Hemostatic complications and systemic heparinization in pediatric post-cardiotomy veno-arterial extracorporeal membrane oxygenation failed to wean from cardiopulmonary bypass.

Background: Hemostatic complications and the need for large amounts of blood products are major obstacles during veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Additionally, the occurrence of coagulopathy after cardiopulmonary bypass (CPB) affects systemic heparinization in pediatric post-cardiotomy patients. This study compares hemostatic complications in pediatric post-cardiotomy VA-ECMO patients for failure to wean from CPB with those who received post-cardiotomy VA-ECMO for other indications, while also exploring the relationship between different stages-hemostatic complications and the timing of systemic heparinization. Methods: We retrospectively analyzed 146 pediatric patients who received post-cardiotomy VA-ECMO support (CPB-ECMO, n=96 vs. non-CPB-ECMO, n=50) from January 2005 to June 2020. Patients were divided into survivors (n=46) and non-survivors (n=50) according to in-hospital mortality in the CPB-ECMO group. We compared clinical outcomes between the groups, then examined the associations between the timing of systemic heparinization after ECMO implantation and different stages-hemostatic complications, in the CPB-ECMO group. Results: We found that the risk of early bleeding was significantly increased in patients who failed to wean from CPB. The presence of early bleeding was accompanied by the higher demand for blood products transfusion in the CPB-ECMO group, and for treatment the patients received a longer delayed continuous heparin infusion. As a result of using delayed systemic heparinization to avoid early bleeding, early hemolysis increased in the CPB-ECMO group. A delayed systemic heparinization of 9.5 hours showed the best Youden index results and the overall greatest accuracy in predicting early hemolysis. Conclusions: A direct transition from CPB to ECMO in pediatric post-cardiotomy patients significantly increases early bleeding. Delayed systemic heparinization to reduce early bleeding has good discrimination for predicting early hemolysis in the CPB-ECMO group. Coagulopathy is complex in pediatric post-cardiotomy VA-ECMO patients who failed to wean from CPB, and, as such, it is extremely important to monitor coagulation-related indicators in multiple dimensions to determine the timing of systemic heparinization.

Enhancing the Cycling Stability by Tuning the Chemical Bonding between Phosphorus and Carbon Nanotubes for Potassium-Ion Battery Anodes.

Phosphorus/carbon (P/C) composites as promising potassium-ion storage materials have been extensively investigated for its compound superiorities of high specific capacity and favorable electronic conductivity. However, the effects of different chemical bonding states between P and the carbon matrix for potassium-ion storage and cycling performance still need to be investigated. Herein, three P/C composites with different chemical bonding states were successfully fabricated through simply ball-milling red P with carboxylic group carbon nanotubes (CGCNTs), carbon nanotubes (CNTs), and reduced carboxylic group carbon nanotubes (RCGCNTs), respectively. When used as potassium-ion battery (PIB) anodes, the red P and CGCNT (P-CGCNT) composite deliver the most outstanding cycling stability (402.6 mAh g-1 over 110 cycles) with a favorable capacity retention of 68.26% at a current density of 0.1 A g-1, much higher than that of the phosphorus-CNT (P-CNT) composite (297.5 mAh g-1 and 50.40%). Based on the results of X-ray photoelectron spectroscopy and electrochemical performance, we propose that the existence of a carboxyl functional group will be instrumental for the formation of the P-O-C bond. More importantly, when compared with the P-C bond, the P-O-C bond can lead to a higher reversible capacity and a better long-term cycling stability as a result of the more robust bonding energy of the P-O-C bond (585 KJ mol-1) than that of the P-C bond (264 kJ mol-1). This work provides some insights into designing high-performance P anodes for PIBs.

Effect of two different colloid priming strategies in infants weighing less than 5 kg undergoing on-pump cardiac surgeries.

