This document discusses preoperative preparation and management of anemic children undergoing surgery. It covers normal hemoglobin levels, causes of anemia including hemoglobinopathies, estimating maximum blood loss, guidelines for transfusing blood products like platelets and fresh frozen plasma, using antifibrinolytics to reduce bleeding, and monitoring coagulation disorders with tests like ROTEM to help manage perioperative bleeding in children.

1. Prof.ssa Marinella Astuto
Director of School of Anesthesia and intensive care, School of Medicine, Catania,
Italy
Catania University Hospital,
Preoperative preparation of the anemic child

2. anaemia

3. Normal Hemoglobin levels

4. The World Health Organisation defines anaemia as an
insuffi cient circulating red cell mass, with a haemoglobin
(Hb) concentration of :

5. Infants vs adults
Infant: 60-90% HbF
3 m.: HbA > HbF
A 6 m.: HbA 99%

6. Perioperative trasfusion of anemic
infants and children:
recommendations of the
Italian Society of Pediatric and
Neonatal Anesthesia
and Intensive Care (SARNePI)

8. Etiology of anemia
➡preoperative
➡intraoperative
➡postoperative

9. preoperative
✓ Haemoglobinopathies
✓ surgery
✓ coagulation disorders

10. ➡talassemia maior
Gibson, B. E., A. Todd, I. Roberts, D. Pamphilon, C. Rodeck, P. Bolton-Maggs, G. Burbin, J. Duguid, F. Boulton, H. Cohen, N. Smith, D. B. McClelland, M. Rowley and G. Turner.
"Transfusion Guidelines for Neonates and Older Children." Br J Haematol 124, no. 4 (2004): 433-53.
Haemoglobinopathies

11. ➡Sickle cell disease
Haemoglobinopathies

12. Preoperative and intraoperative
blood loss
The goals should be to maintain hemodynamic stability and
oxygen carrying capacity , and to prevent and treat
hyperfibrinolysis and dilutional coagulopathy,
considering clinical status of patient
SURGERY
Carson, J. L., B. J. Grossman, S. Kleinman, A. T. Tinmouth, M. B. Marques, M. K. Fung, J. B. Holcomb, O. Illoh, L. J. Kaplan, L. M. Katz, S. V. Rao, J. D. Roback, A. Shander, A. A. Tobian, R. Weinstein, L. G. Swi

13. Kozek-Langenecker, S. A., A. Afshari, P. Albaladejo, C. A. Santullano, E. De Robertis, D. C. Filipescu, D. Fries, K. Gorlinger, T. Haas, G. Imberger, M. Jacob, M. Lance, J. Llau, S. Mallett, J. Meier, N.
Rahe-Meyer, C. M. Samama, A. Smith, C. Solomon, P. Van der Linden, A. J. Wikkelso, P. Wouters and P. Wyffels. "Management of Severe Perioperative Bleeding: Guidelines from the
European Society of Anaesthesiology." Eur J Anaesthesiol 30, no. 6 (2013): 270-382.
Gibson, B. E., A. Todd, I. Roberts, D. Pamphilon, C. Rodeck, P. Bolton-Maggs, G. Burbin, J. Duguid, F. Boulton, H. Cohen, N. Smith, D. B. McClelland, M. Rowley and G. Turner.
"Transfusion Guidelines for Neonates and Older Children." Br J Haematol 124, no. 4 (2004): 433-53.
Trasfusion of blood

14. Estimated maximum
allowable blood loss
BV=Weight x factor
Weight : [Kg]
Hct (Hematocrit): [%]
EABL (Est. Allow. Blood Loss) : [L]
BV ( Blood Volume): [L]
Factor: ranges between 0.095 (preterm) and 0.065
(Adult women)

15. trasfusion of platelet
Kozek-Langenecker, S. A., A. Afshari, P. Albaladejo, C. A. Santullano, E. De Robertis, D. C. Filipescu, D. Fries, K. Gorlinger, T. Haas, G. Imberger, M. Jacob, M. Lance, J. Llau, S. Mallett, J. Meier, N.
Rahe-Meyer, C. M. Samama, A. Smith, C. Solomon, P. Van der Linden, A. J. Wikkelso, P. Wouters and P. Wyffels. "Management of Severe Perioperative Bleeding: Guidelines from the
European Society of Anaesthesiology." Eur J Anaesthesiol 30, no. 6 (2013): 270-382.

