Rational Blood Transfusion in

infant and Children

Lelani Reniarti
Divisi Hematologi-Onkologi
Departemen/SMF Ilmu Kesehatan Anak
RSUPN Dr Hasan Sadikin/Universitas Padjadjaran Bandung
The major indication for RBCs is a need to
increase red blood cell mass and improve oxygen
delivery in patients with anemia and
replace blood volume in intravascular volume
depletion from acute blood loss or systemic disease.
the goal to increase oxygen-carrying capacity of the
blood or maintain satisfactory tissue oxygenation
 Blood Transfusion
Essentials
Is blood transfusion necessary in this patient?
 If so, ensure Safe transfusion
right blood
right patient
right time
right dose
Avoid unnecessary and inappropriate transfusions

NHS Blood and Transplant ‘Transfusion. JPAC.

https://www.transfusionguidelines.org/
 Rational Blood Transfusion
Benefit V Risk
 Treatment
S Transfusion reaction
 live saving Circulatory overload
Infection transmission

Australian Red Cross Blood Services 2021

NHS Blood and Transplant ‘Transfusion.
JPAC.2021
 Blood Transfusion
Ten Commanment
1. the benefits outweigh the risks and there are no appropriate alternatives.
2. Results of laboratory tests are not the sole deciding factor for transfusion.
3. Transfusion decisions should be based on clinical assessment
4. Not all anaemic patients need transfusion
5. Discuss the risks, benefits and alternatives to transfusion with the patient
6. The reason for transfusion should be documented in the patient’s clinical
record.
7. Good communication and team work are essential.
8. Patient identifiers on the ID band and blood pack must be identical. Any
discrepancy, DO NOT TRANSFUSE.
9. The patient must be monitored during the transfusion.
10. Education and training underpin safe transfusion practice
Exchange Transfusion in Infants

Severe hemolytic disease of the fetus and newborn

(HDFN) or progressive hyperbilirubinemia
Recommendation
 RBCs should be hemoglobin S negative,
leukoreduced, < 7 days old, and CMV reduced risk.
The RBCs should be group O or ABO group-
compatible with the infant and the mother, be Rh
negative or Rh identical with the infant,
Distribution of ABO blood groups and antibodies
 Choice of ABO group for blood products for administration to
children
Patient's ABO group ABO group of blood product to be transfused

Red cells Platelets FFP*

O
First choice  O O O
Second choice  – A A or B or
AB
A
First choice  A A A or AB
Second choice  O† O† –
B
First choice  B B‡ B or AB
Second choice  O† A or O† –
AB
First choice  AB AB‡ AB
Second choice  A, B A A
Third choice  O†

Br J Haematol. 2004 Feb;124(4):433-53

 Step of Blood Transfusion
Tentukan Pilih
Hitung jumlah
darah/kompon
Indikasi en
volume

Contoh Isi formulir

permintaan
darah darah

Informed Cocokkan Prosedur

darah yang
consent datang bangsal

Pemantau Persiapan
an transfusi

Evaluasi
akhir
 Blood Components
Whole Blood
A blood component is a constituent of blood, separated from whole blood,
such as:
 Red cell concentrate
 Plasma
 Platelet concentrate
 Cryoprecipitate, prepared from fresh frozen plasma; rich in Factor
VIII and fibrinogen
A plasma derivative is made from human plasma proteins prepared under
pharmaceutical, such as:
 Albumin
 Coagulation factor concentrates
 Immunoglobulin

WHO> Clinical Transfusion Practice

2019 Canadian Blood Services.
Blood components product from whole blood.

Fresh whole
Fesh Plasma Pack Red Cell
blood

Platelet rich Platelet

Plasma concentrat
 Blood Transfusion
Red cells are transfused at up to 5 mL/kg/h (unless there is active major
bleeding) and the transfusion should be completed within 4 hours
The typical dose of Platelet for children weighing
≤ 15 kg is 10–20 mL/kg.
>15 kg a single apheresis donation (approximately 300 mL).
The recommended rate of administration is 10–20 mL/kg/h.
Platelets should be ABO-compatible to reduce the risk of haemolysis caused
by donor plasma.
RhD negative girls should receive RhD negative platelets
FFP should not be administered prophylactically in non-bleeding patients or to
‘correct’ minor abnormalities of the PT or APTT before invasive procedures.
When indicated, a dose of 12–15 mL /kg should be administered at a rate of
10–20 mL/kg/h with careful monitoring for acute transfusion reactions or
circulatory overload.
Joint UK Blood Professional Advisory Committee. JPAC. 2021
 
