Biventricular Support Using ProtekDuo Cannula in a Child.

We report a successful pediatric bridge to transplant following application of the ProTekDuo Cannula to provide right ventricular support in a 12-year-old child with biventricular cardiomyopathy and on left ventricular assist device support. We are unaware of any other reports of pediatric use of this device in the medical literature.

Implementation of a Multidisciplinary Bleeding and Transfusion Protocol Significantly Decreases Perioperative Blood Product Utilization and Improves Some Bleeding Outcomes.

Perioperative transfusion of blood products is associated with increased morbidity and mortality after pediatric cardiac surgery. We report the results of a quality improvement project aimed at decreasing perioperative blood product administration and bleeding after pediatric cardiopulmonary bypass (CPB) surgery. A multidisciplinary team evaluated baseline data from 99 consecutive CPB patients, focusing on the variability in transfusion management and bleeding outcomes, to create a standardized bleeding and transfusion management protocol. A total of 62 subsequent patients were evaluated after implementation of the protocol: 17 with single pass hemoconcentrated (SPHC) blood transfusion and 45 with modified ultrafiltration (MUF). Implementation of the protocol with SPHC blood led to significant decrease in transfusion of every blood product in the cardiovascular operating room and first 6 hours in cardiovascular intensive care unit ([CVICU] p < .05). Addition of MUF to the protocol led to further decrease in transfusion of all blood products compared to preprotocol. Patients <2 months old had 49% decrease in total blood product administration: 155 mL/kg preprotocol, 117 mL/kg protocol plus SPHC, and 79 mL/kg protocol plus MUF (p < .01). There were significant decreases in postoperative bleeding in the first hour after CVICU admission: 6 mL/kg preprotocol, 3.8 mL/kg protocol plus SPHC, and 2 mL/kg protocol plusMUF (p = .02). There was also significantly decreased incidence of severe postoperative bleeding (>10 mL/kg) in the first CVICU hour for protocol plus MUF patients (p < .01). Implementation of a multidisciplinary bleeding and transfusion protocol significantly decreases perioperative blood product transfusion and improves some bleeding outcomes.

Anti-xa directed protocol for anticoagulation management in children supported with extracorporeal membrane oxygenation.

The optimum heparin monitoring method during extracorporeal membrane oxygenation (ECMO) is unknown. We report a protocol utilizing only anti-factor Xa (anti-Xa) to manage anticoagulation in 22 consecutive ECMO patients. Anti-Xa was monitored with heparin titration every hour until goal 0.4-0.8 IU/ml. Once therapeutic, monitoring was progressively spaced up to every 6 hours. Patients received frequent antithrombin III (ATIII). Extracorporeal membrane oxygenation indications were as follows: 13 cardiorespiratory failures, eight extracorporeal cardiopulmonary resuscitations (ECPRs), and one pulmonary hypertension. Median weight was 4 kg, age 12.5 days, and ECMO duration 88 hours. Survival was 50%. Mean heparin dose was 38 ± 11 unit/kg/hr. Eight patients received no heparin for median 9 hours because of postoperative bleeding. Compared with prior activated clotting time (ACT) protocol, there were 20 fewer blood draws per day to manage anticoagulation, p < 0.001. Only 9% of the anti-Xa levels were outside therapeutic range versus 22% using ACT, p < 0.01. Six patients had bleeding complications, and seven had oxygenator change-out. Change-out was associated with blood product administration and bleeding but not with heparin-free period (p = 0.39). Survival to discharge was higher among those who did not require circuit/oxygenator change-outs, 4/7 versus 7/7 (p < 0.01). Anti-factor Xa-based ECMO heparin management protocol is feasible, decreases blood sampling and heparin infusion adjustments, and does not appear to increase complications.

Transhepatic Cannulation for Venovenous Extracorporeal Membrane Oxygenation.

Limited vascular access because of vessel injury or thrombosis may complicate care of children with congenital heart disease. Although transhepatic venous access for cardiac catheterization and central venous catheter placement has been used in children, its use for extracorporeal membrane oxygenation (ECMO) has not been described. We report successful use of transhepatic cannulation for venovenous ECMO to support a 15 month-old child with bidirectional Glenn anatomy and intractable hypoxemia.

Peritoneal dialysis: an alternative modality of fluid removal in neonates requiring extracorporeal membrane oxygenation after cardiac surgery.

Extracorporeal membrane oxygenation (ECMO) is a lifesaving therapy for patients with cardiopulmonary failure after cardiac surgery. Fluid overload (FO) is associated with increased morbidity and mortality in this population. We present our experience using peritoneal dialysis (PD) as an adjunct for fluid removal in eight consecutive neonates requiring ECMO after cardiac surgery between 2010 and 2012. PD was added to FO management when fluid removal goals were not being met by hemofiltration (HF) or hemodialysis (HD). Percent FO was 36% at ECMO initiation; 88% (seven of eight) achieved negative fluid balance before discontinuation of ECMO. PD removed median 119 mL/kg/day (interquartile range [IQR], 70-166) compared with median 132 mL/kg/day (IQR, 47-231) removed by HF/HD. PD and HF/HD fluid removal were performed concurrently 38% of the time. Unlike HF/HD, PD was never stopped secondary to hemodynamic compromise. Median duration of ECMO was 155 hours (IQR, 118-215). Six of eight patients were successfully decannulated. These results suggest PD safely and effectively removes fluid in neonates on ECMO after cardiac surgery. PD may increase total fluid removal potential when combined with other modalities.