Perioperative bleeding management in pediatric patients

Abstract

PURPOSE OF REVIEW Managing the bleeding pediatric patient perioperatively can be extremely challenging. The primary goals include avoiding hypotension, maintaining adequate tissue perfusion and oxygenation, and maintaining hemostasis. Traditional bleeding management has consisted of transfusion of autologous blood products, however, there is strong evidence that transfusion-related side-effects are associated with increased morbidity and mortality in children. Especially concerning is the increased reported incidence of noninfectious adverse events such as transfusion-related acute lung injury, transfusion-related circulatory overload and transfusion-related immunomodulation. The current approach in perioperative bleeding management of the pediatric patient should focus on the diagnosis and treatment of anemia and coagulopathy with the transfusion of blood products only when clinically indicated and guided by goal-directed strategies. RECENT FINDINGS Current guidelines recommend that a comprehensive multimodal patient blood management strategy is critical in optimizing patient care, avoiding unnecessary transfusion of blood and blood product and limiting transfusion-related sideeffects. SUMMARY This article will highlight current guidelines in perioperative bleeding management for our most vulnerable pediatric patients with emphasis on individualized targeted intervention using point-of-care testing and specific coagulation products. Purpose of review Managing the bleeding pediatric patient perioperatively can be extremely challenging. The primary goals include avoiding hypotension, maintaining adequate tissue perfusion and oxygenation, and maintaining hemostasis. Traditional bleeding management has consisted of transfusion of autologous blood products, however, there is strong evidence that transfusion-related side-effects are associated with increased morbidity and mortality in children. Especially concerning is the increased reported incidence of noninfectious adverse events such as transfusion-related acute lung injury, transfusion-related circulatory overload and transfusion-related immunomodulation. The current approach in perioperative bleeding management of the pediatric patient should focus on the diagnosis and treatment of anemia and coagulopathy with the transfusion of blood products only when clinically indicated and guided by goaldirected strategies. Recent findingsCurrent guidelines recommend that a comprehensive multimodal patient blood management strategy is critical in optimizing patient care, avoiding unnecessary transfusion of blood and blood product and limiting transfusion-related side-effects. SummaryThis article will highlight current guidelines in perioperative bleeding management for our most vulnerable pediatric patients with emphasis on individualized targeted intervention using point-of-care testing and specific coagulation products.

Red blood cell transfusion in perioperative pediatric anesthesia: a survey of current practice in Germany

“…The updated ESA guidelines no longer address this subject; the older version calculated the volume as a volume equivalent to five times the required increase in Hb concentration per kilogram of the body weight. The responders of our survey did not know this formula, although it was favored by some authors …”

“…The responders of our survey did not know this formula, although it was favored by some authors. 21,34 Some responding physicians preferred to preoperatively calculate the blood loss that can be tolerated by pediatric patient. Authors propose the use of the formulas:…”

“…Reports of Serious Hazards of Transfusion (SHOT) show that the incidence of adverse events is greater in children, especially in infants . Therefore, experts also recommend the application of PBM and restrictive transfusion strategies in children …”

“…20 Therefore, experts also recommend the application of PBM and restrictive transfusion strategies in children. 13,21 Blood transfusion in pediatric patients is challenging. For instance, collecting blood samples to determine Hb concentrations can be difficult during surgery.…”

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

“…Management of pediatric bleeding and blood product transfusion presents distinctive considerations . Blood volumes and normal hemoglobin concentrations vary per age and weight, with neonates and infants having higher blood volumes per weight but a lower tolerance to losses.…”