Asian Cardiovasc Thorac Ann 2008;16:21-24
© 2008 Asia Publishing EXchange Ltd
Preoperative Autologous Blood Donation for Cardiac Surgery in Children
Narutoshi Hibino, MD,
Mitsugi Nagashima, MD,
Harumitsu Sato, MD,
Takaki Hori, MD,
Hitoshi Ishitoya, MD,
Tetsuo Tomino, MD
Department of Cardiovascular Surgery, Ehime Prefectural Central Hospital, Ehime, Japan
For reprint information contact: Narutoshi Hibino, MD, Tel: 81 89 947 1111, Fax: 81 89 943 4136, Email: nhhibino{at}gmail.com, Department of Cardiovascular Surgery, Ehime Prefectural Central Hospital, 83 Kasuga, Matsuyama, Ehime, Japan.
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ABSTRACT
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Preoperative autologous blood donation has been shown to reduce homologous blood transfusion in cardiac operations, but there have been few reports of its use in children. Of 50 children aged 6 months to 5 years (weight, 6.1–14.8 kg) undergoing primary cardiac surgery for simple anomalies, 23 donated autologous blood before surgery, the other 27 were age and weight-matched controls. Two donations of 10 mL·kg–1 each were collected via the femoral vein under mild general anesthesia 12 ± 5 and 19 ± 7 days preoperatively. No complications related to autologous blood collection were observed. Homologous blood use was significantly less in the group given autologous blood (4.3%) compared to the control group (44.4%). There was no significant difference in hemoglobin levels between groups before, during or after the operation. Preoperative autologous blood donation appears to be safe and effective in reducing homologous transfusions, even in children weighing less than 15 kg.
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INTRODUCTION
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Homologous blood transfusion carries some risks in children because of their immature immune system, so exposure to homologous blood should be avoided as much as possible in pediatric patients.1–3 A blood conservation device used to concentrate blood collected from the operative field is safe and effective in reducing homologous blood use.4,5 Pharmacologic agents such as aprotinin and tranexamic acid are also useful in preventing fibrinolysis caused by cardiopulmonary bypass (CPB).6,7 Although these methods help to avoid homologous blood transfusion in adults, they have limited efficacy in children. Preoperative autologous blood donation (PAD) is an effective method of blood conservation in cardiac operations, which can prevent serious complications caused by homologous transfusion, including acute and delayed immunologic reactions, transfusion-associated graft-versus-host disease, viral hepatitis and retrovirus transmission.4–8 However, the use of this technique in younger or smaller children is associated with some problems, including noncompliance during blood collection, a relatively small blood volume, and the substantial hemodilution during CPB. The aim of this study was to assess the effectiveness of a preoperative blood conservation program for children weighing 5–15 kg.
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PATIENTS AND METHODS
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This non randomized retrospective study enrolled patients weighing < 15 kg requiring reparative cardiac surgery for simple anomalies at the Ehime Prefectural Central Hospital between May 2000 and September 2005. Exclusion criteria included body weight < 5 kg, a recognizable syndrome of congenital anomalies, and previous cardiac surgery. Body weights ranged from 6.1 to 14.8 kg (mean, 8.4 ± 1.2 kg), and ages were 6 months to 5 years (mean, 1.8 ± 1.0 years). The anomalies included atrial septal defect in 6 patients, ventricular septal defect in 15, double-outlet right ventricle in one and incomplete atrioventricular septal defect in one. Institutional review board approval and parental informed consent were obtained, according to institutional guidelines. Autologous blood donation was started in October 2003, and 23 patients donated blood prior to surgery (PAD group). Children with hemoglobin concentrations < 10 g·dL–1 were excluded. Twenty-seven age and weight-matched patients who underwent surgery without pre-donation before September 2003 served as controls.
Preoperative autologous blood donation was performed in hospital under mild general anesthesia using 0.1 mg·kg–1 midazolam and 1 mg·kg–1 ketamine. Two amounts of blood corresponding to 10 mL·kg–1 were removed via the femoral vein 12 ± 5 and 19 ± 7 days preoperatively (total donated was 20 mL·kg–1). During blood donation, Ringer’s solution was infused at 100 mL·kg–1·h–1. After blood collection, all patients received iron therapy. Except for those with hemoglobin > 14 g·dL–1, the autologous donors were given 400 IU·kg–1 erythropoietin intracutaneously immediately after each donation. The donated blood was stored as whole blood in our blood bank until the operation. The surgery in all patients involved primary intracardiac repair of a simple anomaly. After systemic heparinization, moderately hypothermic (30°C–34°C) CPB was instituted using a hollow-fiber membrane oxygenator. The priming volume of the circuit was 320 ± 96 mL. The anesthetic management and other aspects of perfusion in CPB were identical in both groups. We used conventional ultrafiltration during CPB; modified ultrafiltration was not used after CPB. For conservation, the patient’s blood was salvaged by conventional ultrafiltration and cell processing during the operation, and residual blood in the CPB circuit was returned to the patient. The criterion for homologous blood transfusion was anemia with a hemoglobin level < 6 g·dL–1 during CPB or < 8 g·dL–1 after the operation.
The patient data and transfusion-related perioperative factors were recorded. Complications related to autologous blood donation, preservation and reinfusion were also noted. The homologous transfusion rate, perioperative hemoglobin and mean corpuscular hemoglobin concentrations, minimum hemoglobin level during CPB, total protein level and the total postoperative blood loss were analyzed.
