Transfusion in pediatrics☆
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.
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2016, Smith's Anesthesia for Infants and Children, Ninth EditionAnemia and Transfusion in Critically Ill Pediatric Patients. A Review of Etiology, Management, and Outcomes.
2013, Critical Care ClinicsCitation 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.
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2011, Pediatric Critical Care
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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.