Development of nomogram predicting postoperative blood loss among pediatric patients following corrective operation of tetralogy of Fallot_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

SHEN Ruihuan ,  WANG Xu , LU Zhongyuan , LI Shoujun , YAN Jun

Department of Pediatric Cardiac Surgery, Fuwai Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100037, P.R.China;

Corresponding author：

WANG Xu, Email: fwpicu@163.com

Keywords：

Nomogram; tetralogy of Fallot; cyanosis; postoperative blood loss; risk factor

DOI：

10.7507/1007-4848.202003089

Video：

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Objective To identify the risk factors of postoperative blood loss among pediatric patients following corrective operation of tetralogy of Fallot (TOF) and to develop nomogram predicting the risk of postoperative blood loss.Methods A retrospective case-control study was conducted in pediatric TOF patients who underwent corrective operation in our hospital from November 2018 to June 2019. And the clinical data from each enrolled patient were gathered and analyzed. Clinically significant postoperative blood loss was defined as drainage volume from chest tube ≥16 mL/kg during the first 24 h after surgery, which corresponded to the 75^th percentile of the blood loss in our population. The primary outcome was to determine the independent predictors of postoperative blood loss by the least absolute shrinkage and selection operator (LASSO) regression, univariate and multivariate logistic regression analysis. On the basis of the independent predictors of postoperative bleeding, nomogram was developed and its discrimination and calibration were estimated.Results A total of 105 children were selected (67 males and 38 females aged 3-72 months). The drainage volume from chest tube in the bleeding group was significantly higher than that in the non-bleeding group during the first 24 h (P<0.0001). Multivariate logistic regression analysis showed that low body weight (OR=0.538, 95%CI 0.369-0.787, P=0.001), high preoperative hemoglobin concentration (OR=1.036, 95%CI 1.008-1.066, P=0.013) and prolonged intraoperative aortic cross clamp time (OR=1.022, 95%CI 1.000-1.044, P=0.048) were independent risk factors for postoperative blood loss. In the internal validation, the model displayed good discrimination with a C-index of 0.835 (95%CI 0.745-0.926) and high quality of calibration plots in nomogram models was noticed.Conclusion The nomogram demonstrated good discrimination and calibration in estimating the risk of postoperative blood loss among pediatric patients following corrective operation of TOF.

Citation： SHEN Ruihuan, WANG Xu, LU Zhongyuan, LI Shoujun, YAN Jun. Development of nomogram predicting postoperative blood loss among pediatric patients following corrective operation of tetralogy of Fallot. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2021, 28(4): 409-415. doi: 10.7507/1007-4848.202003089 Copy

1.	Willems A, Patte P, De Groote F, et al. Cyanotic heart disease is an independent predicting factor for fresh frozen plasma and platelet transfusion after cardiac surgery. Transfus Apher Sci, 2019, 58(3): 304-309.
2.	Balachandran VP, Gonen M, Smith JJ, et al. Nomograms in oncology: More than meets the eye. Lancet Oncol, 2015, 16(4): e173-e180.
3.	Faraoni D, Willems A, Romlin BS, et al. Development of a specific algorithm to guide haemostatic therapy in children undergoing cardiac surgery: A single-centre retrospective study. Eur J Anaesthesiol, 2015, 32(5): 320-329.
4.	Guzzetta NA, Allen NN, Wilson EC, et al. Excessive postoperative bleeding and outcomes in neonates undergoing cardiopulmonary bypass. Anesth Analg, 2015, 120(2): 405-410.
5.	Savan V, Willems A, Faraoni D, et al. Multivariate model for predicting postoperative blood loss in children undergoing cardiac surgery: a preliminary study. Br J Anaesth, 2014, 112(4): 708-714.
6.	Spiezia L, Di Gregorio G, Campello E, et al. Predictors of postoperative bleeding in children undergoing cardiopulmonary bypass: A preliminary Italian study. Thromb Res, 2017, 153: 85-89.
7.	Heinze G, Wallisch C, Dunkler D. Variable selection — A review and recommendations for the practicing statistician. Biom J, 2018, 60(3): 431-449.
8.	Rosswog C, Schmidt R, Oberthuer A, et al. Molecular classification substitutes for the prognostic variables stage, age, and MYCN status in neuroblastoma risk assessment. Neoplasia, 2017, 19(12): 982-990.
9.	Wu SX, Huang J, Liu ZW, et al. A Genomic-clinicopathologic nomogram for the preoperative prediction of lymph node metastasis in bladder cancer. EBioMedicine, 2018, 31: 54-65.
10.	Zwifelhofer NMJ, Bercovitz RS, Cole R, et al. Platelet function changes during neonatal cardiopulmonary bypass surgery: Mechanistic basis and lack of correlation with excessive bleeding. Thromb Haemost, 2020, 120(1): 94-106.
11.	Kenet G, Barg AA, Nowak-Göttl U. Hemostasis in the very young. Semin Thromb Hemost, 2018, 44(7): 617-623.
12.	Jensen AS, Johansson PI, Idorn L, et al. The haematocrit — An important factor causing impaired haemostasis in patients with cyanotic congenital heart disease. Int J Cardiol, 2013, 167(4): 1317-1321.
13.	荆晶, 王文婷, 常艳, 等. 临床凝血功能异常患者血栓弹力图与常规凝血检测的比较及相关性分析. 中国实验血液学杂志, 2020, 28(2): 629-635.
14.	Ranucci M, Pistuddi V, Baryshnikova E, et al. Fibrinogen levels after cardiac surgical procedures: association with postoperative bleeding, trigger values, and target values. Ann Thorac Surg, 2016, 102(1): 78-85.
15.	Yang L, Vuylsteke A, Gerrard C, et al. Postoperative fibrinogen level is associated with postoperative bleeding following cardiothoracic surgery and the effect of fibrinogen replacement therapy remains uncertain. J Thromb Haemost, 2013, 11(8): 1519-1526.
16.	Hofer A, Kozek-Langenecker S, Schaden E, et al. Point-of-care assessment of platelet aggregation in paediatric open heart surgery. Br J Anaesth, 2011, 107(4): 587-592.
17.	Jensen AS, Johansson PI, Bochsen L, et al. Fibrinogen function is impaired in whole blood from patients with cyanotic congenital heart disease. Int J Cardiol, 2013, 167(5): 2210-2214.

