PEDIATRIC BLOOD TRANSFUSION

1. BLOOD TRANSFUSION
To transfuse !!!!
or
not to
transfuse???
Dr Charul Jakhwal

2. Pediatric age group
 From birth to 18 years of age [IAP]
 up to the age of 21 [U.S. FDA]

3. A Little About The History!
 1628 English physician William Harvey discovers the
circulation of blood. He was the first known to describe
completely and in detail the systemic circulation and
properties of blood being pumped to the brain and body
by the heart.
 1665 The first recorded successful blood transfusion
occurs in England: Physician Richard Lower.( dogs)
 1667 successful transfusions from lambs to humans
 1795 the first human blood transfusion
 1818 first successful transfusion of human blood to a
patient for the treatment of postpartum hemorrhage
 1900 Karl Landsteiner, an Austrian physician, discovers
the first three human blood groups, A, B, and C. Blood
type C was later changed to O.

4.  The major changes in blood transfusion practice
over the last 100 years have largely occurred based
on the experience of military physicians during the
major conflicts of the 20th century. The first use of
preserved blood for transfusion was carried in 1917
in United States
 Transfusion methods altered dramatically around the
time of the Vietnam War in the 1970s, when practice
changed from using whole blood to component
therapy.

5. Human Blood Group Systems
 The term human blood group systems is defined by International
Society of Blood Transfusion as systems in the human species
where cell-surface antigens—in particular, those on blood cells—are
"controlled at a single gene locus or by two or more very closely
linked homologous genes with little or no observable recombination
between them",[1]
 It includes the common ABO and Rh- (Rhesus) antigen systems, as
well as many others; thirty-five major human systems are identified
as of November 2014.[2]
 ABO blood groups were discovered by Landsteiner in 1901 Later on
Rhesus blood groups were discovered by Landsteiner and Wiener in
1940. [3]
1. ISBT (2016). "International Society for Blood Transfusion (ISBT) Committee on Terminology for
Red Cell Surface Antigens, Terminology Home Page". Retrieved 20 February 2016
2. ISBT (2014). "Table of Blood Group Systems v4.0 (November)" (PDF). International Society
of Blood Transfusion. Retrieved 19 February 2016
3. Landsteiner K, Wiener AS (1940). An agglutinable factor in human blood recognized by immune sera for
Rhesus blood. Proc. Soc Exp. Biol. Med. 43:223-224.

6. ABO blood group system
 divided into four blood types on the basis of
presence or absence of A and B surface antigens.
The blood groups are A, B, O and AB.
 The frequency of four main ABO blood groups varies
in the population throughout the world.
 ABO blood group system derives its importance from
the fact that A and B are strongly antigenic and anti A
and anti B naturally occurring antibodies present in
the serum of persons lacking the corresponding
antigen, and these antibodies are capable of
producing intravascular hemolysis in case of
incompatible transfusion
Zaman et al. Study of ABO and Rh-D blood group among the common people of Chittagong city corporation
area of Bangladesh. Journal of Public Health and Epidemiology Vol. 7(9), pp. 305-310, September 2015

7. Rh blood group system
 It is the second most important blood group system,
after ABO, and it consists of 50 defined blood-
group antigens, among which the five antigens D, C,
c, E, and e are the most important. The commonly
used terms Rh factor, Rh positive and Rh
negative refer to the D antigen only.
Rh antibodies are immunoglobulin G (IgG) may cross freely from the placenta
into fetal circulation
Rh incompatibility can occur by 2 main mechanisms
1. secondary to fetomaternal hemorrhage
2. when an Rh-negative female receives an Rh-positive blood transfusion

8. Davis PJ, Cladis FP, Motoyama EK (eds). Smith’s Anesthesia for Infants and
Children, 8th ed. Philadelphia, PA: Elsevier Mosby; 2011: Ch. 3

9. Blood components!!!1 unit whole
blood
=350/450ml
plasma
Platelets poor
plasma
200ml
Platelets
50-70ml
RBC
250ml
CPDA1-35 days
SAGM-42days
1-6’C storage
Frozen in hypertonic
saline – 10years
Rapid Freezing with
in 1hour- FFP
Preserves factor 5 &
8
After thawing to be
used within 24 hours
Used with in 5
days
Stored at 20-24’C
Produced by
apharesis or BCT
The total blood requirement for a child may be as low as 25-100 ml and the child may also require multiple transfusions.
This can be achieved by aliquoting one PRBC unit (About 200 ml) into Pedi-packs. This will avoid multiple donor

