Patient Blood Management for Neonates and Children Undergoing Cardiac Surgery: 2019 NATA Guidelines.
The objective of the NATA[1] task force is to provide evidence-based recommendations regarding anaemia management and blood transfusion practices in the perioperative care of neonates and children undergoing cardiac surgery, and to highlight potential areas where additional research is urgently required. The authors noted major distinctions in the paediatric population compared to adults, particularly: haemostatic system differences, greater haemodilution with CPB, presence of cyanotic heart disease and the complexity of surgical procedures. A systematic review was performed with the published evidence appraised for quality using the GRADE guidelines.
For this review, the highest grading of recommendation was ‘1B Strong recommendation. Moderate-quality evidence’ and was applied to the following practices:
- Prophylactic administration of lysine analogues (TXA) for all neonates and children undergoing surgery with CPB
- Conventional ultrafiltration or ³ 10minutes of modified ultrafiltration for neonates and infants undergoing cardiac surgery with CPB
- The use of whole blood ACT or heparin concentration to assess heparin response in neonates and children
- Targeting an ACT > 480 seconds before and throughout CPB
- The use of intraoperative monitoring of haemostasis to guide the administration of blood products in the presence of excessive bleeding
- A postoperative haemoglobin threshold for transfusion in stable, acyanotic cardiac children of Hb 70g/L, or 80g/L in the presence of clinical signs suggestive of symptomatic anaemia
- DDAVP should not be used for bleeding management in children undergoing cardiac surgery
All other recommendations were based on ‘low quality’ evidence.
Assessment
The international author panel of five hailed from Canada and parts of Europe. Given the paucity of previous recommendations and the limited high quality evidence in the paediatric population, this article represents a comprehensive attempt at collating contemporary evidence and presenting discerning guidelines. There were no conflicts of interest disclosed.
Take Home Message
The 2019 NATA guidelines will assist in validating current blood management practice, provide a basis for optimising patient care and mitigate unnecessary allocation of resources. Recommendations with lower quality of evidence may be identified as key areas for future research.
Reviewed by: Dr Tom Flett
