Transfusion management of severe anaemia in African children: a consensus algorithm

Abstract

Summary The phase III Transfusion and Treatment of severe anaemia in African Children Trial (TRACT) found that conservative management of uncomplicated severe anaemia [haemoglobin (Hb) 40–60 g/l] was safe, and that transfusion volume (20 vs. 30 ml/kg whole blood equivalent) for children with severe anaemia (Hb <60 g/l) had strong but opposing effects on mortality, depending on fever status (>37·5°C). In 2020 a stakeholder meeting of paediatric and blood transfusion groups from Africa reviewed the results and additional analyses. Among all 3196 children receiving an initial transfusion there was no evidence that nutritional status, presence of shock, malaria parasite burden or sickle cell disease status influenced outcomes or modified the interaction with fever status on volume required. Fever status at the time of ordering blood was a reliable determinant of volume required for optimal outcome. Elevated heart and respiratory rates normalised irrespective of transfusion volume and without diuretics. By consensus, a transfusion management algorithm was developed, incorporating three additional measurements of Hb post‐admission, alongside clinical monitoring. The proposed algorithm should help clinicians safely implement findings from TRACT. Further research should assess its implementation in routine clinical practice.

A predictive algorithm for identifying children with sickle cell anemia among children admitted to hospital with severe anemia in Africa

“…In summary, a high proportion of all children with severe anemia who were recruited to the TRACT trial in Uganda had either known‐ or unknown‐SCA. Standard case management was equally effective in these children as it was in those without SCA 29 . We present an algorithm that could allow the detection of more than 70% of all children with undiagnosed SCA among those admitted with severe anemia with a NNT of less than 2.…”

“…Standard case management was equally effective in these children as it was in those without SCA. 29 We present an algorithm that could allow the detection of more than 70% of all children with undiagnosed SCA among those admitted with severe anemia with a NNT of less than 2. Implementing our algorithm could present a cost-efficient approach to the targeted testing of such children that could help direct those found to be affected to appropriate care.…”

Whole blood versus red cell concentrates for children with severe anaemia: a secondary analysis of the Transfusion and Treatment of African Children (TRACT) trial

“… 11 , 21 However, we found no evidence of overload in children receiving whole blood compared with red cell concentrates, or with a larger volume of blood received, irrespective of the severity of anaemia or underlying sickle cell disease. 10 , 22 Most transfusion-related lung injuries or cardiac overloads were deemed by the endpoint review committee (who were unaware of treatment assignment) to be unrelated to the intervention. 10 In the TRACT trial, no child received a diuretic or heart failure medication, and although there were differences between pack types in heart rate and respiratory rate at 48 h, these were too small to be clinically meaningful.…”

“…In conclusion, our study suggests that the use of packed or settled cells rather than whole blood leads to additional transfusions; thus increasing the use of a scarce resource in most of sub-Saharan Africa. Although further consideration should be given by blood transfusion services on how to streamline requirements to include whole blood, as well as when and for whom whole blood transfusion is most needed, 22 rather than a one-size-fits-all policy for all regional blood transfusion services, a clinical trial comparing whole blood transfusion with red cell concentrates might be needed to inform policy makers.…”

Point‐of‐care haemoglobin testing in African hospitals: a neglected essential diagnostic test

“…To update current guidelines, with the new findings from the TRACT trial, a consensus severe anaemia management algorithm was developed with the aim of improving evidencebased clinical practice and averting the unnecessary use of transfusion in children with uncomplicated severe anaemia. 32 However, two vital components of the transfusion management algorithm included both clinical and Hb monitoring. Using data from the TRACT trial, we were able to show that a minimum of three additional measurements of Hb over 48 h of hospital stay would identify~50% developing severe and complicated anaemia since 76% of children required a transfusion following of a drop in Hb < 40 g/l.…”