10. Pediatric Blood transfusion
Children of <4 months
1. Physiological anemia
2. Predominance of HbF
3. the lower oxygen delivering
capacity.
4. inefficient humoral system
with attenuated formation
of antibodies to allogeneic
RBCs
5. the premature infant's have
limited EPO response to
decreased oxygen delivery
6. Relatively Greater blood
volume
Children of >4 months
1. No Physiological anemia
2. Predominance of HbA
3. Better oxygen delivering
capacity
4. Strong immune system
5. Normal EPO response to
decreased oxygen delivery
6. Relatively lower blood
volume
Smith’s Anesthesia for Infants and Children, 9th Edition, by Drs. Peter Davis
and Franklyn Cladis

11. RED BLOOD CELLS
Children of <4 months
Indications:
1. Massive blood loss or acute blood loss
due to trauma, surgery or other cause
associated with hypovolemic shock
2. Hgb < 8 g(dL (Hct < 24%) in stable
neonates with clinical manifestations of
anemia (tachycardia, tachypnea, poor
feeding, poor weight gain, apnea)
3. Hgb < 10 g/dL (Hct < 30%) in neonates
with:
a. 02 requirement < 35% by hood or nasal
cannula
b. On continuous positive airway pressure
(CPAP) or stable ventilator setting (mean
airway pressure < 6 cm of water)
c. Significant apnea or bradycardia,
significant tachycardia or tachypnea
d. Low weight gain (poor feeding)
Children of >4 months
Indications:
1. Massive blood loss or acute blood
loss due to trauma, surgery, or other
cause associated with hypovolemic
shock (>15% total blood volume)
2. Hgb < 8 g/dL emergent/urgent
surgery; symptomatic anemia
(tachypnea, tachycardia,
hypotension), chemo/radiotherapy;
hernodynamically stable pediatric
ICU patients
3. Significant preoperative anemia
when other corrective therapy not
available
4. Hgb < 10 g/dL and severe brain
injury
*Blood center of Wisconsin 2015

12. RED BLOOD CELLS
Children of <4 months
4. Hgb < 12 g/dL (Hct < 35%) in
neonates with:
a. Fi02 requirement > 35%
b. On CPAP or IMV (Intermittent
Mandatory Ventilation) with mean
airway pressure 6-8 cm of water
c. Deteriorating respiratory status
d. With hypotension or shock
requiring vasopressors
e. Recovering from major surgery
f. Severe traumatic brain injury
5. Hgb < 15 g/dL (Hct < 45%) in
neonates
a. With cyanotic congenital heart
disease
Children of >4 months
4. Hgb < 13 g/dL cyanotic heart
disease, ECMO, severe
pulmonary disease
5. Patients with
hemoglobinopathies and/or
chronic hemolytic anemias (e.g.
Sickle cell disease, thalassemia)
and undergo chronic or episodic
transfusions for specific clinical
indications
*Blood center of Wisconsin 2015

13.  Dosing Recommendations:
• 10-15 ml/kg of body weight should raise the Hgb by
2-3 g/dL or the Hct by 6%.
• Transfusion rate is dependent on the clinical
condition and age of the infant/pediatric patient; rate of
transfusion should be prescribed by the ordering
physician.
*Blood center of Wisconsin 2015

14. Platelets
 Indications: Children of < 4 and >4 months:
1. Active bleeding or prior to invasive procedures
a. Platelet count < 50,000/uL in neonates
b. Platelet count < 100,000/uL in sick preterm
neonates or those who need CNS surgery
c. Platelet dysfunction (acquired, including post-
cardiopulmonary bypass, or inherent), regardless
of platelet count
2. As a part of a massive transfusion protocol
3. Prophylactic use may be indicated in patients with a
platelet count < 30,000/uL (depending on age)
*Blood center of Wisconsin 2015

15. Platelets -Dosing Recommendations:
Children of < 4 months:
• 10-15 ml/kg of body
weight gives an expected
platelet count rise of
30,000/uL to 50,000/uL
Children of < 4 months:
 The following dose usually
raises the platelet count
by 30,000/uL to
50,000/uL:
1. If child less than 10 kg
of body weight, 1/4
apheresis platelet
2. If child 10-30 kg of body
weight, 1/2 apheresis
platelet
3. If child greater than 30
kg of body weight, 1
adult apheresis platelet
*Blood center of Wisconsin 2015