Our aim was to explore the effect of two different priming strategies (artificial colloid only vs. artificial colloid combined with human serum albumin) on the prognosis of children weighing less than 5 kg undergoing on-pump congenital heart disease (CHD) surgery. A total of 65 children weighing less than 5 kg who underwent on-pump CHD surgery in our hospital from September 2016 to December 2017 were enrolled in this study. The children were randomly divided into two groups: artificial colloid priming group (AC group, n = 33) and artificial colloid combined albumin priming group (ACA group, n = 32). The primary clinical endpoint was the peri-CPB colloid osmotic pressure (COP). Secondary clinical endpoints included perioperative blood product and hemostatic drug consumption, postoperative renal function, coagulation function, postoperative renal function, and postoperative recovery parameters. COP values were not significant in the priming system as well as peri-CPB time points between the two groups (P > .05). Platelet consumption in the AC group was significantly lower than that in the ACA group (P < .05). There were no significant differences in the use of other blood products and hemostatic drugs as well as perioperative coagulation parameters between the two groups (P > .05). Postoperative length of stay in the AC group was significantly lower than that in the ACA group (P < .05). There were no significant differences in mortality, postoperative mechanical ventilation time, ICU time, and perioperative adverse events (including postoperative AKI) occurrences between the two groups (P > .05). In the on-pump cardiac surgeries of patients weighing less than 5 kg, total colloidal priming would not affect peri-CPB COP values, postoperative coagulation function, and blood products consumption. Total artificial colloidal priming strategy is feasible in low-weight patients.

Effect of artificial colloid priming during cardiopulmonary bypass on the coagulation function of pediatric patients weighting less than 5 kg with congenital heart disease / 中国胸心血管外科临床杂志

@#Objective    To investigate the effect of artificial colloid on coagulation function in pediatric patients weighing less than 5 kg with congenital heart disease during cardiopulmonary bypass in congenital heart disease surgery by using artificial colloid instead of human serum albumin. Methods    A total of 65 pediatric patients with weight less than 5 kg who underwent congenital heart disease surgery in our hospital from September 2016 to December 2017 were included in the study. They were randomly divided into two groups: an artificial colloid group (the experimental group, n=33) and a human serum albumin combined artificial colloid group (the control group, n=32). Perioperative hemoglobin concentration (Hb), blood products and hemostatic drugs used, postoperative coagulation function index and pleural fluid volume 24 hours after surgery were monitored. Results    There was no significant difference in perioperative Hb and chest tube drainage between the two groups. The platelet utilization rate in the experimental group was significantly lower than that in the control group (P<0.05). No significant difference was found in the dosage of other blood products and hemostatic drugs between the two groups during the perioperative period. There was no significant difference in coagulation parameters between the two groups before and after surgery (P>0.05). Conclusion    The use of artificial colloid as colloid priming solution during cardiopulmonary bypass has no adverse effect on coagulation function in pediatric patients weighting less than 5 kg with congenital heart disease.

Substitution of artificial colloids for fresh frozen plasma in pediatric cardiopulmonary bypass surgery.

