Transfusions in the Critically Ill Pediatric Patient

Jelena Roganovic

Pediatr Health. 2010;4(2):201-208.

Abstract and Introduction

Abstract

Anemia is one of the most common medical complications encountered in critically ill children. Based on the results of clinical trials, transfusion practices across the world have generally become more restrictive. The decision process leading to the conduction of a red blood cell transfusion should be based on available evidence as much as possible. The risks and benefits of the transfusion as well as the risks attributable to anemia must be taken into account. This review summarizes the current practice approach to the critically ill pediatric patient.

Introduction

Critically ill patients in pediatric intensive care units (PICUs) are at significant risk for developing anemia. The causes are multifactorial and include overt and occult bleeding, iatrogenic blood loss through diagnostic phlebotomy, underlying disease, chronic anemia and treatment causing bone marrow suppression.^[1] An inadequate erythropoietin response to anemia in critically ill children has been described.^[2]

The optimal hemoglobin (Hb) threshold for conducting a red blood cell (RBC) transfusion in this group of patients is unknown, as is the target Hb concentration that the pediatrician should aim to achieve. Children have a different physiology and pathology compared with adults during their growth and development, and that should also be taken into consideration.^[3] Historically, critically ill pediatric patients received an extraordinarily large number of RBC transfusions and recently conducted studies revealed that almost 50% of children who are admitted to PICUs are transfused.^[4]

Red blood cell transfusions are associated with multiple disadvantages, including limited availability, high costs, multiple risks and side effects. This review summarizes the evaluation of anemia in acute illness and treatment guidelines in the pediatric emergency department.

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Table 1. Suggested red blood cell transfusion thresholds for infants under 4 months of age according to The British Committee for Standards in Hematology Transfusion Task Force.
	Hemoglobin threshold
Anemia in the first 24 h of life	Hb: 12 g/dl (Hct circa: 0.36)
Cumulative blood loss in 1 week in a neonate requiring intensive care	10% blood volume
Neonate receiving intensive care	Hb: 12 g/dl
Acute blood loss	10% blood volume
Chronic oxygen dependency	Hb: 11 g/dl
Late anemia in a stable infant	Hb: 7 g/dl

Hb: Hemoglobin; Hct: Hematocrit.
Adapted from ^[16].

Box 1. Guidelines for red blood cell transfusion in patients less than 4 months of age.
Hct <20% with a low reticulocyte count and symptoms of anemia^† Hct <30% in an infant: On <35% hood O₂ On O₂ via a nasal cannula On continuous positive airway pressure and/or intermittent mandatory ventilation with mechanical ventilation with a mean airway pressure of <6 cm H₂O With significant apnea or bradycardia^‡ With significant tachycardia or tachypnea^§ With a low weight gain^¶ Hct <35% in an infant: On >35% hood O₂ On continuous positive airway pressure/intermittent mandatory ventilation with a mean airway pressure of ≥6–8 cm H₂O Hct <45% in an infant On ECMO With congenital cyanotic heart disease

^†Tachycardia, tachypnoea or poor feeding.
^‡More than six episodes in 12 h or two episodes in 24 h requiring bag and mask ventilation while receiving therapeutic doses of methylxanthines.
^§Heart rate >180 beats/min for 24 h; respiratory rate >80 breaths/min for 24 h.
^¶Gain of <10 g/day observed over 4 days while receiving ≥100 kcal/kg/day.
Hct: Hematocrit; ECMO: Extracorporeal membrane oxygenation.
Adapted from ^[18].

Box 2. Suggested hemoglobin thresholds for red blood cell transfusions in the pediatric age group.
*Infants less than 4 months of age* Hb <7 g/dl in a stable patient with late anemia Hb <8 g/dl for symptomatic anemia Hb <10 g/dl for major surgery Hb <10 g/dl in cases of moderate cardiopulmonary disease Hb <13 g/dl in cases of severe cardiopulmonary disease *Children* Hb <7 g/dl for symptomatic anemia Hb <9 g/dl in cases of cardiopulmonary disease Acute blood loss >30% of circulating blood volume

Hb: Hemoglobin.

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