Neonatal RBC transfusions: Do benefits outweigh risks?

Intraoperative transfusion practice and associated outcomes following neonatal surgery in a middle-income country: A 5-year single center retrospective review

BACKGROUND

Neonates undergoing surgery are at greater risk of requiring packed red blood cell transfusion. Pediatric transfusion practices vary widely between countries and institutions, especially in the management of neonates.

AIMS

The aim of this study was to describe the use of intraoperative blood product transfusion during neonatal surgery in current clinical practice at our institution.

METHODS

A retrospective contextual, descriptive, and comparative study was conducted at Chris Hani Baragwanath Academic Hospital. A total of 1078 anesthetic records of neonates who underwent surgery from January 1, 2015 to December 31, 2019 were reviewed. Descriptive and inferential statistics were used to analyze the data.

RESULTS

Blood products were transfused during 374 (34.7%) neonatal surgeries. Packed red blood cells, platelet concentrate, and fresh frozen plasma were administered during 327 (30.3%), 133 (12.3%), and 85 (7.9%) of the total 1078 surgeries, respectively. The median (interquartile range) volume of packed red blood cells, fresh frozen plasma, platelets, and clear fluid administered was 15 (10-21.8) mL/kg, 12.3 (10-23.5) mL/kg, 13.6 (10-20.5) mL/kg, and 19 (9.1-28.8) mL/kg, respectively. Very low weight, low preoperative hemoglobin, long total anesthetic time, emergency surgery, and major surgery were independently associated with blood product transfusion. Gestational age at birth, blood product transfusion, emergency surgery, and major surgery were independently associated with the composite adverse outcomes. The median preoperative hemoglobin was 11.8 g/dL.

CONCLUSIONS

Intraoperative blood product transfusion occurred at a much higher rate with a high median pre-transfusion hemoglobin compared to other studies.

Fetal and Neonatal Anesthesia

Anesthesia for fetal and neonatal surgery requires subspecialized knowledge and expertise. Attention to important anatomic, physiologic, and metabolic differences seen in pregnancy and at birth are essential for the optimal care of these patients. Thorough preoperative evaluations tailored intraoperative strategies and careful postoperative management are critical when devising the anesthetic approach for each of these cases.

Neonatal Transfusion Practice: Hemolysis Markers After In Vitro Infusion of Packed Red Blood Cells by the Gravitational Method or Syringe Pump in a Peripheral Catheter

The objective of this study was to verify the influence of the gravitational infusion method or syringe infusion pump on changes in hemolysis markers of irradiated and nonirradiated packed red blood cells (PRBCs) in vitro administered in a neonate peripheral intravenous catheter. An experimental study was conducted in a laboratory under controlled environmental conditions. Irradiated and nonirradiated PRBCs were administered in triplicate by the gravitational method and 10-mL/hour syringe infusion pump, in peripheral intravenous catheter, Vialon, 24-G caliber. Aliquots were collected directly from the PRBC bag, after manual filling of the infusion system and after infusion by the catheters. The following hemolytic markers were analyzed: degree of hemolysis (%), hematocrit (Ht, %), free hemoglobin (fHb, g/dL), potassium (K, mmol/L), and lactate dehydrogenase (LDH, U/L). Mann-Whitney and Student's t tests were used, P ≤ .05. The gravitational method significantly influenced increasing fHb (P = .007), Ht (P = .002), K (P = .002), and LDH (P = .003) values after PRBC irradiated infusion. The infusion of irradiated and non-irradiated PRBCs interferes with changes in hemolytic markers with the gravitational method. Syringe infusion pump proved to be a beneficial and safe alternative to irradiated and nonirradiated PRBC transfusion in newborns.

