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Minimizing perioperative blood loss and transfusions in children

[Réduire les pertes sanguines et les besoins transfusionnels en chirurgie pédiatrique]

Joanne Guay, MD FRCPC^*, Philippe de Moerloose, MD and Dominique Lasne, MD

^* From Departments of Anesthesiology, Maisonneuve-Rosemont Hospital, University of Montreal, Montreal, Quebec, Canada;
University Hospital of Geneva,Geneva, Switzerland; and the
Laboratoire d’hématologie,Hôpital Necker, Paris, France.

Address correspondence to: Dr. Joanne Guay, Department of Anesthesiology, Maisonneuve-Rosemont Hospital, 5415 L’Assomption blvd, Montreal, Quebec H1T 2M4, Canada. Phone: 514-252-3426; Fax: 514-252-3542; E-mail: joanne.guay{at}umontreal.ca

	Abstract

TOP Abstract Introduction Developmental aspects of... Preoperative laboratory... Patient and surgical risk... Reducing allogenic blood... Administration of blood products Conclusion References

 
Purpose: To summarize the physiology and pathophysiology relevant to perioperative blood loss in children. Strategies to reduce blood losses are reviewed.

Methods: The literature was reviewed using the electronic library PUBMED and the Cochrane Database of Systematic Reviews. Relevant studies published in English or French with an English abstract are included. The following keywords were used: children, blood transfusion, surgical blood loss, erythropoietin, autologous blood, red blood cell saver, normovolemic hemodilution, desmopressin, aminocaproic acid, tranexamic acid, aprotinin, cardiac surgery, liver transplantation and scoliosis surgery.

Main findings: For patients with idiopathic scoliosis, predonation with or without the addition of erythropoietin is a safe and effective way to avoid the use of allogenic blood products. For open heart procedures: whole blood of less than 48 hr is helpful for children of less than two years of age undergoing complex procedures; tranexamic acid may be helpful for cyanotic heart disease and, to a lesser degree, for reoperations; while anti-kallikrein blood levels of aprotinin may both reduce the need for allogenic blood transfusions and improve postoperative oxygenation in infants.

Conclusion: Reducing perioperative allogenic blood transfusions is possible in pediatric patients provided that prophylactic measures are adapted to age, disease and type of surgery.

	Introduction

TOP Abstract Introduction Developmental aspects of... Preoperative laboratory... Patient and surgical risk... Reducing allogenic blood... Administration of blood products Conclusion References

 
IN normal children perioperative blood loss leading to administration of allogenic transfusion may be encountered if: the surgical site does not allow easy access to surgical hemostasis, the surgery is performed on highly vascularized tissues that are not easily sutured or cauterized (for example bone elements such as in spinal fusion or correction of craniosynostosis) or the surgery itself induces various disturbances of hemostasis (dilution of factors and induction of fibrinolysis as in cardiac surgery with the use of extracorporeal bypass). The pathology justifying the surgical procedure may also induce various coagulation and/or hemostatic abnormalities. Children suffering from congenital cardiac or liver disease may have thrombocytopenia, abnormal platelet function (congenital heart disease) and/or inadequate amounts of various coagulation factors.¹ Perioperative management of children with congenital coagulation and hemostatic diseases will not be discussed in this review.

	Developmental aspects of hemostasis

TOP Abstract Introduction Developmental aspects of... Preoperative laboratory... Patient and surgical risk... Reducing allogenic blood... Administration of blood products Conclusion References

