Elsevier

Critical Care Clinics

Volume 20, Issue 2, April 2004, Pages 299-311
Critical Care Clinics

Transfusion in pediatrics☆

https://doi.org/10.1016/S0749-0704(03)00113-1Get rights and content

Section snippets

Pathophysiology of anemia

The most important consequence related to anemia is a reduction of oxygen delivery (DO2). There is a large debate about what are the lowest hemoglobin level and DO2 (critical DO2) under which oxygen consumption is in jeopardy. In healthy adults, Weiskopf et al [3] showed that the critical DO2 is less than 10 mL of oxygen per kg per minute, a level reached at a hemoglobin concentration of 5.0 g/dL. The critical hemoglobin concentration may be higher in critically ill children for many reasons.

Risks versus benefits

Essentially, risks and benefits of RBC transfusion to critically ill children remain to be documented. Blood transfusions are administered to increase oxygen carrying capacity and oxygen consumption [17], [18], [19]. There are a number of risks associated with transfusions, however, including the transmission of infectious diseases through blood products and transfusion reactions [20]. RBC transfusion also may be immunosuppressive [21], [22], [23], [24], [25], [26], which might explain why

Clinical evidence

It remains unclear at what degree of anemia in critically ill children that the benefits of RBC transfusions outweigh the risks resulting from the underlying condition. In the authors' review of the literature, there is very little clinical evidence addressing this question.

Indeed, the authors found four before-and-after studies primarily asking whether red cell transfusion improves oxygen delivery and consumption. Two studies were conducted in children following septic shock [18], [19], one

Guidelines

Despite the limited clinical evidence, there are many guidelines that address transfusion practice in critically ill children. They are based largely upon expert opinion, common practice, and evidence extrapolated from the adult literature, rather than high-quality clinical trials conducted in children [47]. The authors found recommendations in major textbooks on general pediatrics and pediatric subspecialties, including critical care medicine, hematology, anesthesiology, surgery, and

Other considerations

There are several additional considerations and potential approaches to the administration of red cells in critically ill children.

There is a consensus that everything must be done to limit blood loss in PICUs. The blood volume of children is smaller than it is in adults (for example, the blood volume of a 5 kg child is 400 mL rather than 5 L). Micro sampling techniques must be used to collect blood, and the number of blood samples must be limited as much as possible. Coagulopathy should be

Summary

In reviewing the literature, the authors noted an important variation in stated [56] and observed transfusion practice patterns [2] among pediatric critical care practitioners, and in published guidelines on RBC transfusion. They also noted a paucity of clinical evidence with respect to RBC transfusion to critically ill children. There has been only one large randomized trial in adults [42], and the authors do not believe that the results from this trial should be generalized to critically ill

Acknowledgements

The authors thank the members of the Canadian Critical Care Trials Group for their support to the research program on red blood cell transfusion to critically ill children.

First page preview

First page preview
Click to open first page preview
View PDF

References (78)

  • R.H Beekman et al.

    Acute hemodynamic effects of increasing hemoglobin concentration in children with a right to left ventricular shunt and relative anemia

    J Am Coll Cardiol

    (1985)
  • M English et al.

    Blood transfusion for severe anaemia in children in a Kenyan hospital

    Lancet

    (2002)
  • E.M Lackritz et al.

    Effect of blood transfusion on survival among children in a Kenyan hospital

    Lancet

    (1992)
  • A.M Goodman et al.

    Pediatric red blood cell transfusions increase resource use

    J Pediatr

    (2003)
  • C.E Henling et al.

    Cardiac operation for congenital heart disease in children of Jehovah's Witnesses

    J Thorac Cardiovasc Surg

    (1985)
  • S.L Bratton et al.

    Packed red blood cell transfusions for critically ill pediatric patients: when and for what conditions?

    J Pediatr

    (2003)
  • M Chaı̈bou et al.

    Clinically significant upper gastrointestinal bleed acquired in a pediatric intensive care unit: a prospective study

    Pediatrics

    (1998)
  • R.B Weiskopf et al.

    Human cardiovascular and metabolic response to acute, severe isovolemic anemia

    JAMA

    (1998)
  • J.J Ronco et al.

