How much variation remains in neonatal cardiopulmonary bypass (CPB) priming? A European survey of 71 cardiac surgery centers found reported prime volumes ranging from 75 to 450 mL, substantial differences in prime composition, and uneven access to hemostatic resources. The findings provide a useful picture of current practice, but do not identify a superior priming recipe or demonstrate improved patient outcomes.
What the investigators studied
Sascha Meier and colleagues conducted a prospective, 26-item web-based cross-sectional survey endorsed by the European Association of Cardiothoracic Anaesthesiology and Intensive Care (EACTAIC). The questionnaire was distributed to 122 identified European neonatal cardiac surgery programs between March and June 2025. Seventy-one centers in 32 countries responded, giving a 58% response rate.
Respondents included anesthesiologists, congenital cardiac surgeons, and perfusionists. The investigators examined circuit equipment and priming constituents, blood-product availability, point-of-care coagulation testing, and institutional protocols. Duplicate institutional responses were reviewed to retain one dataset per center.
Key findings for perfusion teams
- Prime volume varied sixfold: reported volumes ranged from 75 to 450 mL. One center did not report a numeric volume.
- Red cells remained common in the prime: 58 centers (82%) reported adding red blood cells. Albumin was reported by 36 centers (51%).
- Prime composition was heterogeneous: centers used different crystalloid solutions, buffers, and additional constituents, frequently with customized tubing configurations.
- Formal protocols were not universal: 51 centers (72%) reported institutional transfusion protocols, while 44 (62%) reported formal coagulation-management protocols.
- Product availability and speed differed: the detailed results reported fibrinogen concentrate availability at 63 centers (89%), prothrombin complex concentrate at 60 (85%), and cryoprecipitate at 21 (30%). Availability does not establish frequency of administration.
Why prime volume matters
In neonatal perfusion, extracorporeal circuit volume can be large relative to the patient’s circulating blood volume. The survey therefore highlights an important design question: how do local circuit choices, oxygenator options, and blood-management processes affect the amount and composition of prime required?
The wide range of reported volumes offers a starting point for benchmarking and collaborative research. However, the survey did not compare matched patients treated with different circuits. A smaller reported volume should not automatically be interpreted as a safer circuit or evidence of better clinical results. Patient size, procedure requirements, institutional expertise, and other perfusion practices were not standardized in this comparison.
Blood-product access is part of the workflow
All participating centers reported access to red cells for intraoperative use. The types of plasma and platelet products available differed, as did access to coagulation-factor concentrates. Reported median delivery intervals were 5–10 minutes for red cells, 20–25 minutes for plasma, and 10–15 minutes for platelet products.
For perfusion teams, these findings emphasize the importance of understanding local logistics alongside the prime recipe. A product listed on a formulary may have a very different practical role depending on preparation time, delivery time, and institutional approval requirements. The survey describes these resources; it does not test whether one product or replacement strategy is clinically preferable.
Coagulation testing and communication
The authors describe widespread use of point-of-care coagulation assessment, with differences in platforms, turnaround times, and integration into hospital information systems. Fifty centers reported that results were accessible to other specialties through the central reporting system, while 18 reported standalone printed results.
This makes communication a relevant quality-improvement topic. Shared access to results and clear local protocols may be useful areas for review, but the study did not measure whether electronic integration or protocol use reduced bleeding, transfusion, or complications.
Study limitations and interpretation
This was a descriptive, self-reported survey rather than a patient-level outcomes study. Nonresponse and incomplete answers may affect representativeness. The questionnaire did not capture several important aspects of bypass management, including temperature targets, acid-base strategy, ultrafiltration practices, or the timing of transfusion during CPB. No formal sample-size calculation or questionnaire reliability and validity testing was performed.
The publication also contains inconsistencies between selected abstract statements, narrative results, tables, and figure captions. These include some plasma-product counts and descriptions of factor-concentrate availability. The figures summarized above are drawn from the detailed results and tables; uncertain subgroup counts should be interpreted cautiously.
Most importantly, reported availability is not equivalent to actual clinical use. The study cannot establish that a particular prime, hematocrit target, blood product, or coagulation-management strategy improves neonatal outcomes.
Practical relevance
The survey supports a structured review of local neonatal CPB practice: document circuit and prime volumes consistently, understand blood-product delivery pathways, review access to coagulation results, and identify gaps in institutional protocols. Its strongest contribution is identifying variation and research priorities. Prospective studies linking clearly defined perfusion strategies to patient outcomes are needed before these observations can support comparative treatment recommendations.
Source: Meier S, Kousi T, Romlin B, Haxhiademi D, Lance M, on behalf of the EACTAIC committees. Cardiopulmonary Bypass Priming Practices and Blood Product Availability in Neonatal Cardiac Surgery: A European Survey. Journal of Cardiothoracic and Vascular Anesthesia. 2026;40:3101–3110. doi:10.1053/j.jvca.2026.06.045.
Attribution: © 2026 The Authors. Published by Elsevier under CC BY 4.0. This IPA educational summary is independently paraphrased; the downloadable source PDF is unchanged. The authors declare no competing interests. Cover artwork is a conceptual illustration.