 
An excellent summary of the developmental physiology of coagulation, based mainly on the extensive work of Maureen Andrew, may be found in a recent review by Kuhle et al. and is summarized in Table I.² Since maternal coagulation factors do not cross the placental barrier, blood levels measured at birth are the result of fetal synthesis that starts around the fifth week of gestation. Fetal blood becomes clottable around 11 weeks of gestation. Except fetal fibrinogen which has an increased content of sialic acid, all coagulation and inhibitor factors are qualitatively normal at birth, and differ from adults in their quantity only. Factor VIII would be the only factor present in normal quantity at birth. In neonates and up to six months of age where they reach approximately 80% of adult values, plasma levels of vitamin K-dependent factors (II, VII, IX and X) are reduced, but the prothrombin time (PT) remains within normal limits. The activated partial PT (aPTT) is slightly prolonged up to three months of age as a result of decreased blood levels of contact factors (XII, prekallikrein and high molecular-weight kininogens). A decrease in platelet function during the first years of life has also been shown.³ Clinical implications of the prolonged aPTT observed up to three months of age and of decreased platelet function throughout childhood are unclear, since measurement of whole blood coagulation shows a relative hypercoagulable state as demonstrated by a decreased reaction-time with the thromboelastograph in infants (under one year of age).⁴ Moreover, the bleeding time is shorter in newborns. This might be due to higher levels of von Willebrand factor and increased hematocrit. Finally, except for cardiac surgery with the use of extracorporeal bypass where higher blood losses in infants have been clearly demonstrated, neonates usually do not demonstrate excessive bleeding during surgery.⁵

	Preoperative laboratory investigation

TOP Abstract Introduction Developmental aspects of... Preoperative laboratory... Patient and surgical risk... Reducing allogenic blood... Administration of blood products Conclusion References

 
The Canadian Anesthesiologists’ Society proposes that before any surgery: "Laboratory investigations indicated by the history and physical examination should be carried out. These should take into consideration the physical condition of the patient and the proposed operation". When the patient’s personal or familial history discloses possible congenital or acquired diseases of hemostasis or the proposed surgery generally implies major blood loss, coagulation screening is indicated. Recommendations, however, are not as clear for healthy children undergoing a surgery with a low or moderate risk of intra- or postoperative bleeding. Though many valuable studies have tried to evaluate the cost/benefit ratio of routine coagulation screening tests before adeno-tonsillectomy, the question remains unresolved. Although screening assays have been abandoned by many specialized centres, coagulation tests are still ordered by some physicians before an adeno or tonsillectomy (45–81%).^9,10 Post-tonsillectomy hemorrhage occurs in 1.6 to 3.5% of the patients and is less frequent in younger children (under three years of age) despite the risk of undiagnosed hematologic disease in those children.^11,12 On the other hand, history alone may fail to detect patients with congenital or acquired bleeding disorders, even those with diseases as severe as hemophilia type A.¹³ In predicting adeno-tonsillectomy perioperative bleeding, history coupled with routine classical laboratory screening tests (including PT, aPTT, platelets count) has both a low sensitivity and a very low post-test probability due to the low prevalence of bleeding. When routine coagulation tests are performed, abnormal tests are found in approximately 3% of children but diseases susceptible to induce abnormal perioperative bleeding occur in only 0.5% of the children, von Willebrand’s disease and factor XI deficiency being by far the two most common diseases encountered.^14,15 The prevalence of von Willebrand’s disease in the surgical population is estimated at 0.6%.¹⁶ Thus, if the clinician chooses to evaluate the coagulation status of all children undergoing adeno-tonsillectomy, aPTT measurement and a platelet function test would probably be the most useful. For evaluation of platelet function, bleeding time was often performed in this setting. However this test (which can leave long term scars) can be advantageously replaced by newer on-site monitoring devices such as the PFA-100 which has been shown to offer a higher sensitivity to detect von Willebrand’s disease: for example, in one study, 100 and 87% for epinephrine and adenosine diphosphate cartridge, respectively, compared to only 37% for the bleeding time.¹⁷ For PT or international normalized ratio measurements in the pediatric population, and for international normalized ratio values ranging from 1.05 to 5.25, the near patient instrument with the least bias relative to the classical laboratory test (CA-1000) is the RapidpointCoag® (r² = 0.923), the correlations (r²)of the CoaguCheck®, Hemochron Jr®., and ProTime® being 0.877, 0.834, and 0.885, respectively.¹⁸ Bilirubin levels up to 20 mg·dL^–1 (342 µmol·L^–1) do not interfere with any of these methods. For other types of surgery, preoperative coagulation tests have been reported to be useful in predicting the magnitude of blood losses in open heart, liver transplant and scoliosis surgery.^19–21 Routine coagulation tests have also been recommended by some before any neuraxial blockade in children under one year of age, but the real benefit of this recommendation remain to be shown.²²

