How a New “Blood Roadmap” is Changing Baby Heart Surgery
Featured paper: A ROTEM-guided algorithm aimed to reduce blood product utilization during neonatal and infant cardiac surgery
Disclaimer: This content was generated by NotebookLM and has been reviewed for accuracy by Dr. Tram.
When a baby is born with a heart defect, it is a race against time. Surgeons today can perform miracles, repairing hearts no bigger than a strawberry. However, these complex surgeries, which often require a heart-lung machine, come with a major challenge: heavy bleeding. For years, doctors have had to rely on a mix of experience and “standard” blood tests to decide how many blood products a baby needs during surgery.
But a new study published in The Journal of ExtraCorporeal Technology by Dr. Aymen Naguib and his team at Nationwide Children’s Hospital is changing the game. They developed a new “roadmap” using a technology called ROTEM to give babies exactly what they need, exactly when they need it, reducing the amount of extra blood products used.
The Problem: Tiny Patients, Big Challenges
Neonates (newborns) and infants undergoing heart surgery face a unique struggle. Because they are so small, their total blood volume is tiny compared to the tubes and pumps of the heart-lung machine (also called cardiopulmonary bypass or CPB). This causes their blood to become diluted, thinning out the proteins and cells that help the blood clot.
Additionally, the materials used in the heart-lung machine can “activate” the blood in ways that make it harder for it to clot normally once the surgery is over. To fix this, doctors often have to give transfusions of platelets, plasma, and cryoprecipitate (specialized parts of the blood that help with clotting). In the past, these were often given in “standard” doses based on a doctor’s best guess, rather than a real-time look at what the baby’s blood was actually doing.
What is ROTEM? The Real-Time Clot Monitor
The hero of this story is a technology called Rotational Thromboelastometry, or ROTEM.
Think of ROTEM as a way to watch a blood clot form in “high definition”. Instead of just telling a doctor if a clot will form, ROTEM measures the quality and strength of the clot as it develops. It provides a rapid assessment of:
- How long it takes for a clot to start.
- How firm the clot is.
- How stable the clot remains over time.
ROTEM uses different “assays” (mini-tests) to look at specific parts of the blood. For example, the FIBTEM assay ignores platelets to see if the baby has enough fibrinogen (a “glue-like” protein), while HEPTEM can check the blood even if there is still heparin (a blood thinner) present. This gives doctors a level of detail that traditional lab tests, which can take a long time to return results, simply cannot match.
The Study: Putting the Algorithm to the Test
The researchers at Nationwide Children’s Hospital wanted to see if using a strict ROTEM-guided “algorithm” (a step-by-step decision tree) would work better than the old way of doing things.
They looked at two groups of babies:
- The Control Group (28 patients): Babies who had surgery the “old way,” where doctors gave blood products based on routine clinical practice.
- The ROTEM Group (40 patients): Babies whose blood product doses were decided by the new ROTEM roadmap.
The study focused on the most complex “high-risk” procedures, such as the Arterial Switch and the Norwood procedure.
The Results: Less is More
The results were impressive. By using the ROTEM roadmap, the team found they could achieve better clotting with fewer products.
Key Findings:
- Fewer Platelets: Babies in the ROTEM group received significantly fewer platelets during surgery (36 mL/kg vs. 49 mL/kg in the old group).
- Less “Blood Glue”: They used nearly 50% less cryoprecipitate (8 mL/kg in the ROTEM group vs. 15 mL/kg in the control group).
- Better Recovery: Once the babies got to the Intensive Care Unit (ICU), those in the ROTEM group had higher blood counts (hematocrit) and less bleeding from their chest tubes.
Basically, because the doctors had a clearer “picture” of the blood, they didn’t have to over-transfuse “just in case”.
Safety First: The Balancing Act
Giving blood products is a delicate balance. If you don’t give enough, the baby can bleed dangerously. If you give too many, or use too many “clot-promoting” drugs (called factor concentrates), the baby could develop an unwanted blood clot (thrombosis).
In this study, ten patients across both groups did develop blood clots. The researchers noted that these clots were usually linked to using multiple types of “factor concentrates” (powerful drugs like rFVIIa or Kcentra) rather than the ROTEM technology itself. This highlights that while ROTEM is a powerful tool, doctors must still use it carefully, especially when using high-strength clotting medicines.
The Future of “Bloodless” Surgery
For some families, such as those who are Jehovah’s Witnesses, avoiding blood transfusions is a religious requirement. Nationwide Children’s Hospital originally started these strategies to respect those beliefs, but they soon realized that reducing blood use is better for everyone.
By using the ROTEM algorithm, the hospital is moving closer to the goal of “bloodless” surgery for even the smallest patients. While the study was small and more research is needed, the team feels much more confident managing the complex bleeding that happens during heart surgery.
Conclusion
Surgery on a newborn is one of the most stressful events a family can face. Knowing that doctors are using cutting-edge “roadmaps” like ROTEM to provide precise, personalized care can offer a huge sense of relief. By focusing on targeted administration, we aren’t just giving babies blood—we are giving them exactly what their tiny hearts need to heal.
Definitions for the Reader:
- Hematocrit: The percentage of red blood cells in the blood (helps carry oxygen).
- Neonates: Babies in their first 28 days of life.
- Cardiopulmonary Bypass (CPB): The machine that does the work of the heart and lungs during surgery.
- Thromboembolic Event: An unwanted blood clot that can block a vessel.The information in the “Definitions” section is provided for context and is not directly sourced from the study.