BACKGROUND: In many centers, fresh frozen plasma is generally used as the main component of pump prime in pediatric cardiopulmonary bypass. However, many factors have resulted in stringent control of plasma transfusion and prompted the study of safe and efficient substitutes. AIMS: The aim of this study was to investigate the feasibility of a priming strategy with gelatin during cardiopulmonary bypass in pediatric patients undergoing cardiac surgery and identify the factors associated with postoperative chest-tube drainage. METHODS: We reviewed 1164 pediatric patients who underwent cardiac surgery with cardiopulmonary bypass between January 2012 and April 2013 in Fuwai hospital. Infants and children were primed with different types of solution: plasma or gelatin. Clinical data included postoperative coagulation function (pharmacological agents, chest-tube drainage, and transfusion requirements), recovery indicators (mechanical ventilator time, ICU stay and hospital stay), incidence of in-hospital mortality, and morbidity. Multivariate linear regression analysis was used to identify factors correlated with postoperative chest-tube drainage. RESULTS: No difference in mortality or morbidity was found between the plasma and gelatin groups. In infants, increased chest-tube drainage (postoperation 12 hours, median difference -0.046 ml/kg/hr, 95%CI: -0.105 to -0.007, P = 0.001; postoperation 24 hours, median difference -0.047 ml/kg/hr, 95%CI: -0.081 to -0.025, P < 0.001), and decreased transfusion (red blood cell, median difference 0.00 ml/kg/hr, 95%CI: 0.000-100, P < 0.001; fresh frozen plasma, median difference 5.556 ml/kg/hr, 95%CI: 2.30-8.333, P = 0.001), and recovery time (mechanical ventilator time, median difference 3.00 hours, 95%CI: 1.00-5.500, P < 0.001; ICU stay, median difference 17.00 hours, 95%CI: 1.00-22.000, P = 0.001; hospital stay, median difference 1.00 day, 95%CI: 0.00-2.000, P = 0.038) were demonstrated in the gelatin group. In children, the transfusion requirements (red blood cell, median difference 100 ml, P < 0.001;fresh frozen plasma, median difference 1.11 ml/kg, 95%CI: 0.000-2.42, P = 0.001) were decreased in the gelatin group. Multivariate linear regression analysis revealed that the type of priming solution (ß = 1.940,95%CI: 1.057-2.823,P < 0.001), bypass time (ß = 0.024, 95%CI: 0.013-0.036, P < 0.001), and age (ß = -0.257, 95%CI: -0.422 to -0.09, P = 0.002) were independent variables correlating with chest-tube drainage in infants. CONCLUSION: In the general pediatric patients undergoing elective cardiac surgery, substitution of gelatin for fresh frozen plasma in cardiopulmonary bypass is feasible.

The influence of cardiopulmonary bypass priming without FFP on postoperative coagulation and recovery in pediatric patients with cyanotic congenital heart disease.

UNLABELLED: Transfusion guidelines have been produced for the evidence-based use of fresh frozen plasma (FFP). However, the inappropriate use of FFP is still a worldwide problem, especially in the prophylactic settings. In the present study, 100 cyanotic pediatric patients (age 6 months to 3 years) undergoing cardiac surgery with cardiopulmonary bypass (CPB) were randomized to receive either 10-20 ml/kg FFP (FFP group, n = 50) or 10-20 ml/kg 4 % succinylated gelatin (Gelofusine, GEL group, n = 50) in the priming solution. Rapid thromboelastography (r-TEG) was measured before skin incision and 15 min after heparin neutralization. Postoperative renal and hepatic function, mediastinal chest tube drainage, transfusion requirements, and recovery time were observed. The relationships between hematologic and demographic data and postoperative bleeding volume were also analyzed. The results showed that there were significantly elevated levels of fibrinogen (r-TEG parameters: fibrinogen contribution to maximal amplitude (MAf) and fibrinogen level (FLEV)) in the FFP group compared to the GEL group. The postoperative blood loss, total transfusion requirements, and recovery time were not significantly different between the two groups, indicating that there were no obvious clinical benefits of using FFP in the priming. The maximal amplitude (MA) of r-TEG measured after heparin neutralization was correlated with the 6-h postoperative bleeding volume. In addition, preoperative fibrinogen level rather than FFP priming was an independent predictor of postoperative blood loss. CONCLUSION: Prophylactic use of FFP in the priming solution does not have obvious clinical benefits in cyanotic congenital heart disease (CCHD) patients. Gelofusine, an artificial colloid, is a safe and effective substitute of FFP in the priming solution. Furthermore, r-TEG can be used as a "real-time" assessment tool to evaluate postoperative bleeding and guide transfusion after cardiac surgery in pediatric patients.

Perioperative monitoring of thromboelastograph on blood protection and recovery for severely cyanotic patients undergoing complex cardiac surgery.