	Patient and surgical risk factors known to increase perioperative blood loss

TOP Abstract Introduction Developmental aspects of... Preoperative laboratory... Patient and surgical risk... Reducing allogenic blood... Administration of blood products Conclusion References

 
A good knowledge of the surgical technique itself will help in predicting blood loss, determine the extent of prophylactic measures needed to avoid allogenic blood transfusions, and prepare for blood loss replacement. For scoliosis surgery, the number of fused vertebrae and the presence or absence of an underlying disease such as neuromuscular dystrophies are probably the most important factors that determine the magnitude of blood loss.^23,24 For repair of craniosynostosis, the type of skull deformation and surgical procedure determine the extent of intraoperative bleeding.²⁵ For orthognatic surgery, double-jaw procedures result in more blood loss than single-jaw procedures, boys have a higher average blood loss than girls, but average blood loss is not significantly affected by patients’ age.²⁶ For pediatric open heart surgery, risk factors clearly associated with increased blood loss include: age less than one month, body weight under 8 kg, complexity of the procedure (arterial switches for transposition of the great vessels, Fontan procedures, Glenn shunts and truncus arteriosus repairs), duration of cardiopulmonary bypass, resternotomy, and low platelet count during cardiopulmonary bypass.^1,5,27–30 For pediatric liver transplants, apart from retransplantation, factors that have been associated with increased intraoperative blood losses include: hypoplastic portal vein, use of a reduced-size liver graft, requirement of in-hospital supportive care, intra-abdominal malformations and signs of severe liver failure (encephalopathy, ascites, prolonged PT).^20,31–33 Children younger than two years, and particularly those under one year of age experience higher blood loss.^34,35 Transplantation of a reduced (fraction of an adult human organ) liver not only increases intra- and postoperative blood loss, but has been associated with an increase in the percentage of patients undergoing reoperation for continued blood loss, from 9.6 to 19.2%.³⁶

	Reducing allogenic blood transfusions

TOP Abstract Introduction Developmental aspects of... Preoperative laboratory... Patient and surgical risk... Reducing allogenic blood... Administration of blood products Conclusion References

 
As in adults, various strategies have been used to reduce allogenic blood transfusion in children.^37–51 Of all the types of surgeries, spinal fusion and cardiac operations have been the most extensively studied (Tables II and III). For patients with idiopathic scoliosis, predonation with or without the addition of erythropoietin is probably the safest and the most effective way to avoid the use of allogenic blood products. When an adequate amount of predonated blood is available, acute normovolemic hemodilution, intraoperative blood salvage and retransfusion, as well as antifibrinolytics agents offer little to further reduce allogenic blood transfusion, with the possible exception of patients with predicted blood losses over 2000 mL or small body weight.⁵² Desmopressin has been proven ineffective for idiopathic as well as neuromuscular disease induced-scoliosis.^43,44 The safety of retransfusing shed wound blood has not been well established. This practice carries a definite risk of bacterial contamination and, for scoliosis or open heart surgery,⁵³ cannot be recommended. Recombinant factor VIIa may be another therapeutic tool to reduce perioperative allogenic blood transfusion, but has not been studied systematically in children so far. This drug has, however, been reported to benefit two patients with neuromuscular disease induced-scoliosis with severe postoperative dilutional coagulopathy unresponsive to plasma administration.⁵⁴

	Administration of blood products

TOP Abstract Introduction Developmental aspects of... Preoperative laboratory... Patient and surgical risk... Reducing allogenic blood... Administration of blood products Conclusion References

 
Blood volume can be estimated from the patient’s body weight and age (Table IV). Maximal blood losses allowed before administration of red blood cells and plasma will vary according to age and associated diseases. There are actually very few pediatric data which could help determine the minimal acceptable hemoglobin concentration in children. In one study of more than 200 pediatric cardiopulmonary arrests, there was no long term survival in children with a pre-arrest hemoglobin concentration less than 57 g·L^–1.66Some authors believe that infants less than four months old should be considered as a different population, while others have fixed a limit at one year of age.^67,68 For children over six to 12 months of age without cardiac or respiratory disease, a minimal hemoglobin concentration of 70 g·L^–1, as recommended for adults, is probably acceptable.⁶⁹ For younger patients, it is probably advisable to maintain a minimal hemoglobin concentration of 80 to 90 g·L^–1,⁶⁸ although clinical data to support such a recommendation are lacking. Assuming that blood volume remains normal, the maximal amount of blood loss that can be tolerated before administration of red blood cells can be calculated with the following formula:

Where:

MBL: maximal blood loss allowed before administration of red blood cells

Hcti: initial hematocrit level

Hctf: minimal hematocrit level that will be tolerated according to age and underlying diseases

Hctm: mean hematocrit level defined as (Hctf+Hcti)/2

EBV: estimated blood volume (Table IV)

Irradiated blood is recommended for intrauterine red blood cell transfusions to the fetus, selected immunocompromised infants, newborns infants receiving blood from a relative, and infants who have previously received an in utero transfusion.⁷⁰ Most guidelines also recommend the provision of cytomegalovirus-negative blood components for low birth weight infants.⁷⁰

For children over six months of age, criteria for administration of fresh frozen plasma and platelet concentrates are the same as for adult patients. When the extent of blood loss approaches one blood volume, PT, aPTT and platelet count should be determined. With active bleeding and a PT and/or aPTT longer than one and a half times normal values, 15 to 20 mL·kg^–1 of fresh frozen plasma may be administered. For infants less than six months of age, many clinicians will start the administration of fresh frozen plasma with blood losses between 20 to 50% of the estimated blood volume as blood levels of coagulation factors are lower in this age group, and the administration of crystalloids as the sole replacement therapy for blood loss often leads to hemodynamic instability. Administration of fresh frozen plasma may also be indicated earlier for children with certain underlying diseases, such as hepatic insufficiency (when presenting for liver transplantation) or congenital cardiopathy.^71,72 Though the literature on this subject is virtually non existent, administration of colloid solutions in children is part of the standard practice of many centers. At least one study demonstrated that, in children, hemostatic variables will not be affected by the administration of colloid solutions (even after cardiopulmonary bypass) until a volume greater than 20 mL·kg^–1 is administered.⁷³ The administration of 0.1 unit of platelets per kilogram of body weight should increase the platelet count by 7 to 11 G·L^–1. The minimal acceptable platelet count will vary between 50 and 100 G·L^–1 depending on the type of surgery and the presence of other hemostatic diseases and/or coagulopathies. Administration of 0.5 U·kg^–1 of cryoprecipitate (when available) may be indicated for factor VIII levels lower than 0.5 U·mL^–1 or fibrinogen levels lower than 1 g·L^–1 and to restore blood factor levels in infants for whom the administration of large amounts of fluids may pose a problem. For example, in infants less than 8 kg of body weight who have undergone open heart surgery, coagulation factor levels are better restored by cryoprecipitates than by fresh frozen plasma, which may induce further dilution of coagulation factors.²⁷ If cryoprecipitates are unavailable, specific factor concentrates may be used.

Warming of blood products is mandatory in children who may be particularly sensitive to hypothermia. Citrate intoxication with hypocalcemia is possible if the speed of administration exceeds 3 mL·kg^–1·min^–1 for red blood cells and 1.5 to 2.0 mL·kg^–1·min^–1 for fresh frozen plasma. Hyperkalemia has also been reported with rapid red blood cell administration in children, especially if volemia has not been properly restored first.⁷⁴

	Conclusion

TOP Abstract Introduction Developmental aspects of... Preoperative laboratory... Patient and surgical risk... Reducing allogenic blood... Administration of blood products Conclusion References

 
The management of perioperative blood loss in children requires good clinical knowledge of the developmental physiology and of the pathophysiology of diseases affecting children coming to surgery. Reducing allogenic blood transfusions is possible in this age group, provided that prophylactic measures are adapted to age, disease and type of surgery.

