Indications for Red Blood Cell Transfusion in Infants and Children

Official reprint from UpToDate

www.uptodate.com 2013 UpToDate

AuthorJun Teruya, MD, DSc

Section EditorDonald H Mahoney, Jr, MD

Deputy EditorAlison G Hoppin, MD

Indications for red blood cell transfusion in infants and children

Disclosures

All topics are updated as new evidence becomes available and our peer review process is complete.Literature review current through: Sep 2013. | This topic last updated: Nov 27, 2012.INTRODUCTION Transfusion of red blood cells (RBCs) can be life-saving in patients with severe blood lossor patients with severe chronic anemia. On the other hand, RBC transfusion has significant risks, includingvolume overload, transmission of infectious agents, transfusion reactions, and various immunologicconsequences including graft-versus-host disease.

The indications for RBC transfusion in infants and children will be reviewed. The selection of the proper bloodcomponents, methods of administration, the complications of RBC transfusion and issues concerning blooddonation and laboratory testing of donated blood are discussed separately. (See "Red cell transfusion in infantsand children: Selection of blood products" and "Administration and complications of red cell transfusion in infantsand children" and "Blood donor medical history" and "Laboratory testing of donated blood" and "Red blood cellcompatibility testing (crossmatching)".)PREVALENCE OF PEDIATRIC RED CELL TRANSFUSION The transfusion rate for any blood component inhospitalized children remains uncertain. In children hospitalized at academic children's hospitals, the rate oftransfusion of either RBCs or platelets is approximately 5 percent.

This was best illustrated at a multicenter study from the Pediatric Health Information System of hospitalizedpatients who were 18 years or younger between 2001 and 2003 cared for at 35 academic children's hospitals [1].Of the approximately one million hospitalized children in this database, RBC transfusions were performed in 4percent and platelet transfusions in 1 percent of the patients. The distribution of transfusion based upon age wasas follows:

Neonates (patients less than 30 days of age) - 17.5 percent30 days to 2 years of age - 22.6 percentGreater than 2 years of age - 58.6 percent

Increased severity of illness was associated with a higher rate of transfusion. The most common diagnoses ofpatients who received transfusions were as follows:

AgranulocytosisSickle cell crisisMalignancy including leukemiaRespiratory distress syndrome

GENERAL INDICATIONS There are few studies of RBC transfusion requirements in children except inpatients with sickle cell disease and neonates. As a result, guidelines for RBC transfusion in infants and childrengenerally have been established by taking standards from adult patients and modifying them according to clinicalexperience [2,3]. (See "Indications and hemoglobin thresholds for red blood cell transfusion in the adult".)In both children and adults, clinicians have sought a "transfusion trigger," an absolute hemoglobin (Hgb) orhematocrit (Hct) value below which the patient needs RBC transfusion [4]. However, assigning an absolute levelis difficult since the hemoglobin level at which transfusion is required varies with the clinical setting (eg, acute orchronic) and physiologic status of the patient. In addition, the physiologic response to anemia in children is

Indications for red blood cell transfusion in infants and children http://www.uptodate.com/contents/indications-for-red-blood-cell-transf...

1 of 8 21/10/2013 9:18

different from adults. In children, dyspnea, impaired consciousness, and other symptoms of hemodynamiccompromise may not appear until the Hgb is

Acuity of anemia and intravascular volume Chronically anemic children often tolerate Hgbconcentrations as low as 6 to 7 g/dL or an Hct of 20 percent, because they are able to maintain adequateintravascular volume and tissue oxygenation [8]. On the other hand, patients with an acute loss of bloodand hypovolemia often require transfusion regardless of their level of Hgb or Hct.

Surgery A preoperative Hgb level of 10 g/dL is recommended for patients who will receive generalanesthesia, because lower values are associated with an increase in perioperative complications[2,11,12]. This is especially important in children with sickle cell disease [13,14]. RBC transfusion isrecommended if other corrective therapy is not available or did not raise the Hgb concentration to 10 g/dL.RBC transfusion during surgery is also needed if intraoperative blood loss is 15 percent of blood volume,regardless of the Hgb or Hct level. Estimated circulating blood volume ranges from 84 mL/kg in infants 1to 6 months, to 71 mL/kg in adolescents [15].

