To develop and internally validate nomogram predicting postoperative blood loss risk among pediatric patients with pulmonary atresia (PA) undergoing cardiopulmonary bypass (CPB). All patients aged from 6 months to 6 years with PA who underwent surgery at Fuwai Hospital from June 2015 to December 2019 were selected. And the prediction nomogram model was developed in the training set based on the selected patients. The demographic characteristics and laboratory data from each enrolled patient were gathered. Postoperative blood loss was defined as a blood loss exceeding 20.0 ml/kg within the first 24 postoperative hours. The least absolute shrinkage and selection operator (LASSO) method was used to optimize feature selection for multivariate logistic regression analysis that was applied to build a nomogram composed of all the features selected in the LASSO algorithm. The concordance index (C-index), calibration plot, and decision curve analysis (DCA) were used to evaluate the discrimination, calibration, and clinical net benefit of the nomogarm, respectively. Finally, internal validation was performed using the bootstrap technique. Of the 66 pediatric patients in the training set, 21 (31.82%) and 45 (68.18%) patients were assigned into bleeding group and non-bleeding group, respectively. The first postoperative 24-h blood loss in the bleeding group was significantly higher than that in the non-bleeding group during ICU stay (P = 0.000). Multivariate logistic regression analysis showed that, the immediate postoperative prothrombin time (odds ratio = 1.419, 95% confidence interval: 1.094-1.841, P = 0.008), the immediate postoperative platelet count (odds ratio = 0.985, 95% confidence interval: 0.973-0.997, P = 0.015) and the immediate postoperative red blood cell (RBC) count (odds ratio = 0.335, 95% confidence interval: 0.166-0.667, P = 0.002) were independent predictors of postoperative blood loss risk. The model presented favorable calibration and good discrimination with satisfactory calibration curve and a C-index of 0.858 (95% confidence interval: 0.758-0.958). High C-index value of 0.837 was achieved in the internal validation. The DCA revealed that the nomogram was great clinical effect when intervention was decided among nearly the entire range of threshold probabilities. We developed and internally validated an accurate nomogram to assist in the clinical decision-making concerning the presence of postoperative blood loss in pediatric patients with PA undergoing CPB. However, the nomogram should be endorsed by external validation before it can be recommended for routine practice.
Keywords: Cardiopulmonary bypass; Cyanosis; Laboratory tests; Nomogram; Postoperative blood loss; Pulmonary atresia.