Data are expressed as mean ± standard deviation. Differences between groups were determined by Student’s t test and the chi-squared test. Changes in data were compared between groups by analysis of variance. A p value < 0.05 was considered statistically significant.
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RESULTS
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Both groups were similar with regard to preoperative variables that could influence outcome: age, weight, sex, diagnosis and hemoglobin level on admission (Table 1
). Surgical factors did not differ significantly between the groups (Table 2). Blood collection was successful in all 23 consecutive patients in the PAD group. No complications such as decreased blood pressure or vasovagal syncope were observed during blood donation. The entire amount of blood donated was transfused during and after CPB. In most cases, half of the donated blood was used for pump priming and the rest was used after CPB. No complications related to autologous blood preservation and reinfusion were observed. The incidence of homologous transfusion was significantly lower in the PAD group than in the controls (Table 2). No significant differences in the hemoglobin and mean corpuscular hemoglobin concentrations were found between the 2 groups before, during or after surgery (Figures 1 and 2). The total protein level was not significantly different between the 2 groups, and changed very little throughout the course of treatment (Figure 3). Blood loss during the first 24 hours after the operation was significantly lower in the PAD group than in the control group, and the duration of chest tube drainage was significantly shorter in the PAD group (Table 2).
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Figure 1. Perioperative hemoglobin (Hb) levels reached the lowest level during cardiopulmonary bypass (CPB) and recovered to the preoperative (Pre-op) level on postoperative day (POD) 14. There was no significant difference between the preoperative autologous blood donation (PAD) and control groups.
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Figure 2. Perioperative mean corpuscular hemoglobin concentration (MCHC). There was no significant difference between the preoperative autologous blood donation (PAD) and control groups. POD = postoperative day.
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Figure 3. Perioperative total protein (TP) level; the TP level was not significantly different between the 2 groups, and it changed very little during treatment. PAD = preoperative autologous blood donation, POD = postoperative day.
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DISCUSSION
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To reduce homologous blood transfusions in pediatric cardiac operations, several methods such as a blood conservation devices, pharmacologic agents or reduction of the CPB priming volume have been used.9–13 Although these help to avoid homologous blood transfusion in adults, their efficacy is limited in children because of the substantial hemodilution during CPB. Hemodilution was introduced in the 1950s to decrease the use of homologous blood.14 However, it might also reduce the perfusion pressure, which increases the risk of an adverse neurologic outcome after CPB.15 In a prospective randomized single-center trial involving 147 infants < 9 months of age undergoing reparative cardiac surgery with CPB, Jonas and colleagues16 reported that greater hemodilution during hypothermic CPB was associated with increased risk of developmental impairment. To reduce the degree of hemodilution during CPB, reduction of the priming volume is useful. Ando and colleagues13 reported CPB systems with remote pump heads minimized the priming volume (181 ± 32.5 mL) for patients weighing 5 kg or less. Preoperative autologous blood donation might be more useful if it was combined with a reduction in the priming volume.
Autologous blood transfusion is one of the most effective and popular methods of avoiding homologous blood transfusion in adults, and its indications have been extended. However, few studies have been conducted on PAD for pediatric open-heart surgery because of the associated family stress, labor intensiveness of the procedure and concerns about worsening the primary cardiac lesion.8,17–19 Masuda and colleagues19 collected 48 ± 17 mL·kg–1 blood 6 ± 2 times 50 ± 16 days prior to surgery in children weighing less than 20 kg (age range, 3–9 years; weight range, 13–20 kg). The patient’s blood was withdrawn and processed into packed red cells, fresh frozen plasma and whole blood. Our study involved younger children weighing < 15 kg. Considering the similar perioperative hemoglobin levels in our 2 groups, the lower homologous transfusion rate in the PAD group supports the applicability of autologous blood transfusion.
Preoperative blood collection disturbs not only the medical staff but also the patients and their families, particularly in the case of infants. Masuda and colleagues19 succeeded in obtaining PAD in 37 of 62 children who were considered potential candidates. Murayama and colleagues20 collected 5–10 mL·kg–1 blood from the medial cubital vein 2 or 3 times 2–3 weeks before the operation under individual attention, encouragement, and support from the parents and medical staff. Fukuhara and colleagues18 collected autologous blood from infants by scheduling the blood donations at the time of cardiac catheterization. In our study, PAD (10 mL·kg–1) was performed twice via the femoral vein under mild general anesthesia in the hospital, and stored as whole blood. In spite of some risks such as respiratory depression, hemodynamic instability or anaphylaxis, intravenous general anesthesia is invariably used for safe and reliable blood collection. Midazolam was used in combination with ketamine under strict infusion management and overnight hospitalization. This was useful for keeping patients well sedated without any complications. Prior to blood donation, the area near the femoral vein was cleaned to prevent infection.
Some limitations of this study should be considered. Firstly, it was a retrospective nonrandomized study, and future prospective randomized studies are required to refine the optimal protocol for PAD. Secondly, the cost of the PAD program is high, but it is important to reduce the amount of homologous blood transfusion, particularly in pediatric cardiac surgery. Our results suggest that PAD is a safe and effective method for reducing homologous blood transfusions in pediatric open-heart surgery. This procedure could be further improved in combination with other comprehensive blood conservation techniques and advances in CPB, thereby reducing the need for homologous blood transfusion.
Presented as a poster at the Society of Thoracic Surgeons 42nd Annual Meeting, Chicago, IL, USA, January 30–February 1, 2006.
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ABSTRACT
INTRODUCTION