16. Plasma
Children of < 4 months:
 Indications
1. Documented coagulopathy and bleeding or
thrombosis
2. Support during Disseminated Intravascular
Coagulation (DIC), Massive Transfusion,
and during or within 24 hours after
ECMO/CPB
3. Replacement therapy for clinically
significant deficiency, including:
a. Multiple coagulation factor deficiency (i.e.
liver disease)
b. When specific factor concentrates are not
available (i.e. Factor II, Factor V, Factor X,
Factor XI)
c. Clinically significant plasma protein
deficiency (i.e. ADAMTS13, protein S)
4. Emergent correction of vitamin K deficiency
(i.e. active bleeding, emergent surgery); but this
does not preclude Vitamin K replacement
5. Neonates with unexplained bleeding
unresponsive to other measures may be given
plasma without PT, PTT.
Children of > 4 months:
 Indications:
1. Support during Disseminated
Intravascular Coagulation (DIC), Massive
Transfusion, and during or within 24 hours
after ECMO/CPB
2. Replacement therapy for clinically
significant deficiency, including:
a) Multiple coagulation factor deficiency
(i.e. liver disease)
b) When specific factor concentrates
are not available (i.e. Factor II,
Factor V, Factor X, Factor XI)
c) Clinically significant plasma protein
deficiency (i.e. ADAMTS13, protein
S)
3. Emergent reversal of vitamin K
antagonist or correction of vitamin K
deficiency (i.e. active bleeding, emergent
surgery)

17. Dosing Recommendations:
 • A dose of 10-20 mL/kg of body weight typically
raises procoagulant factors into hemostatic levels;
monitor for desired outcome.

18. Cryoprecipitate (all ages)
 Rich in– Fibrinogen, von Willebrand factor, Factor XIII and
factor VIII
 Supplied as single unit for smaller patients(neonates) or as 5-
pool for larger patients
 Indications:
1. Hypofibrinogenemia (Fibrinogen < 125 mg/dL) or
dysfibrinogenemia, with active bleeding or undergoing an
invasive procedure'
2. Hemophilia A (deficiency in factor VIII) or von Willebrand
disease, only when virally-inactivated or recombinant
concentrate is unavailable or DDAVP is not appropriate.
3. Replacement therapy in Factor XIII deficiency with active
bleeding or undergoing an invasive procedure'
 Dosing Recommendations:One single unit of cryoprecipitate
(20-25mL) per 7 kg of body weight will typically raise the
fibrinogen by 100 mg/dL. Monitor for desired outcome.
*Blood center of Wisconsin 2015

19. Why it is important to give blood?
 Anaemia is the commonest encountered abnormal
laboratory finding in critical care (Vincent et al CCM
2006)
 Inadequate O2 delivery with severe anemia
 RBC transfusion improves O2 delivery
 Critically ill patients more susceptible to adverse
effects of oxygen depletion
• impairs oxygen delivery to critical organs
• cardiovascular system must compensate
 RBC transfusion should improve outcomes
Sepsis in European Intensive Care Units:
Results of the SOAP Study Vincent et al CCM
2006

20. Anemia from acute inflammatory response
in critical care
 Reduction in red cell production
 Increased red cell destruction
 Blood loss (acute or chronic)
 Diminished erythropoietin response
 Impaired proliferation and differentiation of erythroid
progenitors in the bone marrow
 Phlebotomy
ACCP Critical Care Medicine Board Review: 21st Edition >
< Previous Chapter
Next Chapter >
Chapter 22. Anemia and RBC Transfusion in the ICU
2015

21. Trauma resuscitation!
Pediatric massive blood transfusions
Massive transfusion in the pediatric population is defined as the transfusion of blood
components equaling one or more blood volumes within a 24-hour time frame or
half of a blood volume in 12 hours.
Whole blood- obsolete
 deficient in clotting factors and has high levels of potassium, ammonia, and hydrogen
ions.
 Volume overload
Blood component therapy
Packed red blood cells
Fresh frozen plasma (FFP)
Platelets
Plasma, red blood cell and platelet ratios of 1:1:1
appear to be the best substitution for fresh whole
blood
Sara J. Chidester et al. A pediatric massive transfusion protocol J Trauma Acute Care
Surg. 2012 Nov; 73(5): 10

22. Sara J. Chidester et al. A pediatric massive transfusion protocol J Trauma Acute Care
Surg. 2012 Nov; 73(5): 10

23. Smith’s Anesthesia for Infants and Children, 9th Edition, by Drs. Peter
Davis and Franklyn Cladis

24. Whole blood transfusion!
Smith’s Anesthesia for Infants and Children, 9th Edition, by Drs. Peter
Davis and Franklyn Cladis

26. Sloan SR, Benjamin RJ, Friedman DF, Webb IJ, Silberstein L. Transfusion medicine. In:
Nathan & Oski’s Textbook of Hematology of Infancy and Childhood, 6th ed. Philadelphia:
Saunders, 2003:1709−56.
 Children are quite different from adults during growth
and development, and that should be taken into
different consideration.

