Venoarterial extra corporeal membrane oxygenation and blood component usage in pediatric patients undergoing cardiac surgery: Single centre experience.

Background: Extra Corporeal Membrane Oxygenation (ECMO) is a well-known tool for providing life-saving support in patients developing post cardiotomy cardiogenic shock in post cardiac surgeries. The current study was designed to evaluate blood transfusion requirements and its relation to mortality in neonate and pediatric cardiac patients requiring venoarterial cardiac ECMO during post-operative period following cardiac surgery. Materials and Methods: Overall 24 pediatric patients (including neonates) who underwent VA ECMO in post cardiac surgery at our institute from January 2016 to October 2017 were included in the study. The details of demographics, blood transfusion, ECMO, and morbidity and mortality were collected for all the patients. Objective of the Study: The primary objective of our study was to assess the outcome of patients on ECMO in post pediatric cardiac surgery. The secondary objective of the study was to assess the effect of blood transfusion on the outcome of the patients. Results: Overall mortality rate was 50% (n = 12). The overall transfusion rate of packed red blood cells was higher in patients who did not survive even after institution of VA ECMO. The transfusion of other blood products like platelets, cryoprecipitate, and fresh frozen plasma were also higher in this group of patients though it was statistically non-significant except for packed red cell transfusion. Though statistically non-significant, the patients who didn't survive even after institution of VA ECMO post-surgery had relatively higher mean age (703.88 ± 998.94 days) as compared to their counterparts (510.63 ± 384.36 days). Conclusion: The use of ECMO is associated with considerable morbidity and mortality. Packed red cell transfusion is definitely higher in expired patients, indicative of deteriorated status of the patient. However, considering non-significant association of other blood components, except packed red cell it is recommended that patients' overall clinical condition should be taken into consideration for transfusion of blood products and not only targeting the transfusion triggers.

Effect of Red Blood Cell Storage Duration on Outcome After Paediatric Cardiac Surgery: A Prospective Observational Study.

BACKGROUND: Retrospective reviews have found the use of stored packed red blood cells (PRBCs) in priming to be associated with increased risk of postoperative complications. The purpose of study was to prospectively investigate the influence of duration of storage of PRBCs used in priming the cardiopulmonary bypass (CPB) circuit on the metabolic profile of the patients, and postoperative outcome after paediatric cardiac surgery. METHODS: Between January 2015 and December 2015, 198 consecutive children operated for cardiac surgery using CPB and received blood for priming the circuit were included. Patients were divided into two groups based on the duration of storage of the blood, newer PRBCs group who received blood stored for ≤14days and the older PRBCs group who received blood stored for >14 days. RESULTS: Mean duration of blood storage used for priming in newer PRBCs blood group (n=103) was 8.4±3.7days while it was 21.9±4.5days in older PRBCs group (n=95). Metabolic parameters of the PRBCs improved to physiological limits in both the groups after initiation of CPB. Postoperative hepatic, pulmonary, haematological complications, sepsis and multi-organ failure were more in the old PRBCs group. However, the difference was not significant. Similarly, there was no significant difference in incidence of prolonged mechanical ventilation, intensive care unit stay and hospital stay and mortality between the two groups. CONCLUSIONS: Metabolic parameters of the stored blood become normal after initiation of CPB irrespective of duration of storage. In paediatric patients without significant co-morbidity, undergoing cardiac surgery, transfusion of washed stored blood up to 28days in CPB priming is safe especially if lesser amount of transfusion is required.

Monitoring Microcirculatory Blood Flow during Cardiopulmonary Bypass in Paediatric Cardiac Surgery Patients as a Predictor for Anaerobic Metabolism.

INTRODUCTION: Improving tissue oxygenation is one of most important tasks in management of low cardiac output. Central venous oxygen saturation (ScvO2) and lactate are established criteria for monitoring the adequacy of tissue oxygenation. The venous-to-arterial carbon dioxide difference [P(v-a)CO2] is inversely associated with cardiac output. AIM: To study the use of P(v-a)CO2/C(a-v)O2 ratio as a marker of low cardiac output during Cardiopulmonary Bypass (CPB) in paediatric cardiac surgical patients. MATERIALS AND METHODS: The present study was a prospective observational study conducted over a period of nine months from 1st August 2015 to 30th April 2016. A total of 110 children were enrolled, who underwent CPB during cardiac surgery. The CPB time, Mean Arterial Pressure (MAP), flow rate, cross clamp time, were recorded for all the patients as well as Arterial Blood Gas (ABG) and Venous Blood Gas (VBG) were checked at four different points of time: 1) Before CPB, 2) 10 minutes after initiation of CPB, 3) 30 minutes on CPB and 4) off CPB. RESULTS: The results indicated that Receiver Operating Characteristic curve (ROC curve) at 30 minute of CPB time P(v-a)CO2/C(a-v)O2 was more specific and sensitive than lactate to detect anaerobic metabolism. Decrease platelet count was significant on second postoperative day. CONCLUSION: The present study suggests the use of P(v-a)CO2/C(a-v)O2 ratio as a marker to detect low flow on CPB. Our study was single centric and with a small size, studies involving large population and multiple centers are required to support the recent findings.

Effect of Prime Blood Storage Duration on Clinical Outcome After Pediatric Cardiac Surgery.