The Relevance of Fluid and Blood Management Using Microcirculatory Parameters in Children Undergoing Craniofacial Surgery

ABSTRACT

Perioperative management of bleeding in children can be challenging. Microvascular imaging techniques have allowed evaluating the effect of blood transfusion on the microcirculation, but little is known about these effects in children. We aimed to investigate the effects of blood management using macro- and micro-hemodynamic parameters measurement in children undergoing craniofacial surgery. This is a prospective observational repeated measurement study including fourteen children. The indications for blood transfusion were changes of hemoglobin/hematocrit (Hct) levels, the presence of signs of altered tissue perfusion and impaired microcirculation images. Total and perfused vessel densities, proportion of perfused vessels, microvascular flow index, and systemic parameters (hemoglobin, Hct, lactate, mixed venous oxygen saturation, K+, heart rate, mean arterial blood pressure) were evaluated baseline (T1), at the end of the surgical bleeding (T2) and end of the operation (T3). Four patients did not need a blood transfusion. In the other 10 patients who received a blood transfusion, capillary perfusion was higher at T3 (13[9-16]) when compared with the values of at T2 (11[8-12]) (P < 0.05) but only 6 patients reached their baseline values. Although blood transfusions increased Hct values (17 ± 2.4 [T2]-19 ± 2.8 [T3]) (P < 0.05), there was no correlation between microvascular changes and systemic hemodynamic parameters (P > 0.05). The sublingual microcirculation could change by blood transfusion but there was not any correlation between microcirculation changes, hemodynamic, and tissue perfusion parameters even with Hct values. The indication, guidance, and timing of fluid and blood therapy may be assessed by bedside microvascular analysis in combination with standard hemodynamic and biochemical monitoring for intraoperative bleeding in children.

Transfusion practices in a large cohort of hospitalized children

BACKGROUND

While previous studies have described the use of blood components in subsets of children, such as the critically ill, little is known about transfusion practices in hospitalized children across all departments and diagnostic categories. We sought to describe the utilization of red blood cell, platelet, plasma, and cryoprecipitate transfusions across hospital settings and diagnostic categories in a large cohort of hospitalized children.

STUDY DESIGN AND METHODS

The public datasets from 11 US academic and community hospitals that participated in the National Heart Lung and Blood Institute Recipient Epidemiology and Donor Evaluation Study-III (REDS-III) were accessed. All nonbirth inpatient encounters of children 0-18 years of age from 2013 to 2016 were included.

RESULTS

61,770 inpatient encounters from 41,943 unique patients were analyzed. Nine percent of encounters involved the transfusion of at least one blood component. RBC transfusions were most common (7.5%), followed by platelets (3.9%), plasma (2.5%), and cryoprecipitate (0.9%). Children undergoing cardiopulmonary bypass were most likely to be transfused. For the entire cohort, the median (interquartile range) pretransfusion laboratory values were as follows: hemoglobin, 7.9 g/dl (7.1-10.4 g/dl); platelet count, 27 × 10⁹ cells/L (14-54 × 10⁹ cells/L); and international normalized ratio was 1.6 (1.4-2.0). Recipient age differences were observed in the frequency of RBC irradiation (95% in infants, 67% in children, p < .001) and storage duration of RBC transfusions (median storage duration of 12 [8-17] days in infants and 20 [12-29] days in children, p < .001).

CONCLUSION

Based on a cohort of patients from 2013 to 2016, the transfusion of blood components is relatively common in the care of hospitalized children. The frequency of transfusion across all pediatric hospital settings, especially in children undergoing cardiopulmonary bypass, highlights the opportunities for the development of institutional transfusion guidelines and patient blood management initiatives.

Society for the advancement of blood management administrative and clinical standards for patient blood management programs. 4th edition (pediatric version)