 Suggested rates of transfusion

Duration times for transfusion

WHO. Blood Transfusion Safety. Geneva, 2001

 Sugested Pediatric Tranfusion Dosing
Component Dosage Volume Expected Increment

Red Blood Cells 10-15 mL/kg 3-5 g/dL rise in HB

(RBCs)
Washed RBCs 10-15 mL/kg 3-5 g/dL rise in HB
Plasma 10-15mL/kg 15-20% rise in factor
components* level
Platelets 5-10 mL/kg OR 50000‑100000/µL rise
1 unit/10 kg (patient >10 kg) in platelets
Cryoprecipitated/ 1-2 units/10 kg (volume 1 unit 60-100 mg/dL rise in
AHF maksimal 15 ml fibrinogen
Granulocytes† 10-15 mL/kg Until clinical
(1 -2 × 109 sel PMN utk neonatus) improvement
(1x10 10 PMN utk anak)

Pediatrics in Review May 2020, 41 (5) 259-26

 British Journal of Haematology, 2004, 124, 433–453
WHO. Blood Transfusion Safety. Geneva, 2001
AABB Website. 2021
 RED BLOOD CELL

The decision to transfuse red blood cells should be based on

clinical assessment of the patient

•Use of red blood cells is likely to be inappropriate when

Hb>100g/L (level I evidence).
•Use of red blood cells may be appropriate when Hbis in the
range 70–100g/L (level IV evidence).
•Use of red blood cells is likely to be appropriate when
Hb<70g/L (level IV evidence)

In some patients who are asymptomatic and/or where specific

therapy is available, lower threshold levels may be acceptable.

WHO. Blood Transfusion Safety. Geneva, 2001

 
Transfusion thresholds and other strategies for guiding allogeneic red
blood cell transfusion
.

compared restrictive thresholds

(transfusion not indicated until
the hemoglobin level is 7-8
g/dL) with liberal thresholds
(transfusion not indicated until
the hemoglobin level is 9-10
g/dL).

The findings provide good

evidence that transfusions with
allogeneic RBCs can be
avoided in most patients with
haemoglobin thresholds above
7 g/dL to 8 g/dL.
 RED BLOOD CELL

Transfusion Procedure
 RBCs transfusion of 10-20ml/kg, Hb concentration ↑ 2-
3g/dl
Administered over 1-2 hours, must be completed in 4 hours
Don’t mix blood with other fluid except NS 0,9%
Risk of circulatory overload (+) PRC
 Sign of heart failure: furosemide 1mg/kg (oral) or
0,5mg/kg
Monitoring the signs of: heart failure, febris, respiratory
distress, tachypnea, hypotension, acute transfusion reaction,
hemolysis, bleeding
 British Journal of Haematology, 2004, 124, 433–
453
WHO. Blood Transfusion Safety. Geneva, 2001
AABB Website. 2021
 Guidelines for Pediatric Red Blood Cell Transfusions
CHILDREN AND ADOLESCENTS
1. Maintain stable status with acute loss of >25% of circulating blood
volume
2. Maintain hemoglobin >7.0 g/dL† in the perioperative period
3. Maintain hemoglobin >12.0 g/dL with severe cardiopulmonary disease
4. Maintain hemoglobin >12.0 g/dL during extracorporeal membrane
oxygenation (ECMO)
5. Maintain hemoglobin >7.0 g/dL and symptomatic chronic anemia
6. Maintain hemoglobin >7.0 g/dL and marrow failure
INFANTS ≤4 MO OLD
1. Maintain hemoglobin >12.0 g/dL and severe pulmonary disease
2. Maintain hemoglobin >12.0 g/dL during ECMO
3. Maintain hemoglobin >10.0 g/dL and moderate pulmonary disease
4. Maintain hemoglobin >12.0 g/dL and severe cardiac disease
5. Maintain hemoglobin >10.0 g/dL preoperatively and during major
surgery
6. Maintain hemoglobin >7.0 g/dL postoperatively
21st Edition of Nelson Textbook of Pediatrics
Ali N. Pediatr7. Maintain hemoglobin >7.0 g/dL and symptomatic anemia
Neonatol. 2018;59(3):227–230
Pediatrics in Review May 2020, 41 (5) 259-26
 Indications for RBC Transfusion for the General Critically Ill Child

recommend a RBC transfusion if the Hb concentration is <5 g/dL

those at risk for critical illness, who are hemodynamically stable
and who have an Hb concentration ≥7 g/dL, we recommend not
administering a RBC transfusion. (Strong recommendation,
Moderate quality pediatric evidence (1B))
acute post-operative non-hemorrhagic anemia (excluding cardiac
surgery), who are hemodynamically stable, we recommend not
administering a RBC transfusion if the Hb concentration is ≥7
g/dL
In children with oncologic diagnoses who are critically ill or at
risk for critical illness, and hemodynamically stable, we suggest an
Hb concentration of 7–8 g/dL be considered a threshold for RBC
transfusion
The TAXI Consensus Conference
recommendations
Pediatr Crit Care Med. 2018
 Guidelines for pediatrics platelet transfusion

