Introduction: Neonates and infants undergoing cardiac surgery with cardiopulmonary bypass (CPB) are highly susceptible to coagulopathy and bleeding due to an immature hemostatic system, complex surgeries, and CPB-related hemodilution. Hypofibrinogenemia, a deficiency of a key clotting protein, is a major contributor to bleeding in this setting. Cryoprecipitate is the standard fibrinogen replacement but carries risks including immunologic reactions, pathogen transmission, and time-consuming preparation. Perioperative bleeding and allogeneic transfusions are independent predictors of morbidity and mortality following pediatric cardiac surgery. Therefore, minimizing the use of allogeneic blood products is a central goal in pediatric blood management.
Methods: Retrospective review from 534 infants who underwent cardiac surgery with CPB. We recorded fibrinogen levels before and after CPB. Change in fibrinogen was calculated for each patient. Data on cryoprecipitate volume, patient weight and age, and CPB time were collected. A complete-case analysis (n=417) was conducted, assuming missing data were completely at random. Linear regression was used to assess associations between fibrinogen change and clinical variables including cryoprecipitate volume, weight, age, and CPB time.
Results: Among 534 infants (mean age 41.3 months, range 0–898), mean pre-CPB fibrinogen was 263.5 mg/dL, increasing to 305.4 mg/dL post-CPB—a mean rise of 41.2 mg/dL (SD 114.2). Missing data (22%) were mainly due to absent pre-CPB measurements. In the complete-case cohort (n=417), linear regression showed cryoprecipitate volume was significantly associated with fibrinogen increase (estimate 1.93, p< 0.001). Higher weight (estimate -2.78, p< 0.001) and older age (estimate -0.90, p< 0.001) were associated with smaller increases. CPB time was not significantly associated with fibrinogen change.
Conclusions: Higher cryoprecipitate volumes are significantly associated with greater increases in fibrinogen following CPB in infants undergoing cardiac surgery, while older age and greater body weight are associated with smaller increases. These findings support the role of cryoprecipitate in fibrinogen restoration in this population. Prospective studies are needed to optimize fibrinogen replacement strategies in pediatric cardiac surgery.
