Transfusion in surgery pediatric cardiac

[mpmiola]

Hello,

I need your help with transfusion of packed red blood cells in pediatric cardiac surgery. Our surgeon requests washed and irradiated red blood cells for all children up to three months old and for children over three months, only if it is the second procedure. Did we ask why? However, he could not answer.

It is important to say that we provide red blood cells of 5 to 7 days of storage, only that is 3-5 days post-irradiation and identical ABO.

I believe it has no significant benefits. Some studies say that washing minimizes the risk of inflammation, but it is not a consensus.
Other risks seem to me to be more worrying than the benefits pointed out, such as:
Risk of contamination - our service does not have automation for the washing of red blood cells;
Loss of yield - in addition to the loss of cells that occurs during the procedure, mechanical trauma can accelerate the process of hemolysis of more fragile cells;
Anyway, I would like to know your opinion on this subject and what is the practice adopted by your service?

Thanks for any input,

[Baby Banker]

We use fresh (less than seven days old) irradiated RBCs.  We wash the units only if they are not fresh.

[mpmiola]

Thank you Baby Banker.
If cardiac surgery is for extracorporeal, should red cells be washed if they present more than 24 hours of irradiation time?

[Neil Blumberg]

The rationale for irradiation is that congenital cardiac anomalies are associated with immune deficiency syndromes.  Some of these are not easy to diagnose in the first months or even first few years of life.  Our own policy is for infants and younger children (<5 years of age) to transfuse only irradiated, ABO identical red cells and the first red cell is washed.  We only wash red cells <21 days of age because of data that washed red cells are associated with less inflammation and clinical complications if of shorter storage (<21 days), but greater inflammation and poorer clinical  outcomes if >28 days of storage.

Pediatr Crit Care Med. 2015 Mar;16(3):227-35

Despite the long standing policy of using "fresher" red cells for these patients, the safest red cells are probably about 10-21 days of storage according to our data and meta-analyses of the randomized trials.  Fresher red cells are associated with a higher incidence of post-operative infections, the major cause of morbidity and mortality in this population.  I would never transfused red cells <7-10 days old to any patient at this point in time.  We have some mechanistic data that is as yet unpublished that the mechanism is dysregulation of oxidation/reduction in freshly collected red cells.

Blood. 2016 Jan 28;127(4):400-10

Washed red cells reduce the risk of post-operative inflammation in the only published randomized trial and there is also a trend towards reduced mortality in the washed arm of the study.  This may be controversial but it's the only data we have to go on, certainly the only randomized trial.

Pediatr Crit Care Med. 2012 May;13(3):290-9.

 

 

[mpmiola]

10 hours ago, Neil Blumberg said:

and the first red cell is washed.

Why the first and not the others? 

[Neil Blumberg]

Most patients only need one red cell for surgery, or less.  The need for the second is usually emergent and there is insufficient time for washing (takes at least 30 minutes).  Just logistics and demographics.  Ideally, all patients would receive washed red cells, but there is not yet convincing data that clinical outcomes are improved.  There were trends to improved outcomes in our randomized trial (mortality in particular) but the trial was powered to demonstrate that washed red cells reduced post-transfusion reduced inflammation, as measured by IL-6 and CRP, which was conclusively demonstrated.

[slsmith]

Our protocol is :

>less than 4 months old : O neg or O pos, irradiated, less than 5 days old(working on moving up to 7), hem S neg and split.

>4 months- 10 years: type specific, hem S neg and split.

The split requirement was made by the cardiac team.

[Sonya Martinez]

For open heart surgery our perfusion team washes the red cells in the OR (faster than we can) and uses those with a small amount of FFP (for babies usually < 1 year especially those < 4kg).  Our policy is to provide 1 fresh, <6 day old, irradiated (<24 hours) AS3, CPD, CPDA-1 or CP2D packed red cell for post CPB but we give then two <= 10 day old unit (irradiated, AS3, CPD, CPDA-1 or CP2D) and mark them "To Be Washed" for priming the CPB.  For non-pump cardiac surgeries we wash if the patient is <4kg.  I would love to get away from washing RBCs for surgeries (we also wash for major open belly procedures on <4kg infants) but over 20 years ago a patient died because of a K+ overload from a RBC that was irradiated 3 days prior to surgery even thought the unit was still <6 days old.  Now I can't even get our Transfusion Committee to even discuss the topic.  Guess I just wait until more surgeons retire.