Impaired pulmonary and cardiac function Patients with severe pulmonary disease, cyanotic heartdisease, or on extracorporeal membrane oxygenation (ECMO) with decreased arterial oxygen saturationshould be transfused when the Hct falls

Barts) has improved following the introduction of intrauterine or early postnatal transfusion but continuedchronic transfusion is required [16]. Patients with Hemoglobin H disease typically do not need transfusionin the first decade of life. (See "Clinical manifestations and diagnosis of the thalassemias", section on'Hydrops fetalis and hemoglobin Barts' and "Clinical manifestations and diagnosis of the thalassemias",section on 'Hemoglobin H disease'.)

Hypoproliferative anemia Other chronic anemic states that require RBC transfusion in children and infantsinclude hypoproliferative anemias, such as Diamond-Blackfan anemia, aplastic anemia, and autoimmunehemolytic anemia. (See "Anemia in children due to decreased red blood cell production" and "Acquired aplasticanemia in children and young adults", section on 'Treatment' and "Autoimmune hemolytic anemia in children".)Oncology patients One of the largest groups of children requiring frequent RBC transfusion are oncologypatients undergoing either cytotoxic chemotherapy or hematopoietic stem cell transplantation.

One approach for RBC transfusion in children with cancer is to transfuse at a Hgb level of 6 to 7 g/dL (whichcorresponds to Hct of 18 to 21 percent) which, as noted above, is the level at which most children becomesymptomatic with malaise, irritability, and/or lassitude [10]. For patients with a Hgb level between 7 to 10 g/dL,RBC transfusion is indicated if they develop symptoms.

Others recommend that RBC transfusion be performed at a higher level when the Hgb level is

While hemostatic agents have reduced blood loss in adult cardiac patients, these drugs have not beenuniformly useful during surgery for children with congenital heart disease [22-28]. Desmopressin(DDAVP), for example, does not reduce RBC transfusion requirements in congenital heart surgeries[26-28]. Aprotinin may reduce bleeding and decrease RBC transfusion requirements when patients areplaced on extracorporeal life support [24,25]. A meta-analysis showed that aprotinin compared to nohemostatic agent reduced the proportion of children who received red blood cell or whole bloodtransfusion during cardiac surgery (RR 0.67, 95% CI 0.51 to 0.89) [31]. However, the safety of aprotininhas been called into question, and it is no longer available in the US. (See "Early noncardiaccomplications of coronary artery bypass graft surgery", section on 'Antifibrinolytic agents'.)Orthopedic surgery Orthopedic surgery, especially for scoliosis, often has significant blood lossesrequiring replacement with RBC transfusion. Several techniques have been used to reduce thetransfusion rates in children undergoing scoliosis repair. These include acute normovolemic hemodilutionduring surgery [32], preoperative management (eg, predonated autologous blood and the administrationof erythropoietin) [33,34], and the use of hemostatic agents. Antifibrinolytic agents (eg, epsilon-aminocaproic acid [19] and tranexamic acid [20]) and recombinant activated factor VII [35] reduced bloodloss and volume of transfused RBCs in adolescent patients who underwent scoliosis repair.

Craniosynostosis Surgical correction of craniosynostosis almost always requires RBC transfusion [36].Measures that have reduced RBC allogeneic transfusions include the preoperative use of erythropoietin[37] and perioperative blood salvage [38]. However, in one report, acute normovolemic hemodilution insurgery for the repair of craniosynostosis did not change the need for transfusion and the volume oftransfused RBC [39]. (See "Overview of craniosynostosis".)Other procedures Occasionally, plastic surgery or surgical oncology patients may require multiple unitsof RBCs.

Newborns Newborns have a total blood volume of approximately 80 to 100 mL/kg [40,41]. Thus, anextremely low birth weight infant (ie, birth weight

prevent or reverse tissue hypoxia due to limited oxygen delivery.

General RBC transfusion guidelines based principally upon patient's clinical status have been developedby pediatric transfusion medicine specialists for patients less than four months of age and those greaterthan four months of age. (See 'General indications' above.)Transfusion indications have been developed for specific pediatric clinical conditions. These includepatients with chronic anemia due to sickle cell anemia, thalassemia, and hypoproliferative anemias,malignancies, requiring surgery, and the neonate. (See 'Specific clinical settings' above and "Red bloodcell transfusions in the newborn", section on 'Indications'.)

Use of UpToDate is subject to the Subscription and License Agreement.

REFERENCES

Slonim AD, Joseph JG, Turenne WM, et al. Blood transfusions in children: a multi-institutional analysis ofpractices and complications. Transfusion 2008; 48:73.

1.

