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Transfusion in critically ill children: indications, risks, and challenges
11Department of Pediatrics, Stony Brook University School of Medicine, Stony Brook, NY. 2Pediatric Hematology/Oncology, Stony Brook Long Island Children's Hospital, Stony Brook, NY.
Insights
Restrictive transfusion practices are evidence-based for pediatric patients, yet implementation varies. Current use of platelet and plasma transfusions often exceeds guidelines, highlighting a need for better adherence to transfusion protocols.
Area of Science:
- Pediatric critical care medicine
- Transfusion medicine
- Hematology
Background:
- Transfusion practices in critically ill children require careful consideration due to unique physiological factors.
- Evidence-based guidelines for pediatric transfusions are evolving, necessitating a review of current practices.
Purpose of the Study:
- To review transfusion-related issues and practices in pediatric patients, especially those critically ill.
- To highlight discrepancies between evidence-based recommendations and clinical application.
Main Methods:
- Comprehensive electronic search of PubMed for pediatric transfusion literature since 2000.
- Manual review of selected articles and their bibliographies for relevant data and conclusions.
Main Results:
- Restrictive transfusion practices for packed red blood cells (RBCs) are supported by strong evidence across pediatric age groups and illnesses.
- Clinical implementation of restrictive RBC transfusion strategies is inconsistent.
- Platelet and plasma transfusion use, both prophylactic and therapeutic, often exceeds evidence-based support.
Conclusions:
- A restrictive packed RBC transfusion policy is recommended for most pediatric conditions based on robust trial data.
- Neonatal transfusion guidelines lack strong experimental data, relying on expert opinion.
- Current practices for transfusing platelets and plasma products are often misaligned with established guidelines, indicating a need for improved adherence to evidence-based transfusion medicine.
Objective:
To provide a concise review of transfusion-related issues and practices in the pediatric patient population, with a focus on those issues of particular importance to the care of critically ill children.
Data Source:
Electronic search of the PubMed database using the search terms "pediatric transfusion," "transfusion practices," "transfusion risks," "packed red blood cell transfusion," "white blood cell transfusion," "platelet transfusion," "plasma transfusion," and "massive transfusion" either singly or in combination.
Study Selection And Data Extraction:
All identified articles published since 2000 were manually reviewed for study design, content, and support for indicated conclusions, and the bibliographies were scrutinized for pertinent references not identified in the PubMed search. Selected studies from this group were then manually reviewed for possible inclusion in this review.
Data Synthesis:
Well-designed studies have demonstrated the benefit of "restrictive" transfusion practices across the entire age spectrum of pediatric patients across a wide spectrum of pediatric illness. However, clinician implementation of the more restrictive transfusion practices supported by these studies is variable. Additionally, the utilization of both platelet and plasma transfusions in either a "prophylactic" or "therapeutic" setting appears to be greater than that supported by published data.
Conclusions:
The preponderance of prospective, randomized trials and retrospective analyses support the use of a restrictive packed RBC transfusion policy in most clinical conditions in children. Neonatal transfusions guidelines rely largely on "expert opinion" rather than experimental data. Current transfusion practices for both platelets and coagulant products (e.g., fresh-frozen plasma and recombinant-activated factor VII) are poorly aligned with recommended transfusion guidelines. As with adults, current transfusion practices in children often do not reflect implementation of our current knowledge on the need for transfusion. Greater efforts to implement current evidence-based transfusion practices are needed.
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