16. Antifibrinolytics
Recommendation
We suggest that perioperative antifibrinolytic therapy
should be used to reduce blood loss and transfusion
requirements in cardiac and non-cardiac paediatric surgery .2A
There is strong evidence that the implementation
of a patient blood management strategy involving intraoperative
prophylactic administration of TXA
Kozek-Langenecker, S. A., A. Afshari, P. Albaladejo, C. A. Santullano, E. De Robertis, D. C. Filipescu, D. Fries, K. Gorlinger, T. Haas, G. Imberger, M. Jacob, M. Lance, J. Llau, S. Mallett, J. Meier, N.
Rahe-Meyer, C. M. Samama, A. Smith, C. Solomon, P. Van der Linden, A. J. Wikkelso, P. Wouters and P. Wyffels. "Management of Severe Perioperative Bleeding: Guidelines from the
European Society of Anaesthesiology." Eur J Anaesthesiol 30, no. 6 (2013): 270-382.

17. Transfusion of fresh frozen plasma
FFP
Kozek-Langenecker, S. A., A. Afshari, P. Albaladejo, C. A. Santullano, E. De Robertis, D. C. Filipescu, D. Fries, K. Gorlinger, T. Haas, G. Imberger, M. Jacob, M. Lance, J. Llau, S. Mallett, J. Meier, N.
Rahe-Meyer, C. M. Samama, A. Smith, C. Solomon, P. Van der Linden, A. J. Wikkelso, P. Wouters and P. Wyffels. "Management of Severe Perioperative Bleeding: Guidelines from the
European Society of Anaesthesiology." Eur J Anaesthesiol 30, no. 6 (2013): 270-382.

18. URGERY/COAGULATION DISORDER
Acquired fibrinogen deficiency

19. coagulation disorders
Kozek-Langenecker, S. A., A. Afshari, P. Albaladejo, C. A. Santullano, E. De Robertis, D. C. Filipescu, D. Fries, K. Gorlinger, T. Haas, G. Imberger, M. Jacob, M. Lance, J. Llau, S. Mallett, J. Meier, N.
Rahe-Meyer, C. M. Samama, A. Smith, C. Solomon, P. Van der Linden, A. J. Wikkelso, P. Wouters and P. Wyffels. "Management of Severe Perioperative Bleeding: Guidelines from the
European Society of Anaesthesiology." Eur J Anaesthesiol 30, no. 6 (2013): 270-382.
Andreasen, J. B., A. M. Hvas, K. Christiansen and H. B. Ravn. "Can Rotem(R)
Analysis Be Applied for Haemostatic Monitoring in Paediatric
Congenital Heart Surgery?" Cardiol Young 21, no. 6 (2011): 684-91.

20. coagulation disorders
routine plasmatic coagulation tests may be of limited help for timely
management of perioperative bleeding due to long turnaround times,
insufficient differential diagnosis of complex acquired intraoperative
coagulopathy, and insensitivity to the function of fibrinogen,
hyperfibrinolysis, and platelet dysfunction .
To overcome these limitations, the use of the rotation
thromboelastometry (ROTEM o TEG ) is increasingly favored for
intraoperative coagulation management in children

21. CONCLUSION
➡preoperative management of hemoglobinopathie
➡blood trasfusions : ranges, triggers and volume
➡trasfusion of component :triggers and volume
➡Clotting factors and antifibrinolytics
➡monitoring of coagulations