Bristol Trials Centre, Faculty of Health Sciences, University of Bristol, Bristol, UK.
Department of Paediatric Cardiac Surgery, Bristol Royal Hospital for Children, University Hospitals Bristol, Bristol, UK.
Semin Thorac Cardiovasc Surg. 2022 Spring;34(1):277-288. doi: 10.1053/j.semtcvs.2021.01.006. Epub 2021 Jan 12.
Bleeding caused by coagulopathy is common in children undergoing cardiac surgery and causes adverse outcomes. Coagulation testing assists selection of treatments to stop bleeding but has an uncertain role for predicting bleeding. We aimed to evaluate how well prospective coagulation testing predicted excessive bleeding during and after cardiac surgery compared to prediction using clinical characteristics alone. The study was a single-center, prospective cohort study in children having a range of cardiac surgery procedures with coagulation testing at anesthetic induction and immediately after cardiopulmonary bypass. The primary outcome was clinical concern about bleeding (CCB), a composite of either administration of prohemostatic treatments in response to bleeding or a high chest drain volume after surgery. In 225 children, CCB occurred in 26 (12%) during surgery and in 68 (30%) after surgery. Multivariable fractional polynomial models using the clinical characteristics of the children alone predicted CCB during surgery (c-statistic 0.64; 95% confidence interval 0.53, 0.76) and after surgery (0.74; 0.67, 0.82). Incorporating coagulation test results into these models improved prediction (c-statistics 0.79; 0.70, 0.87, and 0.80; 0.74, 0.87, respectively). However, this increased the overall proportion of children classified correctly as CCB or not CCB during surgery by only 0.9% and after surgery by only 0.4%. Incorporating coagulation test results into predictive models had no effect on prediction of blood transfusion or postoperative complications. Prospective coagulation testing marginally improves prediction of CCB during and after cardiac surgery but the clinical impact of this is small when compared to prediction using clinical characteristics.
凝血功能障碍引起的出血在接受心脏手术的儿童中很常见，会导致不良后果。凝血检测有助于选择止血治疗方法，但对于预测出血的作用尚不确定。我们旨在评估与仅使用临床特征预测相比，前瞻性凝血检测在心脏手术后期间和之后预测过度出血的效果如何。该研究是一项单中心前瞻性队列研究，纳入了接受各种心脏手术的儿童，在麻醉诱导和体外循环后立即进行凝血检测。主要结局是临床关注的出血（CCB），是由于出血而给予促凝治疗或手术后胸腔引流量大的复合指标。在 225 名儿童中，26 名（12%）在手术期间和 68 名（30%）在手术后发生 CCB。仅使用儿童的临床特征的多变量分数多项式模型预测了手术期间（c 统计量 0.64；95%置信区间 0.53，0.76）和手术后（0.74；0.67，0.82）的 CCB。将凝血检测结果纳入这些模型可以提高预测效果（c 统计量分别为 0.79；0.70，0.87 和 0.80；0.74，0.87）。然而，这仅将手术期间和手术后被正确分类为 CCB 或非 CCB 的儿童比例分别提高了 0.9%和 0.4%。将凝血检测结果纳入预测模型对预测输血或术后并发症没有影响。前瞻性凝血检测可略微改善心脏手术后期间和之后的 CCB 预测，但与使用临床特征预测相比，其临床影响较小。
