Efficacy of cell salvage in neonates and children undergoing cardiac surgery

BACKGROUND: Cell salvage (CS) techniques are used to reduce exposure to allogeneic packed red blood cell (pRBC) transfusion in patients undergoing cardiac surgery. However, some studies suggest that inappropriate use of these techniques is associated with increased incidences of thrombocytopenia, excessive bleeding, and transfusion of non-red blood cell blood products, including fresh frozen plasma (FFP), cryoprecipitate, and platelets. Pediatric patients undergoing cardiac surgery are at higher risk for increased perioperative bleeding and blood product transfusion requirement. To date, limited evidence supports the use of CS to reduce pRBC transfusion in neonates and children undergoing cardiac surgery. OBJECTIVES: This study analyzed the efficacy of systematic use of CS in neonates and children undergoing cardiac surgery with cardiopulmonary bypass (CPB) compared to a historic cohort of children in whom CS was not used. Our primary endpoints included the incidences of pRBC, cryoprecipitate, and platelets transfusion occurring within 48 hours after CPB. METHODS: We performed a retrospective medical chart review to study all neonates and children who underwent cardiac surgery with CPB between January 2013 and December 2014 at Boston Children’s Hospital (BCH). Considering that CS has been systematically applied at BCH since January 2014, children were separated into a control group (before January 2014) and a CS group (after January 2014). Children treated with CS before January 2014 were excluded. We used uni- and multivariable logistic regression analysis to assess the effect of CS on the odds of blood products transfusion. RESULTS: Among 1228 patients included in the analysis, 730 were included in the CS group and 498 in the control group. The results of our multivariate logistic regression analysis showed that age < 12 months (odds ratio (OR): 2.95, 95% confidence interval (CI): 2.26-3.84), American Society of Anesthesiologists Physical Status Classification (ASA) > 3 (OR: 2.95, 95% CI: 2.26-3.84), Risk Adjustment for Congenital Heart Surgery score (RACHS) > 3 (OR: 1.78, 95% CI: 1.28-2.49), and the use of CS (OR: 0.57, 95% CI: 0.44-0.73) were good predictors for perioperative transfusion. Using univariable analysis, the use of CS was associated with a significant reduction in pRBC transfusion (OR: 0.76, 95% CI: 0.61-0.96, p = 0.021), but a significant increase in cryoprecipitate (OR: 1.37, 95% CI: 1.08-1.76, p = 0.009) and platelets transfusions (OR: 1.37 95% CI: 1.08- 1.76, p = 0.004). However, after adjustment for age < 12 months, ASA > 3, and RACHS > 3, the use of CS significantly reduced pRBC transfusion (OR: 0.57, 95% CI: 0.44-0.73, p < 0.001), with no effect on cryoprecipitate (OR: 1.08, 95% CI: 0.83-1.41, p = 0.543) and platelets transfusions (OR: 1.05, 95% CI: 0.81-1.36, p = 0.694). CONCLUSION: The use of CS in neonates and children undergoing cardiac surgery with CPB significantly reduced the incidence of pRBC transfusion. Although the systematic use of CS in adults has been associated with an increased incidence of non-pRBC transfusions, the use of CS in a high risk pediatric population (age < 12 months, ASA > 3, RACHS > 3) was associated with a 43% reduction of pRBC transfusion without any increases in cryoprecipitate and platelets transfusions