Paediatric blood
management is underlined by the basic principles of
maintaining haemoglobin concentration, optimizing haemostasis, and
minimizing blood loss. This article explores these principles and details
further the management of iron deficiency in children. Transfusion of red cells
is necessary in certain situations and this article explains calculations,
practicalities of blood transfusion and consent, as well as the
management of major haemorrhage.
There is evidence in the adult population that
anaemia is associated with poorer post-operative outcomes, longer hospital
length of stay and higher mortality.4 There is now a growing body of evidence
that the same is true of the paediatric population; pre-operative anaemia in
children is associated with worse peri-operative outcomes as well as an
increase in mortality.5 The presence of anaemia pre-operatively is also
associated with an increase in requirement for red cell transfusion in theThe
emphasis during this phase is on the use of tranexamic acid, good surgical
haemostasis and the use of cell salvage when appropriate. These are discussed
in detail below. This is often not practical and the volumes collected in the
paediatric population will often not be sufficient for processing.18This is an
important factor to consider throughout the peri-operative journey. Minimizing
losses through a considered approach to diagnostic laboratory testing must be
employed as well as the use of non-invasive techniques and point-of-care
testing for the monitoring of haemoglobin.2 This is particularly important in
small infants.
This is a point-of-care test that provides a rapid result for the
haemoglobin. The system consists of micro-cuvettes which contain reagents.
Blood is placed in the micro-cuvette and a portable photometer determines the
haemoglobin. It is possible that the result obtained is different from the true
haemoglobin, provided two samples are taken and are analysed and the results
are close then significant errors are unlikely.25speed of result – available
within 45–60 seconds. In a stable child undergoing non-cardiac surgery, without
major co-morbidity or ongoing blood loss, a threshold of 70 g/litre should be used.
This restrictive transfusion practice has no association with an increase in
adverse outcomes and is associated with reduced blood use.13 Decisions to
transfuse should also anticipate any further drop in haemoglobin, especially if
frequent monitoring is not possible. In children undergoing cardiac surgery
with non-cyanotic heart disease a restrictive. As with all aspects of good
medical practice, the individual needs of the patient must be considered. As
outlined previously, in children undergoing elective surgery, a pre-assessment
service allows for appropriate preparation prior to surgery. This provides the
opportunity to ensure that all aspects of patient blood management are
considered preoperatively and allows for these considerations be discussed and
shared with children and their families. The consideration of blood transfusion
and Given the differing size in paediatric patients, from the neonate with a
potentially extremely low birth weight to the teenager, it is clear that one
size does not fit all; measurements in units of blood clearly will not suffice.
We must therefore calculate a volume to transfuse appropriate to the size of
the patient. The below calculation helps us to do this:Volume to transfuse (ml)
= (Desired Hb (g/litre) – Actual Hb (g/litre)) × Weight (kg) × Factor/10A
factor of 4 is often used (but may be Major haemorrhage Trauma is one of the
most common causes of death in children and young people, most notably in the
age groups 1–4 years and 10–19 years.29 The management of major trauma has
developed considerably over the past 20 years and the development of dedicated
trauma centres with standardization of the approach to trauma has improved
outcomes significantly.
