Transfusion Strategies for Hemostatic Blood Products in Critically Ill Children: A Narrative Review and Update on Expert Consensus Guidelines

Abstract

Critically ill children commonly receive coagulant products (plasma and/or platelet transfusions) to prevent or treat hemorrhage or correct coagulopathy. Unique aspects of pediatric developmental physiology, and the complex pathophysiology of critical illness must be considered and balanced against known transfusion risks. Transfusion practices vary greatly within and across institutions, and high-quality evidence is needed to support transfusion decision-making. We present recent recommendations and expert consensus statements to direct clinicians in the decision to transfuse or not to transfuse hemostatic blood products, including plasma, platelets, cryoprecipitate, and recombinant products to critically ill children.

Consensus Blood Product Transfusion Guidelines for a Large Neonatal Care Network

“…Emerging evidence has shown that some transfusion practices are harmful for certain NICU patients, such as platelet transfusions in preterm infants 5,6 . More broadly, transfusion reactions can occur with virtually all blood products 7 and these reactions are likely under-diagnosed, underestimated, and under-reported in pediatric patients 3 . Our intention was to establish optimal transfusion guidelines for our division and neonatal network, including 19 hospitals, based on a review of currently available literature.…”

The ethics of war-time data in paediatric trauma: attitudes, angles and impacts

“…It largely justifies the threshold for more invasive intervention after a resuscitative threshold is met in injured children (over 40 mL/kg within the first 24 hours was associated with excess in-hospital mortality). It has been referenced by the ATOMAC (Arizona, Texas, Oklahoma, Memphis, Arkansas Consortium) trauma consortium,8 and other consensus guidelines 9. In total, it has been cited 149 times to date.…”

Patient Blood Management Is a New Standard of Care to Optimize Blood Health

“…Given that plasma and/or platelet transfusions are associated with adverse reactions (ie, febrile, hypotensive, allergic and anaphylactic reactions [FAHR], transfusion-related acute lung injury [TRALI], transfusion-associated circulatory overload [TACO], and transfusion-related immunomodulation [TRIM]), following these strategies should positively impact pediatric patient outcomes. 15…”

“…14 Expert consensus was lacking until recently when considering the management of hemostatic blood components. Management guidelines for transfusion of hemostatic blood components, such as plasma, platelets, cryoprecipitate, and recombinant products in pediatrics, are summarized by Valentine et al 15 This review provides recommendations to direct clinicians in the decision to transfuse or not to transfuse hemostatic blood components to critically ill children. Given that plasma and/or platelet transfusions are associated with adverse reactions (ie, febrile, hypotensive, allergic and anaphylactic reactions [FAHR], transfusion-related acute lung injury [TRALI], transfusion-associated circulatory overload [TACO], and transfusion-related immunomodulation [TRIM]), following these strategies should positively impact pediatric patient outcomes.…”

“…Given that plasma and/or platelet transfusions are associated with adverse reactions (ie, febrile, hypotensive, allergic and anaphylactic reactions [FAHR], transfusion-related acute lung injury [TRALI], transfusion-associated circulatory overload [TACO], and transfusion-related immunomodulation [TRIM]), following these strategies should positively impact pediatric patient outcomes. 15 PBM is clearly distinct from transfusion medicine, shifting the focus away from transfusion and toward the patient's blood preservation/conservation. 16 Allogeneic blood transfusion, once considered an essential therapeutic measure for anemia and blood loss, carries the risk of increased morbidity and mortality in a dose-dependent relationship.…”