	References

TOP Abstract Introduction Developmental aspects of... Preoperative laboratory... Patient and surgical risk... Reducing allogenic blood... Administration of blood products Conclusion References

 
1 Guay J, Rivard GE. Mediastinal bleeding after cardiopulmonary bypass in pediatric patients. Ann Thorac Surg 1996; 62: 1955–60.[Abstract/Free Full Text]

2 Kuhle S, Male C, Mitchell L. Developmental hemostasis: pro- and anticoagulant systems during childhood. Semin Thromb Hemost 2003; 29: 329–37.[Medline]

3 Hezard N, Potron G, Schlegel N, Amory C, Leroux B, Nguyen P. Unexpected persistence of platelet hyporeactivity beyond the neonatal period: a flow cytometric study in neonates, infants and older children. Thromb Haemost 2003; 90: 116–23.[Medline]

4 Miller BE, Bailey JM, Mancuso TJ, et al. Functional maturity of the coagulation system in children: an evaluation using thromboelastography. Anesth Analg 1997; 84: 745–8.[Abstract]

5 Williams GD, Bratton SL, Riley EC, Ramamoorthy C. Association between age and blood loss in children undergoing open heart operations. Ann Thorac Surg 1998; 66: 870–5.[Abstract/Free Full Text]

6 Vieira A, Berry L, Ofosu F, Andrew M. Heparin sensitivity and resistance in the neonate: an explanation. Thromb Res 1991; 63: 85–98.[Medline]

7 Chan AK, Berry LR, Monagle PT, Andrew M. Decreased concentrations of heparinoids are required to inhibit thrombin generation in plasma from newborns and children compared to plasma from adults due to reduced thrombin potential. Thromb Haemost 2002; 87: 606–13.[Medline]

8 Monagle P, Michelson AD, Bovill E, Andrew M. Antithrombotic therapy in children. Chest 2001; 119: 344S–70.[Medline]

9 Patel RI, DeWitt L, Hannallah RS. Preoperative laboratory testing in children undergoing elective surgery: analysis of current practice. J Clin Anesth 1997; 9: 569–75.[Medline]

10 Leclerc J, Sorba F, Mrugalski P, Vallet B. Preoperative assessment of hemostasis in private clinics in Nord-Pas-de-Calais. Ann Fr Anesth Reanim 2001; 20: 699–704.[Medline]

11 Windfuhr JP, Chen YS. Incidence of post-tonsillectomy hemorrhage in children and adults: a study of 4,848 patients. Ear Nose Throat J 2002; 81: 626–8.[Medline]

12 Liu JH, Anderson KE, Willging JP, et al. Posttonsillectomy hemorrhage: what is it and what should be recorded? Arch Otolaryngol Head Neck Surg 2001; 127: 1271–5.[Abstract/Free Full Text]

13 Burk CD, Miller L, Handler SD, Cohen AR. Preoperative history and coagulation screening in children undergoing tonsillectomy. Pediatrics 1992; 89: 691–5.[Abstract/Free Full Text]

14 Gabriel P, Mazoit X, Ecoffey C. Relationship between clinical history, coagulation tests, and perioperative bleeding during tonsillectomies in pediatrics. Clin Anesth 2000; 12: 288–91.

15 Sandoval C, Garcia C, Visintainer P, Ozkaynak MF, Jayabose S. The usefulness of preoperative screening for bleeding disorders. Clin Pediatr 2003; 42: 247–50.[Free Full Text]

16 Biron C, Mahieu B, Rochette A, et al. Preoperative screening for von Willebrand disease type 1: low yield and limited ability to predict bleeding. J Lab Clin Med 1999; 134: 605–9.[Medline]

17 Cariappa R, Wilhite TR, Parvin CA, Luchtman-Jones L. Comparison of PFA-100 and bleeding time testing in pediatric patients with suspected hemorrhagic problems. J Pediatr Hematol Oncol 2003; 25: 474–9.[Medline]

18 Nowatzke WL, Landt M, Smith C, Wilhite T, Canter C, Luchtman-Jones L. Whole blood international normalization ratio measurements in children using near-patient monitors. J Pediatr Hematol Oncol 2003; 25: 33–7.[Medline]

19 Williams GD, Bratton SI, Ramamoorthy C. Factors associated with blood loss and blood product transfusions: a multivariate analysis in children after open-heart surgery. Anesth Analg 1999; 89: 57–64.[Abstract/Free Full Text]

20 Ozier YM, Le Cam B, Chatellier G, et al. Intraoperative blood loss in pediatric liver transplantation: analysis of preoperative risk factors. Anesth Analg 1995; 81: 1142–7.[Abstract]

