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Recommendations on RBC Transfusions in Critically Ill Children With Acute Respiratory Failure From the Pediatric
Pierre Demaret1, Guillaume Emeriaud2, Nabil E Hassan3
1Division of Pediatric Critical Care Medicine, Department of Pediatrics, CHC, Liège, Belgium.
Insights
Recommendations for red blood cell (RBC) transfusions in critically ill children with respiratory failure are presented. RBC transfusions are strongly recommended for hemoglobin levels below 5 g/dL but not for stable patients with levels above 7 g/dL.
Area of Science:
- Pediatric Critical Care Medicine
- Hematology
- Transfusion Medicine
Background:
- Critically ill children with bleeding require specific transfusion guidelines.
- The Pediatric Critical Care Transfusion and Anemia Expertise Initiative convened experts to address this need.
- Evidence-based and expert-based recommendations were developed for red blood cell (RBC) transfusions.
Framework:
- A consensus conference involving 38 multidisciplinary experts was conducted.
- Literature searches spanned from 1980 to May 2017 across major databases.
- The Research and Development/UCLA Appropriateness Method ensured expert agreement.
Implementation:
- Seven recommendations focused on pediatric acute respiratory failure.
- Strong recommendation for RBC transfusion if hemoglobin < 5 g/dL.
- Strong recommendation against routine RBC transfusion if hemodynamically stable with hemoglobin ≥ 7 g/dL.
Implications:
- Guidelines address hemoglobin thresholds for RBC transfusion in pediatric respiratory failure.
- Research priorities include identifying physiologic thresholds and transfusion alternatives.
- Further evidence is needed for specific subpopulations of critically ill children.
Objectives:
To present the recommendations and supporting literature for RBC transfusions in critically ill children with bleeding developed by the Pediatric Critical Care Transfusion and Anemia Expertise Initiative.
Design:
Consensus conference series of international, multidisciplinary experts in RBC transfusion management of critically ill children.
Methods:
The panel of 38 experts developed evidence-based and, when evidence was lacking, expert-based clinical recommendations as well as research priorities for RBC transfusions in critically ill children. The respiratory subgroup included six experts. Electronic searches were conducted using PubMed, EMBASE, and Cochrane Library databases from 1980 to May 2017. Agreement was obtained using the Research and Development/UCLA Appropriateness Method. Results were summarized using the Grading of Recommendations Assessment, Development, and Evaluation method.
Results:
Transfusion and Anemia Expertise Initiative experts developed seven recommendations focused on children with acute respiratory failure. All recommendations reached agreement (> 80%). Transfusion of RBCs in children with respiratory failure with an hemoglobin level less than 5 g/dL was strongly recommended. It was strongly recommended that RBCs not be systematically administered to children with respiratory failure who are hemodynamically stable and who have a hemoglobin level greater than or equal to 7 g/dL. Experts could not make a recommendation for children with hemodynamic instability, with severe hypoxemia and/or with an hemoglobin level between 5 and 7 g/dL. Specific RBC transfusion strategies using physiologic-based metrics and biomarkers could not be elaborated.
Conclusions:
The Transfusion and Anemia Expertise Initiative Consensus Conference developed specific recommendations regarding RBC transfusion management in critically ill children with respiratory failure, as well as recommendations to guide future research. Clinical recommendations emphasize relevant hemoglobin thresholds. Research recommendations emphasize the need to identify appropriate physiologic thresholds, suggest a better understanding of alternatives to RBC transfusion, and identify the need for better evidence on hemoglobin thresholds that might be used in specific subpopulations of critically ill children.
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