BACKGROUND: In this study, we tested the hypothesis that in pediatric patients undergoing cardiac surgery using cardiopulmonary bypass (CPB) with blood prime, the storage duration of the packed red blood cells (PRBCs) used in prime led to differences in postoperative complications and metabolic profiles of the patients. METHODS: For this prospective observational study we included 400 pediatric patients undergoing cardiac operations using CPB and requiring PRBCs prime. To study the effect of storage duration of PRBCs on postoperative morbidity, mortality, and metabolic profile, patients were divided into four groups (based on storage duration of PRBCs used in prime). Group 1: ≤7 days, group 2: 8 to 14 days, group 3: 15 to 21 days, and group 4: >21 days. RESULTS: On univariate analysis, patients transfused with PRBCs stored >14 days had significantly higher incidence of postoperative complications, for example, liver dysfunction, hematological complications, sepsis, and multiorgan failure. However, after regression analysis and adjusting for the other confounder's effects, no significant association was found between storage duration of PRBCs and postoperative complications and mortality. Metabolic profile of PRBCs was observed to become deranged with increasing duration of storage. This, however, improved to near physiological range early after the initiation of CPB and remained normal one hour after weaning from CPB, irrespective of the storage duration. CONCLUSION: Storage duration of PRBCs used for priming the pediatric CPB circuit neither affects the metabolic profile of the patients on CPB or early after surgery, nor it has any association with postoperative complications and mortality.

Hemodiafiltration-A Technique for Physiological Correction of Priming Solution in Pediatric Cardiac Surgery: An In Vitro Study.

Pediatric cardiopulmonary bypass (CPB) circuit invariably requires priming with packed red blood cells (PRBCs). Metabolic composition of stored PRBCs is unphysiological and becomes worse with increasing duration of storage. It is recommended to correct these abnormalities before initiation of CPB. We tested the hypothesis that hemodiafiltration of the prime with 0.45% saline is sufficient for reducing the metabolic load and reaching a physiologic state. In an in vitro study, 100 mL of blood each from 45 units of PRBCs stored for 3-20 days were used for priming the 45 neonatal CPB circuits. Based upon the method used for removal of excess crystalloid from the prime, circuits were divided into three groups. Group 1: Direct removal through manifold line. Group 2: Ultrafiltration of prime. Group 3: Hemodiafiltration of the prime. Blood gas analyses were obtained from the PRBCs and from the prime before and after removal of crystalloid. Both direct removal of crystalloid and ultrafiltration resulted in significant reduction in biochemical and metabolic load of blood (P < 0.001). However, the final composition of the prime was far from being physiological. Hemodiafiltration resulted in improvement of metabolic parameters to near physiological range (lactate: 33.8 ± 4.44 vs. 14 ± 2.53 mg/dL, pH: 7.05 ± 0.15 vs. 7.34 ± 0.06, bicarbonates: 4.83 ± 0.59 vs. 27.6 ± 2.94 meq/L; P < 0.001). Similarly, sodium (147.76 ± 12.73 vs. 144.6 ± 5.96 meq/L) and potassium (9.6 ± 2.83 vs. 4.23 ± 0.37 meq/L) also changed significantly (P < 0.001) to near physiologic range. Hemodiafiltraion of final prime is a simple, efficients and rapid method of correcting the biochemical parameters and reducing the metabolic load of stored PRBCs towards the physiological range before initiating the CPB.

Comparison of Albumin, Hydroxyethyl Starch and Ringer Lactate Solution as Priming Fluid for Cardiopulmonary Bypass in Paediatric Cardiac Surgery.

INTRODUCTION: In paediatric cardiac surgery, there is still not any information with regard to the best choice of priming fluids for Cardiopulmonary Bypass (CPB). Albumin, Hydroxyethyl Starch (HES) & ringer lactate are equally used, but each has its advantages & disadvantages. Albumin & HES had better fluid balance which affect outcome in paediatric cardiac surgery significantly. AIM: To compare priming solution containing albumin, hydroxyethyl starch and ringer lactate during elective open-heart surgery in paediatrics aged up to 3 years. MATERIALS AND METHODS: All patients were managed by standardized institution protocol and were randomly distributed into three groups based on the priming solution which is used in the CPB Circuit and having 35 patients in each group. Group A: Receive albumin 10 ml/kg in priming solution, Group B: Receive Hydroxyethyl starch (HES130/0.4) 6% 20ml/kg in priming solution, Group C: Receive ringer lactate priming solution. Primary outcome variable included perioperative haemoglobin, total protein, colloid osmotic pressure, platelets, fluid balance, urine output, post-operative blood loss, blood products usage, renal & liver function, extubation time, ICU stay & outcome. RESULTS: Patients receiving albumin had higher perioperative platelet count, total protein level & colloid osmotic pressure, lesser post-operative blood loss & blood products requirement. Patients receiving HES had lower level of platelets postoperatively than ringer lactate group but not associated with increase blood loss. HES did not affect renal function & haemostasis in this dose. Patients receiving ringer lactate had positive fluid balance intraoperatively. All three groups have similar effect on renal & liver function, urine output, time to extubation, ICU stay & outcome. CONCLUSION: We conclude that albumin is expensive but better prime as maintain haemostasis, colloid oncotic pressure & reduced blood product requirement. HES will not hamper haemostasis & renal function in lower dose & better than crystalloid as maintain negative fluid balance. Patient outcome & ICU stay was similarly affected by priming solutions.

Novel technique for pediatric ostial cardioplegia delivery.

Antegrade ostial cardioplegia is an important mode of cardioplegia administration in pediatric patients. We present our innovative, simple, and cost-effective method of pediatric ostial cardioplegia delivery.

A rare variety of mixed total anomalous pulmonary venous connection.

We describe a rare case of mixed supra- and infracardiac total anomalous pulmonary venous connection in a 2-month-old boy weighing 2.3 kg who was admitted with central cyanosis. Although the surgical repair was successful, the child died due to pulmonary hypertensive crisis.