Asian Cardiovasc Thorac Ann 1998;6:237-238
© 1998 Asia Publishing EXchange Pte Ltd
Bloodless Pediatric Cardiac Surgery? Deliverance with Erythropoietin
W David Creery, MD,
Michael D Black, MD1,
Ian Adatia, MD2,
Brian McIntyre, MD3
Division of Critical Care Medicine
1 Division of Cardiovascular Surgery
2 Division of Cardiology
3 Division of Anesthesia The Hospital for Sick Children and University of Toronto, Faculty of Medicine Toronto, Canada
|
|
For reprint information contact: Michael D Black, MD Division of Cardiovascular Surgery (Rm 1525) The Hospital for Sick Children 555 University Avenue Toronto M5G 1X8, Canada Tel: 1 416 813 6418 Fax: 1 416 813 7984 Email: michael.black{at}mailhub.sickkids.on.ca
|
 |
ABSTRACT
|
|---|
A 2-year-old 11.6 kg boy with congenital heart disease whose parents refused homologous blood products was treated preoperatively with iron and human recombinant erythropoietin for 6 weeks. Surgical repair was performed without exposure to blood products other than human albumin. Treatment with iron and erythropoietin in combination with post-bypass modified ultrafiltration, minimization of hemodilution, reinfusion of residual pump prime, and diuresis may reduce or avoid the need for blood transfusion in acyanotic children undergoing elective cardiac surgery.
|
INTRODUCTION
|
|---|
There is great interest in the avoidance of all blood products during elective cardiac surgery. Several techniques currently used and popularized to avoid transfusion in adults have limited applicability in small children.1 Parental donations have recently been introduced but not all patients are eligible and the procedure is not without risk.2 Normal or supranormal preoperative hemoglobin concentrations may reduce the need for a blood prime of the bypass circuit. We report the case of a child who was given recombinant human erythropoietin in combination with iron preoperatively and underwent uncomplicated repair of his congenital cardiac defect without receiving blood products other than albumin.
|
CASE REPORT
|
|---|
A 2-year-old 11.6 kg boy with an atrioventricular canal defect was referred for surgical repair because of failure to thrive, congestive cardiac failure, and multiple hospital admissions for pulmonary infections. Moderate left atrioventricular valve regurgitation, an ostium secundum atrial septal defect, and accessory chordal tissue within the left ventricular outflow tract were identified on preoperative studies. His weight and body surface area (0.49 m2) indicated that a blood prime would be necessary for safe cardiopulmonary bypass. All ABO-compatible relatives who were potential sources of directed-donor blood were cytomegalovirus positive, while the patient was cytomegalovirus negative. There was a previous family history of severe and fatal cytomegalovirus infections; therefore, the parents refused the use of any directed-donor blood. As an alternative, the patient was given erythropoietin at a dose of 600 IU·kg–1 three times weekly for 8 weeks beginning 10 weeks prior to surgery. Elemental iron was administered at a dose of 6 mg·kg–1 per day. The hemoglobin level increased from 119 g·L–1 to 140 g·L–1 after 6 weeks and 159 g·L–1 after 8 weeks.
The cardiopulmonary bypass tubing was shortened and the pump was positioned close to the operating table in order to reduce the volume of the crystalloid prime. Following the intracardiac repair, the patient was successfully weaned from cardiopulmonary bypass. Intraoperative modified ultrafiltration was undertaken and the remainder of the bypass circuit blood was reinfused with furosemide diuresis. The patient's postoperative course was uneventful and he was discharged from hospital on the 5th post-operative day. He received no blood products other than human albumin. Immediate postoperative, postfurosemide diuresis, and discharge hemoglobin levels were 78, 113, and 103 g·L–1 respectively. There were no demonstrable side effects from this pharmacological mode of therapy.
|
DISCUSSION
|
|---|
Recombinant human erythropoietin is the synthetic form of a naturally occurring glycoprotein hormone that increases hemoglobin concentrations by stimulating the growth and development of erythroid progenitor cells.3 Erythropoietin therapy combined with iron supplementation has been used to elevate hemoglobin concentrations in children with a number of conditions.4,5 Use of erythropoietin has recently been reported in adults undergoing cardiovascular surgical procedures and in children before or following heart transplantation.6–8 Erythropoietin may offer an effective alternative to the use of homologous blood transfusion in acyanotic children undergoing elective cardiac surgery.
In our patient, therapy with erythropoietin increased the hemoglobin level by 5 g·L–1 each week. Data collected from our institution indicate that children with similar lesions receive an average of 1.7 units of red blood cells perioperatively. We suggest that elevation of hemoglobin with erythropoietin and iron may be a useful strategy to reduce the exposure to blood in acyanotic children. Whether erythropoietin is efficacious, safe, feasible, and cost-effective in avoiding blood product exposure in all children undergoing cardiovascular surgery has not been established and the optimal dose and dosing regimen have not been determined. We believe that a prospective trial is indicated to address these questions.
|
REFERENCES
|
|---|
-
Price TH, Goodnough LT, Vogler WR, et al. The effect of recombinant human erythropoietin on the efficacy of autologous blood donation in patients with low hematocrits: a multicenter, randomized, double-blind, controlled trial. Transfusion
1996;36:29–36.[Medline]
-
Pink J, Thomson A, Wylie B. Infectious disease markers in autologous and directed donations. Transfus Med
1994; 4:135–8.[Medline]
-
Dunn CJ, Wagstaff AJ. Epoetin alfa. A review of its clinical efficacy in the management of anaemia associated with renal failure and chronic disease and its use in surgical patients. Drugs Aging
1995;7:131–56.[Medline]
-
Montini G, Zacchello G, Perfumo F, et al. Pharmacokinetics and hematologic response to subcutaneous administration of recombinant human erythropoietin in children under-going long-term peritoneal dialysis: a multicenter study. J Pediatr1993; 122:297–302.[Medline]
-
Bolonaki I, Stiakaki E, Lydaki E, et al. Treatment with recombinant human erythropoietin in children with malignancies. Pediatric Hematol Oncol
1996;13:111–21.
-
Cooley DA. Conservation of blood during cardiovascular surgery. Am J Surg
1995;170:53S–9S.[Medline]
-
Hayashi J, Kumon K, Takanashi S, et al. Subcutaneous administration of recombinant human erythropoietin before cardiac surgery: a double-blind, multicenter trial in Japan. Transfusion
1994;34:142–6.[Medline]
-
Shaddy RE, Bullock EA, Tani LY, et al. Epoetin alfa therapy in infants awaiting heart transplantation. Arch Pediatr Adolesc Med
1995;149:322–5.[Abstract/Free Full Text]
TOP
ABSTRACT
INTRODUCTION
