For hemofiltration and ZBUF during CPB, a Minntech Hemocor HPH MINI (Minntech, Minneapolis, MN) was used. The CPB circuit consisted of a Terumo FX-05 ® oxygenator (Terumo Cardiovascular Systems Corporation, Ann Arbor, MI), a 1/8-inch arterial line, 3/16-inch venous line, 3/16-inch arterial boot, and 3/16-inch suckers. The patient received erythropoietin (EPO) injections (Amgen, Inc., Thousand Oaks, CA) that were administered subcutaneously (500 U/kg) every day for three days before the procedure. The neonate was diagnosed with transposition of the great arteries and an intact ventricular septum and presented for an arterial switch operation. 18 m 2) whose parents are of the JW faith and requested no blood products be administered. The following is a case report of a 4-day-old male (2.7 kg, 48 cm. ANH removal and readministration were modified so as to be maintained in a constant contiguous circuit with the patient’s circulation ( 4 – 6). The CPB circuit fulfills this obligation as the patient’s blood circulates in a contiguous loop. These included the necessity of maintaining a patient’s circulating blood volume (CBV) in physical contact with the patient at all times. JW patients reject allogeneic blood product transfusions based on their religious beliefs therefore, as an institution, we have protocols in place for this select population. Our Heart Center is a referral site for children of the Jehovah’s Witness (JW) faith who present with congenital cardiac defects that require repair using CPB. We also use both acute normovolemic hemodilution (ANH) and retrograde autologous prime (RAP)/venous antegrade prime (VAP) before CPB to minimize hemodilution ( 1 – 5). We have miniaturized circuits, perform zero-balance ultrafiltration (ZBUF), and after CPB perform modified ultrafiltration (MUF) to reduce the prime volume impact on the patient. Our institution has endeavored to perform bloodless pediatric cardiac surgery whenever possible. Many potentially negative risks are associated with the transfusion of blood products including costs, increased risk of infection, increased 30-day mortality, and the incidences of poor outcomes ( 1, 2). A close collaboration among the surgeon, anesthetist, cardiac intensive care unit intensivists, and perfusionist is imperative to achieve the goal of avoidance of blood product administration during and after procedures requiring cardiopulmonary bypass (CPB) ( 1). The avoidance of allogeneic blood use in pediatric cardiac surgery remains a challenge to the entire operating room (OR) team. The patient was discharged on post-op day nine with a hematocrit of 36%. The patient’s first hematocrit in the OR was 43%, lowest hematocrit on bypass was 15%, and first hematocrit in the cardiothoracic intensive care unit post-procedure was 21%. The patient received no allogeneic blood product administration throughout the entire hospitalization. We present the case of a 4-day-old patient of the JW faith weighing 2.7 kg with transposition of the great arteries and an intact ventricular septum who underwent an arterial switch operation. These techniques include preoperative treatment with erythropoietin, intraoperative acute normovolemic hemodilution, CPB circuit miniaturization, ultrafiltration during and after CPB, limiting blood gas analyses or other unnecessary blood draws, and using hemostatic agents during and after CPB. Our institution is a referral center for children of JW families because we have developed techniques to minimize blood loss with the hope of performing bloodless pediatric cardiac surgery whenever possible. Patients of families of the Jehovah’s Witness (JW) faith reject the use of these products because of religious beliefs.
The amount of circulating blood volume to pump prime volume mismatch of small patients results in hemodilution that frequently results in transfusion of allogeneic blood products. Bloodless pediatric cardiac surgery requiring the use of cardiopulmonary bypass (CPB) remains a challenge for the entire operating room (OR) team.
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