Comparison between intravenous boluses versus infusion of tranexamic acid [TXA] to reduce bleeding in paediatric cyanotic congenital heart disease [CHD] surgeries

Objective: To compare the intravenous boluses and intravenous continuous infusion of tranexamic acid [TXA] to reduce postoperative bleeding in cyanotic congenital heart disease surgeries

Study Design: Single-blinded randomised clinical trial

Place and Duration of Study: Anaesthesia Department, The Aga Khan University Hospital, Karachi, from July 2016 to April 2017

Methodology: Sixty patients of cyanotic congenital heart disease, undergoing either palliative or corrective surgery involving cardiopulmonary bypass [CPB], were recruited. These 60 patients were divided randomly into two groups. The infusion group received intravenous infusion of TXA at 5 mg/kg/hour while the bolus group received three intravenous boluses of 10 mg/kg after induction, after going to bypass and after protamine reversal. Data was collected through predesigned proforma. There were two primary outcomes: postoperative bleeding in the first 24 hours, and chest closure time

Results: Postoperative bleeding was 13.94 [10.27-20.18] ml/kg in the first 24 hours in infusion group and 15.05 [9.04-23.50] ml/kg in the bolus group. Chest closure time was 38.5 [25-45] in infusion group and 30 [20-46.25] minutes in the bolus group. There was no statistically significant and clinical difference between both groups regarding postoperative bleeding in the first 24 hours and chest closure time

Conclusion: These infusion and bolus groups had comparable postoperative bleeding and chest closure time

Establishing a congenital cardiac anesthesia service: challenges in a developing country

Congenital heart disease is the commonest congenital birth defect seen in low and middle income countries and definitive care requires highly sophisticated equipment, drugs, and above all a specially trained professional teams. Financially viable and sustainable congenital heart programs are a big challenge in these countries although examples of creative solutions do exist. Major challenges in establishing services are training, team building and staff retention. There is a lack of recognized fellowship programs as well as centers for training. Investment in a structured program is a cost effective solution for capacity building. One solution is to locate congenital cardiac service in a few strategic centers, with facilities of transport and accommodation which can then serve as recognized training centers. And which may cater to a number of peripheral referring centers. Cost containment strategies such as clinical protocols and checklists, economical alternatives for expensive drugs, minimization of blood and blood product transfusion, prevention of infection, efficient turnover time, and fast track extubation to reduce ICU and hospital length of stay are important for cost effective care