21 Horlocker TT, Nuttall GA, Dekutoski MB, Bryant SC. The accuracy of coagulation tests during spinal fusion and instrumentation. Anesth Analg 2001; 93: 33–8.[Abstract/Free Full Text]

22 Roux CL, Lejus C, Surbleb M, et al. Is haemostasis biological screening always useful before performing a neuraxial blockade in children? Paediatr Anaesth 2002; 12: 118–23.[Medline]

23 Guay J, Haig M, Lortie L, Guertin MC, Poitras B. Predicting blood loss in surgery for idiopathic scoliosis. Can J Anaesth 1994; 41: 775–81.[Abstract/Free Full Text]

24 Meert KL, Kannan S, Mooney JF. Predictors of red cell transfusion in children and adolescents undergoing spinal fusion surgery. Spine 2002; 27: 2137–42.[Medline]

25 Meyer P, Renier D, Arnaud E, et al. Blood loss during repair of craniosynostosis. Br J Anaesth 1993; 71: 854–7.[Abstract/Free Full Text]

26 Moenning JE, Bussard DA, Lapp TH, Garrison BT. Average blood loss and the risk of requiring perioperative blood transfusion in 506 orthognathic surgical procedures. J Oral Maxillofac Surg 1995; 53: 880–3.[Medline]

27 Miller BE, Mochizuki T, Levy JH, et al. Predicting and treating coagulopathies after cardiopulmonary bypass in children. Anesth Analg 1997; 85: 1196–202.[Abstract]

28 Manno CS, Hedberg KW, Kim HC, et al. Comparison of the hemostatic effects of fresh whole blood, stored whole blood, and components after open heart surgery in children. Blood 1991; 77: 930–6.[Abstract/Free Full Text]

29 Seear MD, Wadsworth LD, Rogers PC, Sheps S, Ashmore PG. The effect of desmopressin acetate (DDAVP) on postoperative blood loss after cardiac operations in children. J Thorac Cardiovasc Surg 1989; 98: 217–9.[Abstract]

30 Williams GD, Bratton SL, Riley EC, Ramamoorthy C. Coagulation tests during cardiopulmonary bypass correlate with blood loss in children undergoing cardiac surgery. J Cardiothorac Vasc Anesth 1999; 13: 398–404.[Medline]

31 Carlier M, Van Obbergh LJ, Veyckemans F, et al. Hemostasis in children undergoing liver transplantation. Semin Thromb Hemost 1993; 19: 218–22.[Medline]

32 Ryckman F, Fisher R, Pedersen S, et al. Improved survival in biliary atresia patients in the present era of liver transplantation. J Pediatr Surg 1993; 28: 382–5.[Medline]

33 Superina RA, Pearl RH, Roberts EA, et al. Liver transplantation in children: the initial Toronto experience. J Pediatr Surg 1989; 24: 1013–9.[Medline]

34 Lichtor JL, Emond J, Chung MR, Thistlethwaite JR, Broelsch CE. Pediatric orthotopic liver transplantation: multifactorial predictions of blood loss. Anesthesiology 1988; 68: 607–11.[Medline]

35 Belani KG, Batra YK, Naasz M, Gillingham K, Payne WD. Infants are a higher intraoperative risk group for orthotopic liver transplantation. Transplant Proc 1994; 26: 196–7.[Medline]

36 Bilik R, Greig P, Langer B, Superina RA. Survival after reduced-size liver transplantation is dependent on pre-transplant status. J Pediatr Surg 1993; 28: 1307–11.[Medline]

37 Fearon JA, Weinthal J. The use of recombinant erythropoietin in the reduction of blood transfusion rates in craniosynostosis repair in infants and children. Plast Reconstr Surg 2002; 109: 2190–6.[Medline]

38 Vitale MG, Stazzone EJ, Gelijns AC, Moskowitz AJ, Roye DP Jr. The effectiveness of preoperative erythropoietin in averting allogenic blood transfusion among children undergoing scoliosis surgery. J Pediatr Orthop B 1998; 7: 203–9.[Medline]

39 Murray DJ, Forbes RB, Titone MB, Weinstein SL. Transfusion management in pediatric and adolescent scoliosis surgery. Efficacy of autologous blood. Spine 1997; 22: 2735–40.[Medline]

