groups. Group I (n = 8) patients received aprotinin in a dose of 20,000 kallikrein inhibiting units (KIU)/kg after induction of anesthesia, 20,000 KIU/kg was added to the pump prime, and 20,000 KIU/kg/hour infusion for three hours after weaning from bypass; group II (n = 8) patients received aprotinin 30,000 KIU/kg after induction of anesthesia, 30,000 KIU/kg was added to the pump prime and 30,000 KIU/Kg/hour infusion for three hours after weaning from bypass; group III patients (n = 8) received aprotinin 40,000 KIU/kg after induction of anesthesia, 40,000 KIU/kg was added to the pump prime and 40,000 KIU/kg/hour infusion for three hours after weaning from bypass. Postoperatively, the cumulative hourly blood loss and PRBC requirements were noted up to 24 hours from the time of admission in the intensive care unit (ICU). Use of blood and blood products were noted. Coagulation parameters such as hematocrit, activated clotting time (ACT), fibrinogen, prothrombin time (PT), international normalized ratio (INR), platelet count, and fibrin degradation products (FDP) were investigated before cardiopulmonary bypass (CPB), after protamine administration, and at four hours postoperatively in the ICU. The number of infants reexplored for increased mediastinal drainage was recorded. Renal functions were monitored by measuring urine output (hourly) and serum urea (mg%) and serum creatinine (mg%) at 24 hours. The sternal closure time was comparable in all the three groups. Cumulative blood loss (ml/kg/24 hours) was greatest in group I (17.30 ± 7.7), least in group III (8.14 ± 3.17), whereas in group II, it was 16.45 ± 6.33 (P = 0.019 group I versus group III; (P = 0.036 group II versus group III). Postoperative PRBC requirements were significantly less in high dose group III (P = 0.008, group I versus III; p = 0.116, group II versus group III) . Tests for coagulation performed at four hours postoperatively, viz. ACT, PT, INR, FDP, and platelets were comparable in the three groups. Urine output on CPB was comparable in all the groups. Serum urea and creatinine showed no significant difference between the three groups twenty four hours postoperatively. Aprotinin dosage regimen of 40,000 KIU/kg at induction, in CPB prime and postoperatively for three hours was most effective in reducing postoperative blood loss and PRBC transfusion requirements. Aprotinin does not have any adverse effect on renal function.

A Comparison of aminocaproic Acid and Tranexamic Acid in Adult Cardiac Surgery.

We compared Aminocaproic acid with tranexamic acid, prospectively in 120 patients undergoing coronary artery bypass surgery on cardiopulmonary bypass. Patients were assigned to one of the 3 groups. Group A (n=40) did not receive any drug and acted as the control group. Group B (n=4) received aminocaproic acid 100 mg/kg each at anaesthetic induction, on bypass and after protamine reversal of heparin. group C (n=40) received tranexamic acid 10 mg/kg each at anaesthetic induction, on bypass and after protamine reversal of heparin. Postoperative blood loss at 24 hours, blood and blood product usage, and re-exploration rates were recorded, and tests for coagulation were performed at 6 hours postoperatively. It was found that blood loss in group A at 24 hours (780+/-120 mL) was significantly greater than Group B (360+/-90 mL) and Group C (215+/-70 mL). Plasma and platelet concentrate use in Group A (215+/-30 mL and 150+/-30 mL) was greater than Group B (190+/-20 mL and 75+/-30 mL) and Group C (185+/-20 mL and 80+/-30 mL). Re- explorations in Group A, 8/40 (20%) were greater than Group B, 2/40 (5%) and Group C, 2/40 (5%). Coagulation tests revealed better preservation of fibrinogen and lower levels of fibrin degradation products, in group B and C. These two groups were however statistically indistinguishable in respect to all the parameters studied, when compared with each other. It was concluded that both the antifibrinolytic agents in the doses studied were equally effective in reducing postoperative blood loss, blood and blood products usage and re-exploration rates. Coagulation parameters were better preserved as compared to the control group.

Tranexamic acid in paediatric cardiac surgery.

BACKGROUND & OBJECTIVES: Antifibrinolytic agents are used commonly in adult cardiac surgery to reduce postoperative blood loss. Paucity of literature on the use of a newer antifibrinolytic agent tranexamic acid (TA) in children undergoing cardiac surgery promoted us to conduct this study in children with cyanotic heart disease. METHODS: One hundred and twenty consecutive children with cyanotic heart disease were randomised into two groups. Control (group A) (n=24) given no drug while the study (group B, n=96) group was given tranexamic acid 10 mg/kg each after anaesthetic induction, on bypass and after protamine at the end of bypass. Postoperatively, total mediastinal chest tube drainage and blood and blood product usage at 24 h were recorded. Tests of coagulation including activated clotting time, fibrinogen, fibrin degradation products and platelet count were performed at 6 h postoperatively. RESULTS: The two groups were comparable in terms of demographic characteristics such as age, sex, weight, operations performed, and preoperative haematocrit. Postoperatively, group B, had a significantly (P<0.05) lower blood loss, blood and blood product usage, re-exploration rate compared to the control group. There was preservation of fibrinogen and lower levels of fibrin degradation products in group B. INTERPRETATION & CONCLUSION: Tranexamine acid was highly effective in reducing post-operative blood loss, blood and blood product usage in children with congenital cyanotic heart disease undergoing corrective surgery.