27. Transfusion complications
Transfusion complications that are generally common
between adult and pediatric patients include
 Acute hemolytic transfusion reactions,
 Febrile non-haemolytic transfusion reactions
(FNHTR)
 Allergic transfusion reactions,
 Delayed hemolytic transfusion reactions,
 Transfusion-related acute lung injury,
 Transfusion-associated graft-versus-host disease,
and
 Infectious complications.

28. Blood grouping and crossmatching
 Blood grouping
The most fatal of all transfusion-related reaction is ABO
incompatibility causing complement-mediated intravascular
hemolysis. Hence, correct blood grouping and typing, and cross-
checking with the blood requisition form is of utmost importance.
ABO typing is carried out by testing RBCs for the A and B antigens
and the serum for the A and B antibodies before transfusion. The
next step involves Rh typing with only 15% of the population being
Rh-negative.
 Cross-matching
Cross-matching involves mixing of donor RBCs with the recipient
serum to detect fatal reactions. [19] . Among the three phases, the first
two phases are more important as they detect those involved in fatal
HTR. The total time taken for all the three phases is in between 45
and 60 min.
Mitra R, Mishra N, Rath GP. Blood groups systems. Indian J Anaesth 2014 [cited 2017 Feb
10];58:524-8.
Miller RD. Transfusion therapy. In: Miller RD, ErikssonLI, Fleischer LA, Wiener-
Kronish JP, Young LA, editors. Miller's Anesthesia. 7 th ed. Philadelphia: Churchill
Livingstone Elsevier; 2010. p. 1739-66.

30.  In emergency lifesaving resuscitation, the risk of
hemolytic transfusion reactions from transfusion of
group O blood to nongroup O recipients constitutes
risk that is outweighed by the benefits.

34. Autologous/placental RBC transfusion
 In small pilot studies, there has been no benefit in autologous
transfusion in neonates as compared with standard allogeneic
transfusion.42,43 Additionally, there is limited benefit due to low
volume of collection in extremely low birth weight infants.42,44–46
The shelf-life of umbilical cord blood autologous product is also
shorter at 14–21 days.47 In addition to these concerns, bacterial
contamination and high cost continue to hamper clinical usage.42,44
42. Strauss RG, Widness JA. Is there a role for autologous/placental RBC transfusions
in the anemia of prematurity. Transfus Med Rev. 2010;24(2):125–129.
43. Brune T, Garritsen H, Hentschel R, Louwen F, Harms E, Jorch G. Efficacy, recovery,
and safety of RBCs from autologous placental blood: clinical experience in 52 newborns.
Transfusion. 2003;43(9):1210–1216.
44. Eichler H, Schaible T, Richter E, et al. Cord blood as a source of autologous RBCs
for transfusion of preterm infants. Transfusion. 2000;40(9):1111–1117.
47. Khodabux CM, van Beckhoven JM, Scharenberg JG, El Barjiji F, Slot MC, Brand A.
Processing cord blood from premature infants into autologous red blood cell products for
transfusion. Vox Sang. 2011;100(4):367–373.

35. 82. Cervia JS, Wenz B, Ortolano GA. Leukocyte reduction’s role in the attenuation of infection
risks among transfusion recipients. Clin Infect Dis. 2007;45(8):1008–1013.
83. Fergusson D, Hébert PC, Lee SK, et al. Clinical outcomes following institution of universal
leukoreduction of blood transfusions for premature infants. JAMA. 2003;289(15):1950–1956.
Blumberg N, Fine L, Gettings KF, Heal JM. Decreased sepsis related to indwelling venous access
devices coincident with implementation of universal leukoreduction of blood transfusions.
Transfusion. 2005;45(10):1632–1639.

36. Leukoreduction
 Removal of leucocytes from various blood products

37. ADVANTAGES OF LEUKOREDUCTION
The reduction in the number of leukocytes, in allogenic
blood products has been proven to be clinically
relevant in the following:
1. Reducing the frequency and severity of Febrile
Non-Hemolytic Transfusion Reactions (FNHTRs).
2. Reducing the risk of cytomegalovirus (CMV)
transmission.
3. Reducing the risk of HLA-alloimmunization and
platelet-refractoriness.
Cervia JS, Wenz B, Ortolano GA. Leukocyte reduction’s role in the attenuation of
infection risks among transfusion recipients. Clin Infect Dis. 2007;45(8):1008–1013.

