抖阴漫画

For families with religious or personal beliefs to avoid blood transfusions, surgery options can be very limited. In the past few years, blood conservation strategies have developed and grown to minimize the need for external blood products during surgery.*

But for babies with a single ventricle heart defect, the long road to repair needs to begin soon after birth. These babies are too small for typical blood conservation strategies. Options for this patient population have been few and far between, with families traveling across the country looking for options for their child.

Le Bonheur Cardiac Surgeon Danielle Gottlieb Sen, MD, MS, MPH, and Chief Perfusionist Jerry Allen, CCP, jumped at the opportunity to bring that innovation to Memphis, Tenn., so that these families could stay close to home for their child’s early heart surgeries. Not only could they develop a new approach to the surgery at Le Bonheur Children’s, but they could honor a family’s beliefs in the care of their child.

“We consider the family part of the team and want to incorporate as much of the family’s belief system into care that is medically sound,” said Gottlieb Sen. “So much innovation can happen if you start there.”

Le Bonheur Cardiac Surgeon Danielle Gottlieb Sen, MD, MS, MPH, jumped at the chance to bring the innovation of a blood conservation surgery to Le Bonheur’s smallest heart patients. With the new technique, Gottlieb Sen can conduct open heart surgery without external blood products for patients less than 10 kgs.

“It’s a challenge to be faced with these types of cases,” said Allen. “My colleagues and I were excited by the opportunity, and it’s very rewarding to know that you helped the parents achieve the goal they wanted.”

Thanks to teamwork across specialties and hospitals, Le Bonheur was able to develop the protocols to provide successful bloodless heart surgery for patients weighing less than 10 kg.

The Challenge

A typical open heart surgery for an infant requires the use of blood bank products to prime the cardiopulmonary bypass machine. Without this external blood product, a patient’s blood would be diluted to the point that not enough oxygen is reaching the brain during surgery, which can cause brain damage.

For patients larger than 20 kg, perfusionists can use a clear fluid to prime the pumps, eliminating the need for external blood products. But a baby with a single ventricle defect cannot wait until they are larger to have this vital surgery.

Allen and Gottlieb Sen had to figure out a way to use this clear fluid without diluting a patient’s blood to a dangerous level. These protocols have been successful at some other centers in the US; they consulted with the team at another children’s hospital who were willing to share their approach, and Allen got to work developing a new protocol for cardiopulmonary bypass for blood conservation surgery.

“Everyone knew what we were trying to accomplish and how we were going to do it,” said Gottlieb Sen. “The team learned new skills because the needs of these families. At the end of the day, by following the protocol that included preoperative medications to increase a baby’s red blood cells, I was confident that we would be able accomplish this.”

Le Bonheur Chief Perfusionist Jerry Allen, CCP, (above) helped to develop the cardiopulmonary bypass means necessary to conduct a bloodless surgery for infants. His new protocol provides an additional option for children and families wishing to avoid blood transfusions.

The Solution

In the protocol developed by the team, the surgery remains the same, but the preparation for surgery is different. The surgeon and anesthesiologist work with each family to understand their religious and personal convictions and select the most appropriate treatment. Then efforts at blood conservation begin weeks before the scheduled surgery.

“Because of our privileged role, we are able to be flexible and maneuver and do what’s best for a child in a given circumstance,” said Gottlieb Sen. “Ultimately that’s what we want to do as a team at Le Bonheur.”

Epogen, a medication that stimulates bone marrow to create more blood cells, is given in the weeks prior to surgery. This helps to raise hematocrit to a higher-than-normal level, which means blood has a higher percentage of red blood cells. This allows the perfusionists the latitude to use clear fluid to prime the bypass machine instead of the blood bank product. The higher hematocrit means that the blood still has enough red blood cells to transport adequate oxygen to the brain after dilution.

Prior to surgery, lab draws are limited to as few as possible, and experts are used for every line placement to minimize blood loss. Every drop of blood counts in a months old baby.

In the operating room, anesthesiologists use acute normovolemic hemodilution (ANH), which removes the child’s own blood to save for reinfusion after surgery. This allows for a whole blood transfusion with the clotting factors needed after an open-heart surgery without using blood bank products.

With these efforts in place, Allen and his team were ready to begin bypass without the use of external blood products. They cut the lines on the machine as short as possible and use a clear fluid to prime the bypass machine, testing the levels of hematocrit every step of the way. Once in place and a safe level of hematocrit is confirmed, the surgery can continue as usual.

In case of an emergency, a child’s caregivers agree to a transfusion of blood for the safety of their child.

“We have innovation in our hands – as a team we had to work together well to provide a bloodless heart surgery,” said Gottlieb Sen. “We came out of the OR with flying colors well above thresholds, and the baby recovered well.”

The Goal

Thanks to the teamwork and family-centered care, families have new options for heart surgery that honor their religious or personal beliefs while providing the highest level of care for their child.

“This new protocol allows us to at least attempt to do bloodless surgery for any age patient who needs heart surgery and wants to be cared for by our team at Le Bonheur,” said Gottlieb Sen.

*STS/SCA/AmSECT/SABM Update to the Clinical Practice Guidelines on Patient Blood Management. Tibi, Pierre et al. The Annals of Thoracic Surgery, Volume 112, Issue 3, 981 - 1004