    Oxygen consumption is independent of increases in oxygen delivery by dobutamine in septic patients who have normal or increased plasma lactate

    Am Rev Respir Dis

    (1993)
  • P.C Hébert et al.

    Review of physiologic mechanisms in response to anemia

    Can Med Assoc J

    (1997)
  • V De Halleux et al.

    The effect of blood transfusion on the hemoglobin oxygen dissociation curve of very early preterm infants during the first week of life

    Semin Perinatol

    (2002)
  • D.G Nathan et al.
  • B Krafte-Jacobs et al.

    Circulating erythropoietin and interleukin-6 concentrations increase in critically ill children with sepsis and septic shock

    Crit Care Med

    (1996)
  • P Hobisch-Hagen et al.

    Blunted erythropoietic response to anemia in multiply traumatized patients

    Crit Care Med

    (2001)
  • R Rivera-Fernandez et al.

    Quality of life before intensive care unit admission and its influence on resource utilization and mortality rate

    Crit Care Med

    (2001)
  • J Lacroix et al.

    Alimentations entérale et parentérale

  • M Casutt et al.

    Factors influencing the individual effects of blood transfusion on oxygen delivery and oxygen consumption

    Crit Care Med

    (1999)
  • S.E Lucking et al.

    Dependence of oxygen consumption on oxygen delivery in children with hyperdynamic septic shock and low oxygen extraction

    Crit Care Med

    (1990)
  • R.B Mink et al.

    Effect of blood transfusion on oxygen consumption in pediatric septic shock

    Crit Care Med

    (1990)

  • Consensus conference. Perioperative red blood cell transfusion

    JAMA

    (1988)
  • R.L Nichols et al.

    Risk of infection after penetrating abdominal trauma

    N Engl J Med

    (1984)
  • P.I Tartter et al.

    Perioperative transfusions associated with colorectal cancer surgery: clinical judgment versus the hematocrit

    World J Surg

    (1986)
  • L.P Fielding

    Red for danger: blood transfusion and colorectal cancer

    BMJ

    (1985)
  • R.W Taylor et al.

    Impact of allogenic packed red blood cell transfusion on nosocomial infection rates in the critically ill patient

    Crit Care Med

    (2002)
  • K.B Quattrocchi et al.

    Cell-mediated immunity in severely head-injured patients: the role of suppressor lymphocytes and serum factors

    J Neurosurg

    (1992)
  • N.V Christou et al.

    Host defense in blunt trauma: inter-relationships of kinetics of anergy and depressed neutrophil function, nutritional status, and sepsis

    J Trauma

    (1980)
  • F.A Moore et al.

    Postinjury multiple organ failure: a bimodal presentation

    J Trauma

    (1996)
  • G.A McGrady et al.

    An outbreak of necrotizing enterocolitis association with transfusion of packed red blood cells

    Am J Epidemiol

    (1987)

    • Cited by (49)

    • Blood Conservation and Transfusion Medicine

      2016, Smith's Anesthesia for Infants and Children, Ninth Edition

    • Anemia and Transfusion in Critically Ill Pediatric Patients. A Review of Etiology, Management, and Outcomes.

      2013, Critical Care Clinics
      Citation Excerpt :

      These methods, however, have not proved to be conclusively helpful in making the decision to transfuse.37 One of the reasons for this may lie in the decreased amount of fetal Hgb relative to that of adult Hgb present in transfused blood, which can alter Do2.38 Along the same lines as the adult and pediatric studies, Bell and colleagues39 attempted to discern a transfusion trigger in 100 preterm infants with birth weights between 500 and 1300 g in a randomized prospective trial.

    • Transfusion Medicine

      2011, Pediatric Critical Care: Expert Consult Premium Edition

    • Clinical impact of length of storage before red blood cell transfusion

      2011, Transfusion Clinique et Biologique

    • Blood Conservation

      2011, Smith's Anesthesia for Infants and Children: Expert Consult Premium Edition - Enhanced Online Features and Print

    • Transfusion Medicine

      2011, Pediatric Critical Care
    View all citing articles on Scopus
    ☆

    This work was supported by Grant No. 84300 from the Canadian Institutes of Health Research. Dr. Desmet received a Fellowship Award from the Fondation de l'Hôpital Sainte-Justine.

    View full text
    Copyright © 2004 Elsevier Inc. All rights reserved.