come in 2 forms:
 random donor platelets, via centrifugation of a whole blood volume of
50 mL and contain 5.5 x1010 platelets per unit (bag)
 single donor units, via apheresis, volume 250 mL and contain 30.0
x1010 platelets per unit.
 do not recommend transfusing more than 6 random donor units or 1
single apheresis unit at a time.
 The posttransfusion goal of most PLT transfusions is to raise the PLT
count well above 50 × 109/L, hopefully to ≥100 × 109/L.
 These increases can be achieved consistently in children weighing up to
30 kg by infusion of 5-10 mL/kg of standard PLT concentrates
 Recipient response to platelet transfusion can be measured usually 10-
60 minutes, after transfusion (a “one hour” post transfusion platelet
count).
A Compendium of Transfusion Practice Guidelines. American Red Cross; 2017
NICE .Blood transfusion (NG24). NICE guideline. 2020
WHO. Blood Transfusion Safety. Geneva, 2001
WHO. Clinical Transfusion Practice. Guidelines for Medical Interns.2020
 Guidelines for Pediatric Platelet Transfusion*
CHILDREN AND ADOLESCENTS
1. Maintain PLT count >50 × 109/L with bleeding
2. Maintain PLT count >50 × 109/L with major invasive procedure;
>25 × 109/L with minor
 (≥ 100,000/μL (100 x 109/L) is recommended prior to neurosurgical and some
ophthalmologic procedures)
3. Maintain PLT count >20 × 109/L and marrow failure WITH hemorrhagic
risk factors
4. Maintain PLT count >10 × 109/L and marrow failure WITHOUT hemorrhagic risk
factors
5. Maintain PLT count at any level with PLT dysfunction PLUS bleeding or invasive
procedure
INFANTS ≤4 MO OLD
1. Maintain PLT count >100 × 109/L with bleeding or during extracorporeal
membrane
oxygenation (ECMO)
2. Maintain PLT count >50 × 109/L and an invasive procedure
3. Maintain PLT count >20 × 109/L and clinically stable
21st 4. Maintain PLT
Edition of Nelson count
Textbook >50 × 109/L and clinically unstable and/or bleeding
of Pediatrics
New5.YorkMaintain PLT
State Council count
on Human at and
Blood anyTransfusion
level with PLT dysfunction PLUS bleeding invasive
Services.2016
Pediatrics in Review May 2020, 41 (5) 259-26
procedure
 Suggested thresholds of platelet counts for platelet transfusion in children

British Journal of Haematology, 2016, 175, 784–828

British Society for Haematology. Guidelines on transfusion for fetuses, neonates and older
Children. 2016
 Prophylactic PLT Transfusion Thresholds

Compendium of Transfusion Practice Guidelines. American Red Cross; 2017

ABB Guideline.2017
Guidelines for pediatric granulocyte
transfusion
Neonates and infants weighing <10 kg should receive 1-2 × 109/kg
neutrophils per each granulocut transfusion (GTX).
Larger infants and small children should receive a minimal total dose of 1 ×
1010 neutrophils per each GTX.
The preferred dose for adolescents is 5-8 × 1010 neutrophils per each GTX, a
dose requiring donors to be stimulated with G-CSF plus dexamethasone.
GTX should be given daily until either the infection resolves or
the blood neutrophil count is sustained above 1.5 × 109/L for a few days.

Because neutrophils transfused per the GTX often passively

increase the blood neutrophil count, it may be necessary to skip 1-2 days of
GTXs to be certain severe neutropenia does not recur, as would be seen if
endogenous myelopoiesis had not recovered.
Guidelines for pediatric granulocyte transfusion

Children and Adolescents

Neutrophils < 0.5 x 109/L and bacterial infection unresponsive to
appropriate antimicrobial therapy
Qualitative neutrophils defect and infection (bacterial or fungal)
unresponsive to appropriate antimicrobial therapy

Infants Within First 4 Mo of Life

Neutrophils < 3.0 x 109 (1 st wk of life) or < 1.0 x 109/L
(thereafter) and fulminant bacterial infection
 
 
 Guidelines for pediatrics FFP transfusion

Guidelines for plasma transfusion in pediatric patients ≈ adults

Plasma for transfusion must be ABO-compatible with the recipient’s red cells
Plasma is usually anticoagulated with citrate and units prepared from whole
blood are approximately 200–250 mL while
apheresis-derived units can contain 400–600 mL.
Plasma dose is determined by patient weight and clinical condition , 10–20
mL/kg patient weight
Plasma contains several anticoagulant proteins (antithrombin III, protein C,
and protein S) whose deficiencies have been associated with thrombosis.