In this study, we assessed the clinical effect of a new transfusion therapy guided by thromboelastograph (TEG) on blood protection. Thirty-one children with severe cyanosis (hematocrit ≥54%), who were diagnosed as having transposition of the great arteries or double outlet right ventricle with or without pulmonary valve stenosis, and underwent arterial switch operation or double roots transplantation, were involved and were divided into two groups. In group F (n=17), the transfusion therapy after cardiopulmonary bypass was performed with fibrinogen administration combined with traditional transfusion, guided by TEG. In group C (n=14), traditional transfusion guided by clinical experiences only was performed. We observed the blood protection effects and recovery conditions of these patients. In surgery, compared with group C, the chest closure time, fresh-frozen plasma (FFP), and platelet (PLT) volume used at closure time had no significant reductions in group F (P>0.05, respectively), and the patients in group F had no significant reductions in the amount of chest drainage (P>0.05). The total PLT and total red blood cells usage were also the same (P>0.05). But during the first 24h, FFP usage in the intensive care unit (ICU) and total perioperative FFP usage had significantly dropped in group F (P<0.05); the mechanical ventilator time, ICU stay, and hospitalization time in group F were much shorter than those in group C (P<0.05). So, TEG was effective in perioperative blood protection. Fibrinogen could be a substitute for FFP to restore hemostasis and improve the prognosis for these patients.

Perioperative monitoring of thromboelastograph on hemostasis and therapy for cyanotic infants undergoing complex cardiac surgery.

This study investigated features and treatments of perioperative coagulopathies in cyanotic infants with complex congenital heart disease (CCHD). Thirty-six infants with cyanotic CCHD were involved and divided into two groups: In group H (n = 20), hematocrit (HCT) > 54%, and in group L (n = 16), HCT < 54%. Blood was sampled at anesthesia induction (T1), rewarming to 36 degrees C (T2), after heparin neutralization (T3), and 4 h after operation (T4). The hemostatic changes were evaluated by thromboelastograph (TEG). After surgery, group H was treated with fibrinogen-combined platelets (PLT), while group L was treated with PLT only. We observed the effect at T4. At T1, the hemostatic function in group H, deteriorating with the increase of HCT (P < 0.01), was obviously lower than that in group L (P < 0.01), but the PLT function was still complete. In group H, the hemostatic function at T2 decreased with a significant drop of PLT function (P < 0.01) and had little change of functional fibrinogen (Ffg) (P > 0.05). At T3, compared with T2, there were improvements in hemostatic function and Ffg (P < 0.01, respectively) without increase of PLT (P > 0.05) in group H. After therapy, PLT function in both groups restored to T1 level (P > 0.05); Ffg at T4 was significantly better than at T1 (P < 0.01) in group H, but Ffg at T4 with still normal function was lower than at T1 in group L (P < 0.01). Whole hemostatic function at T4 was back to normal and had no differences between two groups. So, we proposed that fibrinogen and PLT transfusion in combination should be better for infants with high HCT CCHD, but PLT alone might be enough for low HCT ones.

Experimental study on fibrogenic effect of fur dust on rat lung.

OBJECTIVE: The fibrogenicity of fur dust was studied in rat lung tissues. METHODS: Intratracheal instillation of fur dust, morphologic examination of lungs and analysis of collagen content were performed in Wistar rats. RESULTS: Morphologic examination revealed that the earliest changes consisted of alveolar edema, increased numbers of intraalveolar macrophages, and marked thickening of interalveolar septa with mixed cellular infiltrate. After sixth months, there was moderate thickening of the alveolar walls and the peribronchioli. After 12 months, interstitial positive fibrosis of the alveolar wall and the peribronchioli were weakly seen. In the carding dust group (silica content 17.6%), interstitial nodules were observed composed of fibroblasts, reticular fibers, and collagen fibers. Electron microscopic examination also showed that alveolar walls became thickened and collagen fiber bundles were seen around bronchioles and small vessels in the carding groups after 12 months. At all stages of analysis, the collagen content in lungs of the fur dust groups was significantly higher than that of the control group. CONCLUSIONS: Our study suggested that fur dust might induce weak interstitial fibrosis in the lung.