See also
Australian Red Cross Lifeblood
Key Points
- All blood transfusion activity must comply with the relevant hospital procedures and guidelines
- All children must have consent for blood product administration recorded in the medical record prior to transfusion
- A blood transfusion should only be given when the expected benefits to the child are likely to outweigh the potential hazards
Background
Assessment
- A blood product transfusion may be required to treat acute blood loss associated with surgery or trauma, or when the body cannot make enough blood cells in the case of bone marrow failure, cancer or bone marrow suppression
- A blood transfusion should only be given when the expected benefits to the child are likely to outweigh the potential hazards
All children should have consent for blood product administration recorded in the medical record prior to transfusion
Indications for red blood cell (RBC) transfusion
| Hb (g/L) |
Indication |
<70 |
- RBC transfusion is often indicated
- Lower thresholds may be acceptable in children without clinical features, eg tachycardia, flow murmur, lethargy, dizziness, shortness of breath, cardiac failure and where specific therapy (eg iron) is available
|
70-90 |
- RBC transfusion may be indicated, depending on the clinical setting, eg presence of bleeding or haemolysis, clinical signs and symptoms of anaemia
- Uncorrected congenital heart disease
|
>90 |
- RBC transfusion is often unnecessary and may be inappropriate
|
Transfusion may be indicated at higher thresholds for specific situations:
- Children with haemoglobinopathies (eg thalassaemia or sickle cell disease) or congenital anaemia on a chronic transfusion program
|
Indications for platelet transfusion
Prophylactic platelet transfusions
| Indication |
Transfusion threshold |
Hospitalised, non-bleeding child |
10 x 109/L |
Critical illness |
10 x 109/L |
Reversible or chronic bone marrow failure (disease or therapy-related eg chemotherapy/HSCT) |
10 x 109/L |
Reversible or chronic bone marrow failure or critical illness with additional risk factors for bleeding
- Mucositis
- Fever
- Sepsis/infection
- Disseminated intravascular coagulopathy
- APML
- Anticoagulation
|
20 x 109/L
|
Solid organ tumours |
10 x 109/L |
Tumour location (eg brain/bladder), risk of bleeding or risk of local tumour invasion |
Individualised decision making
(10-30 x 109/L) |
Immune-mediated thrombocytopaenia (eg ITP, HIT, TTP/HUS) |
Not indicated |
Congenital thrombocytopenia |
Individualised decision making |
Therapeutic use
| Indication |
Transfusion threshold |
Minimal* bleeding |
30 x 109/L |
Moderate* bleeding |
50 x 109/L |
Severe* bleeding |
75 x 109/L |
Intracranial haemorrhage or retinal haemorrhage |
100 x 109/L |
Massive haemorrhage protocol |
75 x 109/L |
Bleeding associated with cardio-pulmonary bypass |
100 x 109/L |
*See Simplified Bleeding Assessment Scale in Critically Ill Children (BASIC) below
Pre-procedure
|
Indication |
Transfusion threshold |
Intramuscular injection |
20 x 109/L |
CVC insertion (non-tunnelled) |
20 x 109/L |
Lumbar puncture# |
30 x 109/L |
Lumbar puncture (initial diagnostic for malignancy) |
50 x 109/L |
NG insertion |
30 x 109/L |
CVC insertion (tunnelled line) |
50 x 109/L |
Major surgery |
50 x 109/L |
High risk surgery (eg neurosurgery or ophthalmology) |
100 x 109/L |
Bone marrow aspirate or trephine biopsy |
Not indicated |
Peripheral IV insertion |
Not indicated |
#Clinicians may consider transfusing at higher counts eg 50 x 109/L based on additional clinical features (eg bleeding risk, patient age and weight)
Simplified Bleeding Assessment Scale in Critically Ill Children (BASIC)
Severe bleeding |
ANY of the following criteria |
- Bleeding leading to at least one organ dysfunction within 24 hours
- Bleeding leading to haemodynamic instability (HR increase >20% from baseline or BP decrease >20% from baseline)
- Bleeding causing Hb drop >20% within 24 hours
- Quantifiable bleeding ≥5 mL/kg/hr for ≥1 hour (eg chest tube, drain)
- Intraspinal bleeding with loss of neurological function
- Non-traumatic intra-articular bleeding with decreased range of movement
- Intraocular bleeding impairing vision
|
Moderate bleeding |
ALL of the following criteria: |
- More than minimal bleeding but not meeting criteria for severe bleeding
- Bleeding not leading to organ dysfunction
- Bleeding not causing haemodynamic instability
- Bleeding leading to a drop of Hb ≤20%
- Quantifiable bleeding ≥1 mL/kg/hr but <5 mL/kg/hr (eg chest tube, drain)
|
Minimal bleeding |
ANY of the following criteria: |
- Streaks of blood in endotracheal tube (ETT) or during suctioning
- Streaks of blood in nasogastric (NG) tube
- Macroscopic haematuria or ≤1+ red blood cells on urine dipstick
- Subcutaneous bleeding (including haematoma and petechiae) <5 cm in diameter
- Quantifiable bleeding <1 mL/kg/hr (eg chest tube, drain)
- Bloody dressings requiring changing <6 hourly or weighing <1 mL/kg/hr
|
Adapted from Nellis ME et al. Bleeding Assessment Scale in Critically Ill Children (BASIC): Physician-Driven Diagnostic Criteria for Bleeding Severity. Crit Care Med. 2019 47(12):1766-1772
Indications for fresh frozen plasma (FFP) transfusion
FFP is appropriate for:
- Acute bleeding in the setting of significant coagulopathy
- Warfarin reversal, in the presence of significant or life-threatening bleeding (eg intracranial haemorrhage) in addition to vitamin K and prothrombinex
