Blood Product Transfusions for Children in the Perioperative Period and for Critically Ill Children

Abstract

Background: Approximately 1% to 2% of all hospitalized children receive a transfusion of blood products, in Germany as in other countries. High-quality scientific evidence on transfusions in children is scarce. The available evidence is discussed in this review.

Methods: This review is based on publications on blood product transfusions in children that were retrieved by a literature search, including clinical studies, international guideline recommendations, the recommendations of the German cross-sectional guideline, and results of other recent, relevant publications.

Results: A restrictive transfusion strategy is recommended for all children, including those who are critically ill. Randomized controlled trials have shown that a restrictive strategy for erythrocyte concentrate transfusion in the intensive care unit is safe for children, including neonates. No robust data are available to enable the definition of a suitable threshold for the intraoperative administration of red blood cell concentrates in children undergoing extracardiac surgery. On the basis of studies from pediatric intensive care units, transfusions for hemodynamically stable children with a hemoglobin concentration of more than 7 g/dL are recommended only in exceptional cases. Therapeutic plasma is not recommended as volume replacement, except in massive transfusion. Platelet concentrate transfusions are indicated in case of active hemorrhage, and only rarely for prophylaxis.

Conclusion: There is a broad lack of evidence from randomized controlled trials concerning the indications for transfusions in children. A restrictive transfusion strategy, which has been found safe in the intensive-care setting, is favored by the guidelines in the perioperative setting as well. Further studies are needed to evaluate transfusion triggers and indications for all types of blood products, especially therapeutic plasma. Until more evidence is available, physicians should be aware of what the current evidence supports, and blood products should be given restrictively, and not prophylactically.

Figure

Transfusion and Anemia Expertise Initiative(TAXI) RBC transfusion decision tree for critically ill children (21). Recommendations apply to full-term infants and older children with critical illnesses who are being treated in intensive care. The TAXI guideline differs from the cross sectional guideline in several aspects: no information is given on premature babies, Hb thresholds of 5–7 g/dL are tolerated depending on the patient cohort and clinical condition. No information is given on Hb measurements in unstable children or children in hemorrhagic shock. However, greater detail is given on Hb thresholds in relation to different operations in stable children. * converted to the German product units: 8:4:1 or 4:4:1 Flow chart adapted from Valentine et al. (21); printed with the kind permission of Wolters Kluwer Health Inc.; ACS, acute chest syndrome; ECMO, extracorporeal membrane oxygenation; Hb, hemoglobin; PARDS, pediatric acute respiratory distress syndrome; VAD, ventricular assist device.