Department of Cardiothoracic Anesthesiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
Institute of Clinical Medicine, Health Faculty, University of Copenhagen, Copenhagen, Denmark.
Acta Anaesthesiol Scand. 2022 Nov;66(10):1166-1173. doi: 10.1111/aas.14144. Epub 2022 Sep 11.
Implementation of point-of-care tests is recommended to provide tailored substitution during cardiac surgery. The measurement and substitution of fibrinogen have gained particular interest since it is the first coagulation factor to become depleted during cardiac surgery. However, the prognostic ability of thromboelastography (TEG) 6s has not been evaluated in pediatric patients. The aim of the present study was to describe patient characteristics of infants receiving fibrinogen substitution during cardiac surgery and evaluate the prognostic ability of TEG6s after weaning off cardiopulmonary bypass (CPB).
Infants undergoing congenital cardiac surgery with CPB were retrospectively included (n = 279) between January 2017 to July 2019. Patient and perioperative data were collected on the day of surgery until 6:00 AM the next morning. Hemostatic capacity was assessed with TEG6s. The efficacy of TEG-functional fibrinogen-maximal amplitude (TEG-FF-MA) measurements for the prediction of intraoperative bleeding, and thereby cryoprecipitate need, was evaluated by a sensitivity and specificity analysis.
Among 174 children with TEG-FF-MA data, 147 (84%) received cryoprecipitate intraoperatively. Cryoprecipitate administration was associated with younger age 66 (10-132) versus 98 (45-204) days (p = .044), higher RACHS-1 classification, and intraoperative bleeding 21 (11-47) versus 5 (3-13) ml/kg (p < .001, mean difference 29 ml/kg [CI: 8-50]). Median TEG-FF-MA values were lower in transfused children 7.6 (5.3-11.0) versus 10.5 (7.3-13.4) mm (p = .004, mean difference - 2.4 mm [CI: -4.1 to - 0.73]). The volume of cryoprecipitate was associated with bypass time, TEG-FF-MA values, and in particular intraoperative bleeding volumes. A TEG-FF-MA threshold of 10.0 mm, resulted in sensitivity: 74%, specificity: 56%, positive predictive value: 80%, and a negative predictive value of 47% for the prediction of intraoperative bleeding (>10 ml/kg) and consequently a need of cryoprecipitate transfusion.
Fibrinogen substitution in infants was associated with younger age and higher RACHS-1 category. The prognostic value of TEG6s was evaluated, and cryoprecipitate transfusion was related to TEG-FF-MA values, but also CPB-time, surgical complexity, and in particular excessive intraoperative bleeding. A clear-cut threshold for TEG-FF-MA is difficult to establish in infants undertaken congenital heart surgery.
推荐在心脏手术期间实施即时检测，以提供针对性的替代治疗。纤维蛋白原的测量和替代已成为研究热点，因为它是心脏手术期间第一个耗尽的凝血因子。然而，尚未评估血栓弹性图（TEG）6s 在儿科患者中的预后能力。本研究旨在描述接受心脏手术期间纤维蛋白原替代治疗的婴儿的患者特征，并评估体外循环（CPB）脱机后 TEG6s 的预后能力。
回顾性纳入 2017 年 1 月至 2019 年 7 月期间接受 CPB 心脏手术的婴儿（n=279）。收集手术当天至次日早上 6:00 点的患者和围手术期数据。使用 TEG6s 评估止血能力。通过灵敏度和特异性分析评估 TEG-功能性纤维蛋白原-最大振幅（TEG-FF-MA）测量对术中出血和因此需要冷沉淀的预测效果。
在 174 例有 TEG-FF-MA 数据的儿童中，147 例（84%）术中输注冷沉淀。冷沉淀的应用与更年轻的年龄（66（10-132）天与 98（45-204）天，p=0.044）、更高的 RACHS-1 分级和术中出血（21（11-47）ml/kg 与 5（3-13）ml/kg，p<0.001，平均差值 29ml/kg[CI：8-50]）相关。输注儿童的 TEG-FF-MA 值中位数较低：7.6（5.3-11.0）mm 与 10.5（7.3-13.4）mm（p=0.004，平均差值-2.4mm[CI：-4.1 至-0.73]）。冷沉淀的量与体外循环时间、TEG-FF-MA 值相关，尤其是与术中出血量相关。TEG-FF-MA 阈值为 10.0mm 时，对术中出血（>10ml/kg）和因此需要冷沉淀输注的预测具有敏感性 74%、特异性 56%、阳性预测值 80%和阴性预测值 47%。
婴儿纤维蛋白原替代与年龄较小和 RACHS-1 分级较高有关。评估了 TEG6s 的预后价值，冷沉淀的输注与 TEG-FF-MA 值有关，但也与 CPB 时间、手术复杂性有关，尤其是与术中过度出血有关。在接受先天性心脏病手术的婴儿中，很难确定 TEG-FF-MA 的明确阈值。