Patient Blood Management is the timely application of evidence-based medical and surgical concepts designed to maintain hemoglobin concentration, optimize hemostasis, and minimize blood loss to improve patient outcomes. Conceptually similar to a "bundle" strategy, it is designed to improve clinical care using comprehensive evidence-based treatment strategies to manage patients with potential or ongoing critical bleeding, bleeding diathesis, critical anemia, and/ or a coagulopathy. Patient Blood Management includes multimodal strategies to screen, diagnose and properly treat anemia, coagulopathies and minimize bleeding, using goal-directed therapy and leverages a patient's physiologic ability to adapt to anemia while definitive treatment is undertaken. Allogeneic blood component transfusion is one traditional therapeutic modality out of many for managing blood loss and anemia and, while it may be the best choice in certain situations, other effective and more appropriate options are available and should be used in conjunction or alone. Therefore, comprehensive Patient Blood Management is the new standard of care to prevent and manage anemia and optimize hemostasis and has been recommended by the World Health Organization, the American Society of Anesthesiologists, the European Society of Anaesthesiology and the Australian National Blood Authority. While there is a plethora of expert consensus and good practice guidelines published for blood component transfusion from multiple professional organizations and societies, there remains a need for more comprehensive and broader standards of patient medical management to proactively reduce the risk of exposure to allogeneic transfusions. In 2010, the Society for Advancement of Blood Management published the first comprehensive standards to address the administrative and clinical components of an effective, patient-centered Patient Blood Management program. Recognizing the need to reduce inappropriate transfusions, some professional organizations have placed their emphasis on transfusion guidelines. In contrast, the focus of the Society for Advancement of Blood Management Standard is on the centrality of the patient and the full spectrum of therapeutic strategies needed to improve clinical outcomes in patients at risk for blood loss or anemia, thereby reducing avoidable transfusions as well. The Standards are meant not to replace, but to complement transfusion guidelines by more completely addressing the need for a multi-modal clinical approach with the goal to improve patient outcomes. Compared to adult programs, Pediatric Patient Blood Management programs are currently not commonly accepted as standard of care for pediatric patients. This is partly due to the fact that, until recently, there was a paucity of robust evidence-based literature and expert consensus guidelines on pediatric PBM. Managing pediatric bleeding and blood product transfusion presents a unique set of challenges. The main goal of transfusion is to correct or avoid imminent inadequate oxygen carrying capacity caused by inadequate red blood cell mass. Determining when, what, and how much to transfuse can be difficult. Neonates, infants, children, and adolescents each have specific considerations based on age, weight, physiology, and pharmacology. In this edition of Pediatric Anaesthesia we provide, in abbreviated format, the 4th edition of the Administrative and Clinical Standards for Patient Blood Management; Pediatric Version, first published in 2010 with the addition of a new Pediatric section in 2016. These Standards provide guidance for implementing a comprehensive Pediatric Patient Blood Management program at both pediatric and adult medical institutions. While every hospital may not be equipped to have a dedicated Pediatric Patient Blood Management program, this document highlights important universal clinical strategies that can be implemented to optimize pediatric bleeding management and minimize allogeneic blood product exposure through the use of multi-modal therapeutic strategies that have their central emphasis on the patient rather than the transfusion. Important strategies include: treatment of preoperative anemia, standardized transfusion algorithms, the use of restrictive transfusion thresholds, goal-directed therapy based on point of care and viscoelastic testing, antifibrinolytics, and avoidance of hemodilution and hypothermia as supported by evidence. For the full version, please go to https://www.sabm.org/publications.

Blood, blood components, plasma, and plasma products

This review of 2018 publications identifies side effects of blood, blood components, and plasma products. In addition, albumin, blood transfusion (erythrocytes, granulocytes, and platelets), blood substitutes (hemoglobin-based oxygen carriers), plasma products (alpha1-antitrypsin, C1 esterase inhibitor concentrate, cryoprecipitate, and fresh frozen plasma), plasma substitutes (etherified starches, and gelatin), globulins (intravenous immunoglobulin, subcutaneous immunoglobulin, and anti-D immunoglobulin), coagulation proteins (factor I, factor II, factor VIIa, factor VIII, factor IX, prothrombin complex concentrate, antithrombin III, and von Willebrand factor/factor VIII concentrates), erythropoietin and derivatives, thrombopoietin and receptor agonists, transmission of infectious agents through blood donation, and stem cells are reviewed. This chapter informs the reader about newly recognized and published data in the blood product domain.