title: Reduction in blood transfusion in a cohort of infants having cardiac surgery with cardiopulmonary bypass after instituting a goal-directed transfusion policy.
abstract: BACKGROUND
  Current trends in pediatric cardiac surgery and anesthesiology include goal-directed allogeneic blood transfusion, but few studies address the transfusion of platelets and cryoprecipitate. We report a quality improvement initiative to reduce the transfusion of platelets and cryoprecipitate in infants having cardiac surgery with cardiopulmonary bypass (CPB).
  
  
  METHODS
  Data from 50 consecutive patients weighing four to ten kilograms having cardiac surgery with CPB were prospectively collected after the institution of a policy to obtain each patient's platelet and fibrinogen levels during the rewarming phase of CPB. Data from 48 consecutive patients weighing four to ten kilograms having cardiac surgery with CPB prior to the implementation of the policy change were retrospectively collected. Demographics, laboratory values and blood product transfusion data were compared between the groups, using the Chi-square/Fisher's exact test or the T-Test/Wilcoxon Rank-Sum test, as appropriate.
  
  
  RESULTS
  The results showed more total blood product exposures in the control group during the time from bypass through the first twenty-four post-operative hours (median of 2 units versus 1 unit in study group, p=0.012). During the time period from CPB separation through the first post-operative day, 67% of patients in the control group received cryoprecipitate compared to 32% in the study group (p=0.0006). There was no difference in platelet exposures between the groups.
  
  
  CONCLUSIONS
  Checking laboratory results during the rewarming phase of CPB reduced cryoprecipitate transfusion by 50%. This reproducible strategy avoids empiric and potentially unnecessary transfusion in this vulnerable population.
authors.affiliation: Department of Anesthesiology, Division of Pediatric Anesthesia, Duke University Hospital, Durham, NC, USA kelly.machovec@duke.edu.
authors.forename: Kelly A
authors.initials: KA
authors.lastname: Machovec
authors.affiliation: Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Hospital, Durham, NC, USA.
authors.forename: Gregory
authors.initials: G
authors.lastname: Smigla
authors.affiliation: Department of Anesthesiology, Division of Pediatric Anesthesia, Duke University Hospital, Durham, NC, USA.
authors.forename: Warwick A
authors.initials: WA
authors.lastname: Ames
authors.affiliation: Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Hospital, Durham, NC, USA.
authors.forename: Courtney
authors.initials: C
authors.lastname: Schwimer
authors.affiliation: Department of Anesthesiology, Division of Pediatric Anesthesia, Duke University Hospital, Durham, NC, USA.
authors.forename: H Mayumi
authors.initials: HM
authors.lastname: Homi
authors.affiliation: Department of Anesthesiology, Duke University Hospital, Durham, NC, USA.
authors.forename: Ishwori B
authors.initials: IB
authors.lastname: Dhakal
authors.affiliation: Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Hospital, Durham, NC, USA.
authors.forename: Robert D B
authors.initials: RD
authors.lastname: Jaquiss
authors.affiliation: Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Hospital, Durham, NC, USA.
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Lodge
authors.affiliation: Department of Anesthesiology, Division of Pediatric Anesthesia, Duke University Hospital, Durham, NC, USA.
authors.forename: Edmund H
authors.initials: EH
authors.lastname: Jooste
mesh_terms: D001803:Blood Transfusion / Q000191:economics / Q000379:methods*; D006348:Cardiac Surgical Procedures / Q000379:methods; D002315:Cardiopulmonary Bypass / Q000379:methods; D015331:Cohort Studies; D005169:Factor VIII / Q000627:therapeutic use; D005340:Fibrinogen / Q000032:analysis / Q000627:therapeutic use; D006801:Humans; D007223:Infant; D010976:Platelet Count; D017713:Platelet Transfusion / Q000191:economics / Q000379:methods; D012189:Retrospective Studies
chemical_list: C026912:cryoprecipitate coagulum; D005169:Factor VIII; D005340:Fibrinogen
keywords: blood products; congenital heart disease; goal-directed transfusion; infants; pediatric cardiopulmonary bypass; transfusion management