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RBC Transfusion thresholds for pediatrics


Townsend

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We’d like some input from other pediatric hospitals (or those who transfuse pediatric and neonatal patients) on rbc indications as we further develop our patient blood management program:

·        What are your indications for rbc transfusions? (Hgb thresholds/other justifications for ordering practices)

·        Do you monitor those justifications, and if so, what is your compliance rate and goal?  (i.e. % RBC txns below 8g/dL – usually at 60-70% with a goal of 80%)

Thanks so much for your time!

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  • 2 years later...

What age range are you talking about - when I was in a paed hospital the cutoffs for under 5s were much higher (ie early transfusion) if the Hb was low enough to cause cognitive issues, or depletion of B12/folate from natural replacement. For neonates higher still.

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In general, based upon the randomized trials, don't even think about transfusing non-bleeding patients with adequate marrow function above 7 g/dl or hematocrit 21%.  More harm than benefit. For premature newborns, different guidelines, and each neonatalogist has his or her own ideas.  But the guidelines in the literature are way too high with no evidence of benefit, as for most transfusions these days.  A moving target and often a controversial area with more dogma than data.

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I'm the supervisor at a children's hospital in Central California and here are our indications for the transfusion of RBCs:

Neonates: Term and near term neonates and infants < 4 months of age*

Hgb/Hct < 7g/dl / 21%

         Stable anemia with no clinical manifestations

Hgb/Hct < 10 g/dl / 30%

         Moderate cardiopulmonary disease

         Major surgery

         Increased oxygen (FiO2) requirement <35%, on CPAP lower setting

         Significant apnea or bradycardia, tachycardia or tachypnea

         Low weight gain

Hgb/Hct <12 g/dl / 35%

         Fi02 requirement greater than 35%, on CPAP higher setting

         Recovering from major surgery

         Severe traumatic brain injury

         Significant deterioration of cardiorespiratory status

Hgb/Hct < 15 g/dl / 45%

         FiO2 requirement > 35%

         Severe cardiopulmonary disease or congenital heart disease

         On extracorporeal membrane oxygenation (ECMO)

*No clear transfusion RBC threshold guideline for low birth weight neonates (BW <1500gm) is available. Randomized clinical trial (Transfusion of Prematures) was started in 2013 and is ongoing.

 

Pediatric patients >4 months old through adult

Not bleeding

Reasonable in almost all patients if Hgb/Hct < 7 g/dl / 21%

Almost never indicated if Hgb/Hct >10 g/dl / 30% unless patient is on ECLS

For Hgb between 7-10 g/dl (Hct between 21-30 %):

         Based on organ dysfunction and ability to handle inadequate oxygenation

         Respiratory or cardiac failure

         Chronic disorders of red cell production, severe platelet dysfunction

         Oncology patients

Intra/perioperative conditions or significant bleeding

         Rapid blood loss exceeding >15% blood volume

         Intraoperative period as clinically determined by anesthesiology and/or surgeon

         Immediate postoperative period to restore hemodynamic stability

 

We have built an alert in Epic with our "Prepare RBC" orders (both in mL and in Units) that warns the provider whenever they are placing an RBC order on a patient with a most recent Hgb value > 7 g/dl (or there is no recent Hgb value in the computer on that patient).  This alert must be overridden with a reason from this drop down menu (below) in order for the provider to continue placing the order.  We can run a report on all transfusions that triggered an Override when the order was placed (that also lists out the trigger value, the override reason, and the patient's problem list) and then the medical director performs an appropriateness review on only those outliers.

BPA Overrides: RBC Orders (in mL) and (in Units):

Warning if: No Hgb result or Most recent Hgb > 7 g/dl

Appropriate criteria:

Neonate w/Cardiopulmonary Disease

Respiratory or Cardiac Failure

ECLS Patient

Sickle Cell Patient

Thalassemia Patient

Active Chemotherapy/Immunosuppressed Patient

Hematopoietic Disorder

Rapid Blood Loss

HOLD for Pre-Op/Procedure

Post-Op Hemodynamic Instability

Other – specify as Comment

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