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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 29, No 6, November/December 2018
AFRICA
381
Audit of transfusion of blood products in paediatric
congenital heart surgery on cardiopulmonary bypass
Caroline Tumelo Bayebaye, Michel Kasongo Muteba, Palesa Motshabi Chakane
Abstract
Background:
Cardiac surgery is associated with peri-operative
bleeding, which may result in the need for blood transfusion,
particularly in paediatric congenital cardiac surgery on cardio-
pulmonary bypass (CPB). There is a necessity for regular
auditing in order to improve practices.
Methods:
Retrospective, contextual, descriptive data of 105
patients were collected for the period January to December 2014.
Results:
The median age of patients was four (1–6) years,
weight was 13 (8.4–20) kg, and mean lowest CPB haemoglo-
bin level was 8.3 (1.5) g/dl. There was a statistically significant
difference in median red packed cell (RPC), platelet and cryo-
precipitate units per patient transfused across four RACHS
(risk-adjusted classification for congenital heart surgery)
categories (
p
=
0.03,
p
=
0.0013,
p
=
0.0001, respectively).
There was a statistically significant correlation between trans-
fused fresh frozen plasma units with CPB time (
r
=
0.2634,
p
=
0.0199) and RPC units (
r
=
–0.4654,
p
<
0.001).
Conclusion:
Although no standardised transfusion guidelines
were available, overall transfusion of blood products was
comparable to reported practices.
Keywords:
blood transfusion strategies, paediatric congenital
cardiac surgery, cardiopulmonary bypass
Submitted 22/3/18, accepted 30/8/18
Published online 6/11/18
Cardiovasc J Afr
2018;
29
: 381–386
www.cvja.co.zaDOI: 10.5830/CVJA-2018-048
Bloodproducts are a scarce commodity inSouthAfrica, as reported
by the South African National Blood Service.
1
Cancellation
of surgical cases has been reported due to depletion of blood
products from the blood blank.
2
Blood products are transfused
commonly in paediatric cardiac surgery on cardiopulmonary
bypass (CPB).
3
Transfusion of blood products is intended to treat
anaemia, improve oxygen-carrying capacity of the blood and
oxygen delivery to the tissues, and to maintain haemostasis.
4
Transfusion of blood products is not without complications, and
can result in adverse haemolytic and non-haemolytic reactions.
5
In
paediatric cardiac surgery on CPB, transfusion of blood products
has been associated with cardiovascular instability, acute kidney
injury,
6
delayed extubation time,
7
prolonged mechanical ventilation,
infection,
6,8,9
and increased risk of postoperative bleeding.
10
The World Health Organisation (WHO) recommends the
provision of disease-free blood products, and promotion of
appropriate usage of blood products by healthcare providers.
11
The implementation of blood-conservation strategies to reduce
rates of transfusion of blood products in paediatric cardiac
surgery is recognised by the WHO.
12
These strategies have made
it possible to perform bloodless paediatric cardiac surgery on
CPB,
13
and have also been used successfully in Jehovah’s Witness
patients.
14,15
Blood-transfusion guidelines are available for adult cardiac
surgery patients,
16
but could not be found for paediatric patients.
The lack of standardised guidelines in paediatric cardiac
surgery could be because of multiple factors that influence the
transfusion of blood products in this patient population.
6
There are controversies regarding the safest haemoglobin
level on CPB in paediatric cardiac surgery.
13,17-19
A randomised,
controlled trial from the Boston Children’s Hospital revealed
a poor psychomotor developmental index after a year in
young patients with a range of congenital cardiac conditions
with haematocrits below 21.5% on CPB.
17
By contrast, no
neurodevelopmental impairmentwas observedwithahaematocrit
below 20% in older patients
13
and infants
18
presenting for low-risk
cardiac conditions. There were no outcome differences reported
between liberal (9.5 g/dl) and restrictive (7 g/dl) haemoglobin
strategies during the postoperative period in paediatric patients
post acyanotic cardiac surgery in one study.
19
The WHO requires appropriate use of blood products by
healthcare providers, which can be assessed by regular audits.
Although the appropriateness of transfusion of blood products
during cardiac surgery is undefined, it is essential to audit
institutional practices. Audits are intended to evaluate practices
and identify the need to change or modify these practices to
improve the use of blood products.
This study aimed at evaluating transfusion practices in
paediatric patients at a tertiary hospital, as our practice had
not previously been audited. The objectives of the study were
primarily to describe the demographic and clinical characteristics
of the study participants, and secondarily to assess differences
in the number of units of transfused blood products between
four RACHS (risk-adjusted classification for congenital heart
surgery) and body weight categories of the patients.
Methods
A retrospective, contextual, descriptive study was conducted at
Charlotte Maxeke Johannesburg Academic Hospital. Approval
Department of Anaesthesiology, School of Clinical
Medicine, Faculty of Health Sciences, University of the
Witwatersrand, Johannesburg, South Africa
Caroline Tumelo Bayebaye, MB ChB, DA (SA), FCA (SA)
Palesa Motshabi Chakane, PhD,
motshabi.chakane@gmail.comDivision of Epidemiology and Biostatistics, School
of Public Health, University of the Witwatersrand,
Johannesburg, South Africa
Michel Kasongo Muteba, MB ChB, MSc