A 4-month-old, 5.8-kg infant was referred to the Duke Pediatric and Congenital Heart Center for repair of a congenital atrioventricular septal defect (AVSD). Repair of such a defect requires the use of a cardiopulmonary bypass (CPB) system that supports circulation during surgery.
For infants, blood products are generally added to the CPB circuit in order to maintain hemoglobin levels and clotting factors and decrease the hemodilution caused by the system. This approach most commonly affects babies, because they’re more likely to need transfusions to replace blood lost during surgery and standard postoperative blood draws, given their small blood volume.
Andrew Lodge, MD, a pediatric heart surgeon who specializes in treating infants with birth defects of the heart, along with the surgical team preparing to perform the AVSD repair, believed bloodless surgery was possible for the infant. “An increasing amount of evidence in the critical care literature suggests that blood product transfusions can lead to problems such as an increased risk of infections, postoperative pulmonary complications, and prolonged hospital length of stay. This could be a more significant effect in pediatric patients because of their smaller blood volume relative to the transfused volume,” he says, “so we’re increasingly motivated to consider surgery without the use of blood products whenever we believe it’s safe for the patient.”
The team believed the repair could be performed safely without blood products for this infant, but it would also be challenging because of the baby’s small size. Lodge says that in most cases, children who weigh at least 10 kg do well without blood products because their blood volume will remain at a safe level, whereas in smaller babies, blood is usually needed. In very small babies like this patient, blood volume can become dangerously diluted if blood is not added to the CPB system.
“Avoiding blood products to prevent negative patient outcomes has been a focus of ours for some time now, so we always discuss our strategy for blood product management at the beginning of every case,” says Lodge. “In this case we had a lot of things come together perfectly.”
“This is a remarkable achievement, and to my knowledge is the smallest open heart case we’ve done without the use of blood products,” says Lodge. “When I was in training, it was very common to use blood products in almost every child who had open heart surgery, so we’ve come a long way in our ability to perform these surgeries without blood products. It’s a great example of the dedication and forward-thinking nature of our entire team.”
Lodge says that several factors were important in planning and performing the surgery:
- The procedure was a first-time surgery for the patient and was not unusually complex. The heart functioned well and was stable during surgery.
- The patient had a good starting hematocrit level, and the perfusionist calculated what the dilutional hematocrit level would be during surgery and found it to be acceptable.
- Blood products could be safely added to the CPB system secondarily if needed during surgery to increase the hematocrit level.
- The patient didn’t lose a lot of blood during surgery, and lab tests that would require blood draws were limited postoperatively. Although his blood count was lower than normal, the patient was stable and the count continued to be acceptable without concern for relative anemia.
- The department had a highly experienced, multidisciplinary team of surgeons, anesthesiologists, and cardiac perfusionists on hand, prepared to support the infant before, during, and after surgery.
Just one month postoperatively, the baby’s blood count had returned to normal and his heart was continuing to function well after the AVSD repair.