Roseff SD, Luban NL, Manno CS. Guidelines for assessing appropriateness of pediatric transfusion.Transfusion 2002; 42:1398.

2.

Gibson BE, Todd A, Roberts I, et al. Transfusion guidelines for neonates and older children. Br J Haematol2004; 124:433.

3.

Spence RK, Swisher SN. Red cell transfusion-the transfusion trigger. In: Clinical practice of transfusionmedicine, 3rd, Petz LD, Swisher SN, Kleinman S, et al (Eds), Churchill Livingstone, New York 1996. p.177.

4.

CASE RB, BERGLUND E, SARNOFF SJ. Ventricular function. VII. Changes in coronary resistance andventricular function resulting from acutely induced anemia and the effect thereon of coronary stenosis. AmJ Med 1955; 18:397.

5.

Lacroix J, Hbert PC, Hutchison JS, et al. Transfusion strategies for patients in pediatric intensive careunits. N Engl J Med 2007; 356:1609.

6.

Rouette J, Trottier H, Ducruet T, et al. Red blood cell transfusion threshold in postsurgical pediatricintensive care patients: a randomized clinical trial. Ann Surg 2010; 251:421.

7.

Homi J, Reynolds J, Skinner A, et al. General anaesthesia in sickle-cell disease. Br Med J 1979; 1:1599.8.Sloan SR, Benjamin RF, Friedman DF, et al. Transfusion medicine. In: Nathan and Oski's Hematology ofInfancy and Childhood, 6th, Nathan DG, Orkin SH, Ginsberg D, Look AT (Eds), WB Saunders, Philadelphia2003. p.1709.

9.

Agarwal AK, Hastings CA, and Feusner J. Hematologic supportive care for children with cancer. In:Principles and Practice of Pediatric Oncology, 6, Pizzo PA, Poplack DG (Eds), Lippincott Williams andWilkins, Philadelphia 2011. p.1152.

10.

Carson JL, Duff A, Berlin JA, et al. Perioperative blood transfusion and postoperative mortality. JAMA1998; 279:199.

11.

Carson JL, Noveck H, Berlin JA, Gould SA. Mortality and morbidity in patients with very low postoperativeHb levels who decline blood transfusion. Transfusion 2002; 42:812.

12.

Haberkern CM, Neumayr LD, Orringer EP, et al. Cholecystectomy in sickle cell anemia patients:perioperative outcome of 364 cases from the National Preoperative Transfusion Study. PreoperativeTransfusion in Sickle Cell Disease Study Group. Blood 1997; 89:1533.

13.

Vichinsky EP, Haberkern CM, Neumayr L, et al. A comparison of conservative and aggressive transfusionregimens in the perioperative management of sickle cell disease. The Preoperative Transfusion in SickleCell Disease Study Group. N Engl J Med 1995; 333:206.

14.

Riley AA, Arakawa Y, Worley S, et al. Circulating blood volumes: a review of measurement techniques anda meta-analysis in children. ASAIO J 2010; 56:260.

15.

Singer ST, Styles L, Bojanowski J, et al. Changing outcome of homozygous alpha-thalassemia: cautiousoptimism. J Pediatr Hematol Oncol 2000; 22:539.

16.

Williams GD, Bratton SL, Ramamoorthy C. Factors associated with blood loss and blood producttransfusions: a multivariate analysis in children after open-heart surgery. Anesth Analg 1999; 89:57.

17.


6 of 8 21/10/2013 9:18

Kwiatkowski JL, Manno CS. Blood transfusion support in pediatric cardiovascular surgery. Transfus Sci1999; 21:63.

18.

Florentino-Pineda I, Blakemore LC, Thompson GH, et al. The Effect of epsilon-aminocaproic acid onperioperative blood loss in patients with idiopathic scoliosis undergoing posterior spinal fusion: apreliminary prospective study. Spine (Phila Pa 1976) 2001; 26:1147.

19.

Neilipovitz DT, Murto K, Hall L, et al. A randomized trial of tranexamic acid to reduce blood transfusion forscoliosis surgery. Anesth Analg 2001; 93:82.

20.

Erstad BL. Systemic hemostatic medications for reducing surgical blood loss. Ann Pharmacother 2001;35:925.

21.

Davies MJ, Allen A, Kort H, et al. Prospective, randomized, double-blind study of high-dose aprotinin inpediatric cardiac operations. Ann Thorac Surg 1997; 63:497.

22.

