Book
Transfusion of Blood Components in Paediatric Age Groups
- Introduction
Blood is a vital human tissue and a precious health resource, required to be adequately available, safe, correctly and rationally used and timely administered.12 Blood transfusion is an essential component of modern health-care systems and when used appropriately, it saves lives, improves health conditions and enhances patient outcomes. However, improper or unnecessary use can increase the risk of serious, acute, and delayed adverse complications, and in underprivileged settings it places further strain on already limited health resources.13 In recognition of its critical role in the patient management over a wide variety of medical conditions, blood and blood products are currently incorporated into the World Health Organization (WHO) model list of essential medicines.14
Paediatric transfusion is a complex area of medicine covering a wide age range from intrauterine life to young adults. The prescriber must balance the risks and benefits of transfusion in each age group and be aware of the indications for special components. However, compared to adult practice there is a relative lack of high-quality research to inform evidence-based guidelines.12. The effectiveness of transfusion of whole blood or any of its components depends in large measure on a clear understanding of the anticipated role in supplying a specific deficiency or correcting a pathologic state while realizing the limitations and hazards.15
Children require transfusion of blood components for a vast array of medical conditions, including acute hemorrhage, haematologic and nonhaematologic malignancies, hemoglobinopathy, and allogeneic and autologous stem cell transplant. Evidence-based literature on paediatric transfusion practices is limited, particularly for non-red blood cell products, and many recommendations are extrapolated from studies in adult populations.16 Recognition of these knowledge gaps has led to increasing numbers of clinical trials focusing on children and establishment of paediatric transfusion working groups in recent years.
Red blood cell (RBC) transfusions are used to treat hemorrhage and to improve oxygen delivery to tissues. Transfusion of RBCs should be based on the patient's clinical condition. Indications for transfusion include symptomatic anaemia, acute sickle cell crisis, and acute blood loss of more than 30 percent of blood volume.17
Except during active hemorrhage, holding blood requirements to a minimum frequently serves the patient to greater advantage than maintaining normal hemoglobin levels by frequent and maximal administrations of blood. This restriction is especially pertinent in the refractory anaemias; the aplastic-hypoplastic group. Here multiple transfusions result not alone in hemosiderosis but in a potential suppressive effect on erythropoiesis and hemoglobin synthesis. This restrictive policy, however, does not apply to thalassemia and other hemogobinopathies. It should be emphasized that the hemoglobin concentration at which transfusion is indicated for patients who require single or multiple administrations of blood cannot be arbitrarily fixed but varies with the attendant clinical signs and symptoms and the promise of relief by this form of treatment.18
Fresh frozen plasma (FFP) is indicated for the deficiency of coagulation factors with abnormal coagulation tests in the presence of active bleeding. Fresh frozen plasma is also indicated for a planned surgery or invasive procedure in the presence of abnormal coagulation tests, for the reversal of warfarin in the presence of active bleeding, or planned procedure when vitamin K is inadequate to reverse the warfarin effect, TTP, and congenital or acquired factor deficiency with no alternative therapy. Other situations where the administration of FFP cannot be recommended for or against based on systematic review include FFP transfusion in trauma patients with massive transfusion. Conditions that cause the deficiency of multiple coagulation factors and may require the administration of FFP include liver disease and disseminated intravascular coagulation.19 Platelet transfusion is indicated to prevent hemorrhage in patients with thrombocytopenia. Cryoprecipitate, as a source of FVIII, vWF and FXIII, is used in cases of hypofibrinogenemia, which most often occurs in the setting of massive hemorrhage or consumptive coagulopathy.20
Access to safe and adequate blood supply remains a public health challenge in many countries, particularly in low resource settings (poor economics). In high-income countries the average donation rate is 32.1/1000 population in comparison to 4.6/1000 population in low-income countries, where about 80% of the world’s population lives and has access to only 20% of the world’s safe blood supply.21 While infectious risks are low, non-infectious serious hazards of transfusion, such as transfusion-associated lung injury (TRALI) and transfusion-associated circulatory overload are much more prevalent in critically ill children.22
The aim of this adapted clinical practice guideline (CPG) is to provide evidence-based recommendations for the transfusion of blood components in the paediatric age group. These recommendations were adapted from the relevant CPGs using a formal methodology for CPG adaptation: the Adapted-ADAPTE.
➡️Purpose and Scope
These guidelines have been developed to standardize the delivery of services and to implement the guidance on the prevention, diagnosis and management of transfusion of blood components in paediatric age groups.
It provides guidance to primary health care providers, pediatricians and specially trained nurses.
This guideline focuses on any disease or condition requiring red blood cells, platelets, and/or plasma products transfusion(s) to prevent or control anaemia, bleeding, and thrombotic disorders. It Provides an evidence-based document for the appropriate use of blood components, define indications, dosing, and administration of different blood components.
It also covers safe transfusion practice including pre-transfusion testing, handling of blood components, and close monitoring of transfused patients and includes recommendations in special situations (multi-transfused subjects, massive transfusion, and the critically ill).
This version of the guideline includes recommendations and good practice statements for the transfusion of blood components in paediatric age groups.