1. Willems A, Patte P, De Groote F, et al. Cyanotic heart disease is an independent predicting factor for fresh frozen plasma and platelet transfusion after cardiac surgery. Transfus Apher Sci, 2019, 58(3): 304-309.
2. Balachandran VP, Gonen M, Smith JJ, et al. Nomograms in oncology: More than meets the eye. Lancet Oncol, 2015, 16(4): e173-e180.
3. Faraoni D, Willems A, Romlin BS, et al. Development of a specific algorithm to guide haemostatic therapy in children undergoing cardiac surgery: A single-centre retrospective study. Eur J Anaesthesiol, 2015, 32(5): 320-329.
4. Guzzetta NA, Allen NN, Wilson EC, et al. Excessive postoperative bleeding and outcomes in neonates undergoing cardiopulmonary bypass. Anesth Analg, 2015, 120(2): 405-410.
5. Savan V, Willems A, Faraoni D, et al. Multivariate model for predicting postoperative blood loss in children undergoing cardiac surgery: a preliminary study. Br J Anaesth, 2014, 112(4): 708-714.
6. Spiezia L, Di Gregorio G, Campello E, et al. Predictors of postoperative bleeding in children undergoing cardiopulmonary bypass: A preliminary Italian study. Thromb Res, 2017, 153: 85-89.
7. Heinze G, Wallisch C, Dunkler D. Variable selection — A review and recommendations for the practicing statistician. Biom J, 2018, 60(3): 431-449.
8. Rosswog C, Schmidt R, Oberthuer A, et al. Molecular classification substitutes for the prognostic variables stage, age, and MYCN status in neuroblastoma risk assessment. Neoplasia, 2017, 19(12): 982-990.
9. Wu SX, Huang J, Liu ZW, et al. A Genomic-clinicopathologic nomogram for the preoperative prediction of lymph node metastasis in bladder cancer. EBioMedicine, 2018, 31: 54-65.
10. Zwifelhofer NMJ, Bercovitz RS, Cole R, et al. Platelet function changes during neonatal cardiopulmonary bypass surgery: Mechanistic basis and lack of correlation with excessive bleeding. Thromb Haemost, 2020, 120(1): 94-106.
11. Kenet G, Barg AA, Nowak-Göttl U. Hemostasis in the very young. Semin Thromb Hemost, 2018, 44(7): 617-623.
12. Jensen AS, Johansson PI, Idorn L, et al. The haematocrit — An important factor causing impaired haemostasis in patients with cyanotic congenital heart disease. Int J Cardiol, 2013, 167(4): 1317-1321.
13. 荆晶, 王文婷, 常艳, 等. 临床凝血功能异常患者血栓弹力图与常规凝血检测的比较及相关性分析. 中国实验血液学杂志, 2020, 28(2): 629-635.
14. Ranucci M, Pistuddi V, Baryshnikova E, et al. Fibrinogen levels after cardiac surgical procedures: association with postoperative bleeding, trigger values, and target values. Ann Thorac Surg, 2016, 102(1): 78-85.
15. Yang L, Vuylsteke A, Gerrard C, et al. Postoperative fibrinogen level is associated with postoperative bleeding following cardiothoracic surgery and the effect of fibrinogen replacement therapy remains uncertain. J Thromb Haemost, 2013, 11(8): 1519-1526.
16. Hofer A, Kozek-Langenecker S, Schaden E, et al. Point-of-care assessment of platelet aggregation in paediatric open heart surgery. Br J Anaesth, 2011, 107(4): 587-592.
17. Jensen AS, Johansson PI, Bochsen L, et al. Fibrinogen function is impaired in whole blood from patients with cyanotic congenital heart disease. Int J Cardiol, 2013, 167(5): 2210-2214.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Development of nomogram predicting postoperative blood loss among pediatric patients following corrective operation of tetralogy of Fallot

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