40 Hans P, Collin V, Bonhomme V, Damas F, Born JD, Lamy M. Evaluation of acute normovolemic hemodilution for surgical repair of craniosynostosis. J Neurosurg Anesthesiol 2000; 12: 33–6.[Medline]

41 Copley LA, Richards BS, Safavi FZ, Newton PO. Hemodilution as a method to reduce transfusion requirements in adolescent spine fusion surgery. Spine 1999; 24: 219–22.[Medline]

42 Siller TA, Dickson JH, Erwin WD. Efficacy and cost considerations of intraoperative autologous transfusion in spinal fusion for idiopathic scoliosis with predeposited blood. Spine 1996; 21: 848–52.[Medline]

43 Guay J, Reinberg C, Poitras B, et al. A trial of desmopressin to reduce blood loss in patients undergoing spi-nal fusion for idiopathic scoliosis. Anesth Analg 1992; 75: 405–10.[Abstract/Free Full Text]

44 Theroux MC, Corddry DH, Tietz AE, Miller F, Peoples JD, Kettrick RG. A study of desmopressin and blood loss during spinal fusion for neuromuscular scoliosis: a randomized, controlled, double-blinded study. Anesthesiology 1997; 87: 260–7.[Medline]

45 Letts M, Pang E, D’Astous J, et al. The influence of desmopressin on blood loss during spinal fusion surgery in neuromuscular patients. Spine 1998; 23: 475–8.[Medline]

46 Florentino-Pineda I, Blakemore LC, Thompson GH, Poe-Kochert C, Adler P, Tripi P. The Effect of epsilon-aminocaproic acid on perioperative blood loss in patients with idiopathic scoliosis undergoing posterior spinal fusion: a preliminary prospective study. Spine 2001; 26: 1147–51.[Medline]

47 Neilipovitz DT, Murto K, Hall L, Barrowman NJ, Splinter WM. A randomized trial of tranexamic acid to reduce blood transfusion for scoliosis surgery. Anesth Analg 2001; 93: 82–7.[Abstract/Free Full Text]

48 Sethna NF, Zurakowski D, Brustowicz RM, Bacsik J, Sullivan LJ, Shapiro F. Tranexamic acid reduces intra-operative blood loss in pediatric patients undergoing scoliosis surgery. Anesthesiology 2005; 102: 727–32.[Medline]

49 Cole JW, Murray DJ, Snider RJ, Bassett GS, Bridwell KH, Lenke LG. Aprotinin reduces blood loss during spinal surgery in children. Spine 2003; 28: 2482–5.[Medline]

50 Khoshhal K, Mukhtar I, Clark P, Jarvis J, Letts M, Splinter W. Efficacy of aprotinin in reducing blood loss in spinal fusion for idiopathic scoliosis. J Pediatr Orthop 2003; 23: 661–4.[Medline]

51 Rentoul TM, Harrison VL, Shun A. The effect of aprotinin on transfusion requirements in pediatric orthotopic liver transplantation. Pediatr Transplant 2003; 7: 142–8.[Medline]

52 Simpson MB, Georgopoulos G, Eilert RE. Intraoperative blood salvage in children and young adults undergoing spinal surgery with predeposited autologous blood: efficacy and cost effectiveness. J Pediatr Orthop 1993; 13: 777–80.[Medline]

53 Hishon ML, Ryan A, Lithgow P, Butt W. An evaluation of changes in composition and contamination of salvaged blood from the cardiopulmonary bypass circuit of pediatric patients. Heart Lung 1995; 24: 307–11.[Medline]

54 Tobias JD. Synthetic factor VIIa to treat dilutional coagulopathy during posterior spinal fusion in two children. Anesthesiology 2002; 96: 1522–5.[Medline]

55 Sonzogni V, Crupi G, Poma R, et al. Erythropoietin therapy and preoperative autologous blood donation in children undergoing open heart surgery Br J Anaesth 2001; 87: 429–34.[Abstract/Free Full Text]

56 Reynolds LM, Nicolson SC, Jobes DR, et al. Desmopressin does not decrease bleeding after cardiac operation in young children. J Thorac Cardiovasc Surg 1993; 106: 954–8.[Abstract]