 21st Edition of Nelson Textbook of Pediatrics 

 Guidelines for the transfusion of plasma
Replacement therapy in a bleeding patient or one about to
undergo invasive procedure
When specific factor concentrates are not available, including
but not limited to Factors II, VII, X, and XI, protein C or S
PT/INR >1.5 x mid-range of age-related normal value and/or
PTT >1.5 x top of age-related normal value in a bleeding
patient or one about to undergo invasive procedure
During therapeutic plasma exchange when Plasma is indicated
Reversal of warfarin in an emergency situation, such as before
an invasive procedure with active bleeding  (consider use of
prothombin complex concentrate if available)

 Reprinted with permission from Paediatric

Transfusion: A Physician’s Handbook, 3rd editio
 Guidelines for Pediatric Plasma Transfusions*

1. Severe clotting factor deficiency AND bleeding

2. Severe clotting factor deficiency AND an invasive
procedure
3. Emergency reversal of warfarin effects
4. Dilutional coagulopathy and bleeding (e.g., massive
transfusion)
5. Anticoagulant protein (antithrombin III, proteins C and S)
replacement
6. Plasma exchange replacement fluid for thrombotic
thrombocytopenic purpura

21st Edition of Nelson Textbook of Pediatrics

The indications for plasma in neonates

The indications for plasma in neonates include:

(1) reconstitution of red blood cell (RBC) concentrates to simulate
whole blood for use in massive transfusions (exchange
transfusion,cardiac bypass surgery, and extracorporeal
membrane oxygenation)
(2) hemorrhage secondary to vitamin K deficiency;
(3) Disseminated intravascular coagulation with bleeding; and
(4) bleeding in congenital coagulation factor deficiency when
more specific treatment is either unavailable or inappropriate.
SIDE EFFECTS AND HAZARDS OF BLOOD
TRANSFUSION

Immunologic Complications, Immediate

Immunologic Complications, Delayed
Nonimmunologic Complications
Immunologic Complications, Immediate

1. Hemolytic transfusion reaction, the destruction of transfused red cells, .

2. Immune-mediated platelet destruction, one of the causes of refractoriness to
platelet transfusion, is the result of alloantibodies in the recipient to HLA
or platelet-specific antigens
3. Febrile nonhemolytic reaction is typically manifested by a
temperatureelevation of ≥ 1 C or 2 F
4. Allergic reactions usually occur as urticaria, but may also includ wheezing
or angioedematous reactions respond to antihistamines or, in severe cases,
corticosteroids or epinephrine.
5. Anaphylactoid reactions, are a rare but dangerous complication requiring
immediate treatment with corticosteroids and epinephrine
6. Transfusion-related acute lung injury (TRALI) occurs when acutely
increased permeability of the pulmonary microcirculation causes massive
leakage of fluids and protein into the alveolar spaces andn interstitium,
usually within 6 hours of transfusion
American Red Cross. Practice Guidelines for Blood Transfusion
Immunologic Complications, Delayed

1. Delayed hemolytic reaction

2. Alloimmunization to antigens of red cells, white cells,
platelets, or plasma proteins may occur unpredictably
after transfusion
3. Posttransfusion purpura (PTP) is a rare syndrome
characterized by the development of dramatic, sudden,
and self-limiting thrombocytopenia, typically 7-10
days after a blood transfusion
4. Graft-vs-host disease (GVHD) is a rare but extremely
dangerous

American Red Cross. Practice Guidelines for Blood Transfusion

 Nonimmunologic Complications

1. Transmission of infectious disease

2. Bacterial contamination occurs rarely but can cause acute,
severe,
sometimes life-threatening effects. Onset of high fever (≥2
C or ≥3.5 F rise in temperature), severe chills,
hypotension, or circulatory collapse during or immediately
after transfusion should suggest the possibility of bacterial
contamination and/or endotoxin reaction.
3. Circulatory overload,
4. Hypothermia carries a risk of cardiac arrhythmia or cardiac
arrest.
American Red Cross. Practice Guidelines for Blood Transfusion
Transfusion Reaction Signs and Symptoms

Lotterman S, Sharma S. Blood Transfusion. [Updated 2020 Jul 31]. In:

StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-.
NCBI Bookshelf. A service of the National Library of Medicine, National
Institutes of Health.
 
Summary
 Appropriate use of blood transfusions is an important part of
improving blood safety.
 Safe transfusion need right blood, right patientl, right time
and right dose
 Each blood component should be used for a specific purpose
with therapy targeted to meet specific patient needs
 There will always be risks associated with transfusions BUT

transfusions are only administered when absolutely necessary

THANK YOU