Carrel TP, Schwanda M, Vogt PR, Turina MI. Aprotinin in pediatric cardiac operations: a benefit in complexmalformations and with high-dose regimen only. Ann Thorac Surg 1998; 66:153.

23.

Miller BE, Tosone SR, Tam VK, et al. Hematologic and economic impact of aprotinin in reoperativepediatric cardiac operations. Ann Thorac Surg 1998; 66:535.

24.

Biswas AK, Lewis L, Sommerauer JF. Aprotinin in the management of life-threatening bleeding duringextracorporeal life support. Perfusion 2000; 15:211.

25.

Oliver WC Jr, Santrach PJ, Danielson GK, et al. Desmopressin does not reduce bleeding and transfusionrequirements in congenital heart operations. Ann Thorac Surg 2000; 70:1923.

26.

Seear MD, Wadsworth LD, Rogers PC, et al. The effect of desmopressin acetate (DDAVP) onpostoperative blood loss after cardiac operations in children. J Thorac Cardiovasc Surg 1989; 98:217.

27.

Reynolds LM, Nicolson SC, Jobes DR, et al. Desmopressin does not decrease bleeding after cardiacoperation in young children. J Thorac Cardiovasc Surg 1993; 106:954.

28.

Stylianos S. Liver injury and damage control. Semin Pediatr Surg 2001; 10:23.29.Manno CS, Hedberg KW, Kim HC, et al. Comparison of the hemostatic effects of fresh whole blood, storedwhole blood, and components after open heart surgery in children. Blood 1991; 77:930.

30.

Arnold DM, Fergusson DA, Chan AK, et al. Avoiding transfusions in children undergoing cardiac surgery: ameta-analysis of randomized trials of aprotinin. Anesth Analg 2006; 102:731.

31.

Copley LA, Richards BS, Safavi FZ, Newton PO. Hemodilution as a method to reduce transfusionrequirements in adolescent spine fusion surgery. Spine (Phila Pa 1976) 1999; 24:219.

32.

Anand N, Idio FG Jr, Remer S, Hoppenfeld S. The effects of perioperative blood salvage and autologousblood donation on transfusion requirements in scoliosis surgery. J Spinal Disord 1998; 11:532.

33.

Franchini M, Gandini G, Regis D, et al. Recombinant human erythropoietin facilitates autologous bloodcollections in children undergoing corrective spinal surgery. Transfusion 2004; 44:1122.

34.

Sachs B, Delacy D, Green J, et al. Recombinant activated factor VII in spinal surgery: a multicenter,randomized, double-blind, placebo-controlled, dose-escalation trial. Spine (Phila Pa 1976) 2007; 32:2285.

35.

Faberowski LW, Black S, Mickle JP. Blood loss and transfusion practice in the perioperative managementof craniosynostosis repair. J Neurosurg Anesthesiol 1999; 11:167.

36.

Fearon JA, Weinthal J. The use of recombinant erythropoietin in the reduction of blood transfusion rates incraniosynostosis repair in infants and children. Plast Reconstr Surg 2002; 109:2190.

37.

Dahmani S, Orliaguet GA, Meyer PG, et al. Perioperative blood salvage during surgical correction ofcraniosynostosis in infants. Br J Anaesth 2000; 85:550.

38.

Hans P, Collin V, Bonhomme V, et al. Evaluation of acute normovolemic hemodilution for surgical repair ofcraniosynostosis. J Neurosurg Anesthesiol 2000; 12:33.

39.

Lindemann R, Haines AL. Evaluation and treatment of polycythemia in the neonate. In: Hematologicproblems of the neonate, Christensen RD (Ed), WB Saunders, Philadelphia 2000. p.171.

40.

Ohls RK. Evaluation and treatment of anemia in the neonate. In: Hematologic problems of the neonate,Christensen RD (Ed), WB Saunders, Philadelphia 2000. p.137.

41.

Meliones JN, Hansell DR. Extracorporeal membrane oxygenation: the role of blood components. In:Supporting the pediatric transfusion recipient, Chambers LA, Issitt LA (Eds), American Association ofBlood Banks, Bethesda 1994. p.87.

42.

Remacha AF, Badell I, Pujol-Moix N, et al. Hydrops fetalis-associated congenital dyserythropoietic anemia43.


7 of 8 21/10/2013 9:18

treated with intrauterine transfusions and bone marrow transplantation. Blood 2002; 100:356.

Topic 5910 Version 9.0


8 of 8 21/10/2013 9:18

Documents

Indications for Red Blood Cell Transfusion in Infants and Children