57 McClure PD, Izsak J. The use of epsilon-aminocaproic acid to reduce bleeding during cardiac bypass in children with congenital heart disease. Anesthesiology 1974; 40: 604–8.[Medline]

58 Zonis Z, Seear M, Reichert C, Sett S, Allen C. The effect of preoperative tranexamic acid on blood loss after cardiac operations in children. J Thorac Cardiovasc Surg 1996; 111: 982–7.[Abstract/Free Full Text]

59 Reid RW, Zimmerman AA, Laussen PC, Mayer JE, Gorlin JB, Burrows FA. The efficacy of tranexamic acid versus placebo in decreasing blood loss in pediatric patients undergoing repeat cardiac surgery. Anesth Analg 1997; 84: 990–6.[Abstract]

60 D’Errico CC, Shayevitz JR, Martindale SJ, Mosca RS, Bove EL. The efficacy and cost of aprotinin in children undergoing reoperative open heart surgery. Anesth Analg 1996; 83: 1193–9.[Abstract]

61 Guay J, Hardy JF. Association between age and blood loss in children undergoing open heart operations- Invited commentary. Ann Thorac Surg 1998; 66: 870–6.[Abstract/Free Full Text]

62 Hiramatsu T, Okamura T, Imai Y, et al. Effects of autologous platelet concentrate reinfusion after open heart surgery in patients with congenital heart disease. Ann Thorac Surg 2002; 73: 1282–5.[Abstract/Free Full Text]

63 Oliver WC Jr, Beynen FM, Nuttall GA, et al. Blood loss in infants and children for open heart operations: albumin 5% versus fresh-frozen plasma in the prime. Ann Thorac Surg 2003; 75: 1506–12.[Abstract/Free Full Text]

64 Guay J, Ruest P, Lortie L. Cardiopulmonary bypass induces significant platelets activation in children undergoing open-heart surgery. Eur J Anaesthesiol 2004; 21: 953–6.[Medline]

65 Mössinger H, Dietrich W, Braun SL, Jochum M, Meisner H, Richter JA. High-dose aprotinin reduces activation of hemostasis, allogenic blood requirement, and duration of postoperative ventilation in pediatric cardiac surgery. Ann Thorac Surg 2003; 75: 430–7.[Abstract/Free Full Text]

66 Guay J, Lortie L. An evaluation of pediatric in-hospital advanced life support interventions using the pediatric Utstein guidelines: a review of 203 cardiorespiratory arrests. Can J Anesth 2004; 51: 373–8.[Abstract/Free Full Text]

67 Roseff SD, Luban NL, Manno CS. Guidelines for assessing appropriateness of pediatric transfusion. Transfusion 2002; 42: 1398–413.[Medline]

68 Voak D, Cann R, Finney RD, et al. Guidelines for administration of blood products: transfusion of infants and neonates. British Committee for Standards in Haematology Blood Transfusion Task Force. Transfus Med 1994; 4: 63–9.[Medline]

69 Guidelines for red blood cell and plasma transfusion for adult and children. Report of the Expert Working Group. Can Med Assoc J 1997; 156 (Suppl 11): 1–24.

70 Canadian Paediatric Society. Red blood cell transfusions in newborn infants: revised guidelines. Paediatr Child Health 2002; 7: 553–8.

71 Borland LM, Roule M. The relation of preoperative coagulation function and diagnosis to blood usage in pediatric liver transplantation. Transplant Proc 1988; XX(Suppl 1): 533–5.

72 Kern FH, Morana NJ, Sears JJ, Hickey PR. Coagulation defects in neonates during cardiopulmonary bypass. Ann Thorac Surg 1992; 54: 541–6.[Abstract]

73 Brutocao D, Bratton SL, Thomas JR, Schrader PF, Coles PG, Lynn AM. Comparison of hetastarch with albumin for postoperative volume expansion in children after cardiopulmonary bypass. J Cardiothorac Vasc Anesth 1996; 10: 348–51.[Medline]

74 Brown KA, Bissonnette B, McIntyre B. Hyperkalaemia during rapid blood transfusion and hypovolaemic cardiac arrest in children. Can J Anaesth 1990; 37: 747–54.[Abstract/Free Full Text]

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