**15. Bleeding and organ injury**

The coagulation factors reach the adult level at 6 – 12 months of age. The effects of CPB on blood activation and coagulation is far greater in neonates and infants because of hemodilu‐ tion, hypothermia, greater shear stress, and more blood- air contact activation.

Platelets are the initial therapy for bleeding after adequate heparin reversal. 1 unit of platelets per 10 Kg raises the platelet count by approximately 50,000/mm3. Cryoprecipitate which is a good source of fibrinogen is the next blood component usually used. Antifibrinolytic agents like aprotinin, e-aminocaproic acid, tranexamic acid have become popular to reduce bleeding after complex surgeries and in infants.

Lung, kidney and brain are at risk of injury during CPB. The stress and inflammatory response is 5-10 times greater in neonates and infants. High dose steroids have been used to mask the response and have been shown to be more beneficial in neonates and infants. Ultrafiltration, both conventional and modified are being used for hemoconcentration, removing inflamma‐ tory mediators, and decreasing total body water, with beneficial effects being shown for hematocrit, oxygenation, pulmonary vascular resistance and decreasing duration of mechan‐ ical ventilation.