- Liver disease, with clinically significant bleeding in the context of coagulopathy
- Acute DIC with bleeding and significant coagulopathy
- During massive haemorrhage
- During or post-cardiac bypass for the treatment of bleeding
- Plasma exchange for the treatment of TTP
- Specific factor deficiencies where a factor concentrate is not available
FFP is NOT indicated for:
- Correction of minor coagulation abnormalities (minor prolongation of the INR/APTT) in a non-bleeding child
- Liver disease when there are minor coagulation abnormalities in a non-bleeding child
- For reversal of an INR <2.0 in children undergoing minor procedures
Indications for Cryoprecipitate transfusion
Cryoprecipitate is indicated for:
- Active bleeding and fibrinogen level <1.5 g/L
- During massive haemorrhage when fibrinogen level <1.5 g/L or there is hyperfibrinolysis
- During or post-cardiac bypass, for the treatment bleeding when the fibrinogen level <1.5 g/L or there is hyperfibrinolysis
- Acquired fibrinogen deficiency or acute DIC when there is significant bleeding and the fibrinogen <1.0 g/L
- Prior to an invasive procedure when the fibrinogen <1.0 g/L and there is a risk of significant bleeding associated with the surgery or it is at a critical site (eg neurosurgery or eye surgery)
Cryoprecipitate is NOT indicated for:
- Non-bleeding children with mildly reduced fibrinogen levels
- Liver disease when there are minor coagulation abnormalities and no active bleeding
Management
Transfusion volume and rate guidance
Transfusion volumes in non‐bleeding infants and children
- Maximum prescribed volume should not be greater than the volume for equivalent adult transfusions
- Red cell transfusion volumes in child >20 kg: 1 red cell unit
- Platelet transfusion volumes in child >15 kg: 1 platelet unit
- In infants and children <20 kg, transfusion volumes should be
- calculated based on weight, desired and actual Hb
- prescribed in mL
- maximum Hb increment should be 20 g/L
- In infants and children <15 kg, platelets should be prescribed in mL (10 mL/kg)
Transfusion duration/rate
- The duration/rate of the transfusion must be appropriate with the child’s clinical need, eg in a critical bleeding event, transfuse as fast as clinically indicated
- Transfusion must be completed within four hours of the product leaving blood bank
Transfusion volumes and rate calculation
|
Calculating transfusion volume |
Typical unit volume |
Transfusion rate |
Red cells |
<20 kg: Calculate using formula:
mL = wt (kg) x 0.5 x Hb (g/L) rise (desired Hb – actual Hb)
Eg:
10 kg child requiring Hb rise from 60 g/L to 80 g/L
10 x 0.5 x 20 = 100 mL |
Red cell unit ~260 mL
Paediatric (Pedi-Pak®) ~60 mL
|
5 mL/kg/hr
Consider commencing at slower rate (eg half prescribed rate) for first 15 minutes
Usual maximum rate ~150 mL/hr |
>20 kg: 1 unit and re-assess |
Platelets |
<15 kg: 10 mL/kg |
Apheresis ~210 mL
Pooled ~270 mL
Paediatric (pedipak) ~55 mL |
10-20 mL/kg/hr
Faster transfusion rates (eg transfused over 30 minutes) may result in a transfusion reaction |
>15 kg: 1 unit |
FFP |
All children: 10-20 mL/kg |
FFP ~277 mL
Paediatric (pedipak) ~67 mL |
10-20 mL/kg/hr |
Cryoprecipitate |
All children: 5-10 mL/kg |
Cryoprecipitate (whole blood) ~36 mL (10 mL/kg)
Cryoprecipitate (apheresis) ~60 mL (5 mL/kg) |
10-20 mL/kg/hr |
Note: blood bank will issue blood products based on the medical order, ABO/RhD, modification requirements and availability |
Blood product modifications
Request the appropriate blood component and special requirements. Additional information on modifications can be found at the Australian Red Cross Lifeblood
- Irradiated blood products
- Should be given to all immuno-compromised children, including all immunology and oncology patients, preterm and low birth weight neonates, neonates with cardiac disease, HLA-matched products and directed blood donations to prevent transfusion-associated graft-versus host disease
- CMV negative products
- CMV negative products are only indicated for neonatal exchange transfusion, transfusions to preterm and term neonates up to 28 days post-term, pregnant women and children with severe combined immunodeficiency disease (SCID) who are CMV negative
- See local guidelines (eg RCH local guidance)
- Note: Leucocyte depleted blood products are considered an acceptable alternative to CMV seronegative products at RCH
- Phenotype matched red blood cells
- Indicated for children who are chronically transfused or with red cell alloantibodies
- IgA deficient products
- Children with IgA deficiency who have developed an anti-IgA antibody
- HLA matched platelets
- For children with thrombocytopaenia who are refractory to random donor platelets due to HLA antibodies
Consider consultation with local paediatric/haematology team when
Any child where the blood production prescription is uncertain or further advice is required
Consider transfer when
Child requires care beyond the level of comfort of the local hospital or treating medical team
For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services
Parent information
Blood product transfusions (RCH)
Blood transfusions for babies (Australian Red Cross)
Blood transfusions for children (Australian Red Cross)
Additional notes
Information specific to Royal Children’s Hospital
Information specific to Sydney Children’s Hospital Network (SCHN)
Last updated November 2023