38. Transfusion Triggers
Restrictive
 Hb <7g/dl
 Low Hb
Transfusion
Trigger
liberal
 HB <10g/dl
 High Hb
Transfusion Trigger
“a particular hemoglobin level of discomfort
for the prescribing physician, not defined
by clear physiologic parameters” at which
blood transfusion is required

39. Restrictive versus Liberal Transfusion Strategy.
Definitions for a restrictive versus liberal strategy for blood transfusion
vary in the literature, although hemoglobin criteria for transfusion less
than 8 g/dl and hematocrit values less than 25% are typically reported
as restrictive.
 The report suggests
 Meta-analysis of RCTs comparing restrictive with liberal transfusion
criteria report fewer red blood cell transfusions when restrictive
transfusion strategies are employed
Anesthesiology 2015; 122:241-75

40. P H B Bolton-Maggs, M F Murphy Blood transfusion Arch Dis Child
2004;89:4–7

41.  The availability of blood and platelet transfusion
support has permitted increasingly more intensive
chemotherapy regimes to be used in malignant
disease at all ages,19
 Children with haemoglobinopathies such as beta
thalassaemia major, or with red cell aplasia are
dependent on regular transfusions. These children
should have a more extended blood group
undertaken prior to the first transfusion in order to
minimise the development of red cell alloantibodies,

42. George K. IstaphanousPediatr Red blood cell
transfusion in critically ill children: A narrative review
Crit Care Med 2011 Vol. 12, No. 2

43.  Multi-centre, prospective, randomized study > 24 h
ICU stay expected Hb < 9.0 g/dL within 72 h Volume
resuscitated or normovolaemic Restrictive: Maintain
7-9 g/dL (APACHE II: 20.8) Liberal: Maintain 10-12
g/dL (APACHE II: 21.3)

44. Avnish Bharadwaj, Mamta Khandelwal1, Suresh Kumar Bhargava2, Perioperative neonatal and paediatric blood
Transfusion. Indian Journal of Anaesthesia | Vol. 58 | Issue 5 | Sep-Oct 2014

45. METABOLIC CONSEQUENCES AND
COMPLICATIONS
OF MASSIVE BLOOD TRANSFUSION
 The metabolic consequences of large blood transfusions also occur in adults
but are more frequent in children due to the relationship between blood
component administered and their circulating blood volume
 Hypocalcaemia may be treated by administration of calcium fluoride 5-10
mg/kg IV or calcium gluconate 15-30 mg/kg. If the blood loss is continuous
and prolonged infusion of calcium chloride at the rate of10 mg/kg/h may be
used.
 Hyperkalaemia Use of blood collected within 7 days and administration
slowly with total volume < 1.0 ml/kg/min is recommended. Intravenous
sodium bicarbonate 1 m mol/kg and calcium chloride 20 mg/kg or calcium
gluconate 60 mg/kg may be used to treat hyperkalaemia causing
arrhythmias. Use of intravenous dextrose insulin, hyperventilation and
sympathomimetics can be useful
 HypomagnesaemiaIV magnesium sulphate administered at 25-50 mg/kg
 Acid-base disorders
 Hypothermia Use of blood warmers, maintaining OT temperature, use of
warming blankets and warm fluids for irrigation and intravenous infusion with
monitoring of electrocardiogram, SpO2, skin and core temperature can be
helpful in preventing hypothermia and consequent complications.

50.  Conclusions
 The administration of blood per se did not lead to increased
postoperative infection. Clinicians should reconsider withholding
blood transfusion in patients solely owing to concerns of
predisposition to infection.

52.  In the present study, we found that shorter storage RBCs
transfusion significantly improved ChE recovery and
reduced the amount and duration of atropine usage
 Нese results suggest that RBCs transfusion could
improve clinical therapeutic effects on OPs intoxication
patients. Red blood transfusion may deliver additional
erythrocyte cholinesterase, which could be the potential
target substrate for OP
 packed RBCs transfusion has advantages over whole
blood transfusion, since the total volume administrated
into patients is less that could avoid risks of overloading
and fever or allergy by substances in serum
 Concludes early blood transfusion can e ‫ٴ‬‫و‬ectLvel reduce
the extent of toxic symptoms and prevent further
progression, especially when oximes are not available.

53. Thankyou