Indications for Transfusion of Whole Blood or Red cell Suspension

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SEVERE ANEMIA

  • Severe anemia in children is dependent on age

CLINICAL FEATURES

SIGNS & SYMPTOMS

  • Pallor
  • Tachycardia
  • Fatigue
  • Respiratory distress

INVESTIGATIONS

  • To confirm anaemia
    • Full blood count/ PCV/ Hb
  • To identify cause of anaemia: 
    • Peripheral blood film
    • Sickling test/Hb electrophoresis
    • Malaria parasites (MPs or Rapid diagnostic test [MRDT])

TREATMENTBlood transfusion

  • Transfusion threshold for severe anemia in children is dependent on age

Neonates

Assisted Ventilation

CPAP/HFNC

Low Flow Oxygen(<3L/Min)

Room air

<28 days 

≥ 28 days

< 28 days 

≥ 28 days

FiO2 ≥ 0.21

Well in room air

FiO2 ≥

0.21

FiO2 <

0.21

Hb < 10g/dL

Hb < 10g/dL

Hb < 8g/dL

Hb < 7g/dL

Hb < 12g/dL

Hb < 11g/dL

RBC Transfusion maybe considered at higher thresholds than the above for neonates requiring acute resuscitation

  • In neonates give 20ml/Kg packed cells over 4 hours
    • Frusemide should not be routinely given
    • Withhold feeds for the duration of transfusion due to the possible risk of transfusion associated NEC
    • Additional IV fluids are not required

Children and infants

  • If Hb < 4 g/dl or PCV <12
  • If Hb < 6 g/dl or PCV <18 with any of the following:
    • Shock or clinically detectable dehydration
    • Impaired consciousness
    • Respiratory acidosis {deep labored breathing}
    • Heart Failure
    • Requiring oxygen for any reason
  • Transfuse 20ml/kg of whole blood or 10ml/kg of packed red blood cells over 4 hours.
  • In severely malnourished children give 10mls/kg of packed cells over 4 hours. Give Frusemide 1mg/Kg at the beginning of the transfusion.
    • A diuretic is usually not indicated because many of these children are usually hypovolemic with a low blood volume.
    • Check the respiratory rate and pulse rate every 15 minutes and if one of them rises, transfuse more slowly.
    • If there is evidence of fluid overload due to the blood transfusion, give extra Frusemide (1-2mg/kg).
    • If severe respiratory distress, consider oxygen therapy with or without CPAP as appropriate.
    • If the Hb remains low following a blood transfusion, repeat the transfusion.

Complications

  • Fluid overload, transfusion reactions and infections.

Referral criteria:

  • If no transfusion services are available at health facility
  • Recurrent anaemia requiring repeated transfusions
  • If anaemia is accompanied by thrombocytopenia, leucopenia, and/or leukocytosis
  • Anaemia with bleeding tendencies

 

NON-SEVERE ANEMIAMICROCYTIC ANAEMIA

Anemia Hb less than 9g/dl and Mean Corpuscular Volume (MCV) less than 70.

  • Causes: Iron deficiency anemia, Thalassemia, Lead poisoning, Copper deficiency, Sideroblastic anemia

Children

  • Young children (less than 6 years) are anemic if their Hb is less than 9 g/dl. Begin treatment unless the child has severe malnutrition, in which case, refer to nutrition chapter.
    • Give treatment with iron for 14 days.
    • Review the child in in 14 days.
    • Continue treatment for 3 months.
    • If the child is ≥1 year and has not received Mebendazole in the previous 6 months, give one dose of Mebendazole 500mg alternatively Albendazole (200mg or 400mg depending on age)
    • Advise the mother about good feeding practice

Pregnancy

  • Refer to Reproductive Health (Chapter 12 Malawi STG)

Adults

  • If Hb less than 7 g/dl
  • If Hb less than 8 g/dl and there are clinical complications

Dose

  • One unit of whole blood or one unit of red cell suspension will raise a patient's hemoglobin by 1-1.5g/dl

Pre-operative Surgery

  • If Hb less than 8 g/dl

Red Flags

  • If suboptimal rise or fall in hemoglobin level after transfusion and there are signs of haemolysis (such as jaundice, raised bilirubin level, lactate dehydrogenase), refer the patient for specialist management.

Vitamin B12 deficiency

  • Transfusion should be avoided unless the patient has symptomatic anaemia and even then, the minimum possible amount of blood or red cell suspension should be transfused e.g., one pediatric unit for an adult patient.

ACUTE HAEMORRHAGE WITH SHOCK (See Section on "SHOCK" Under Management of Emergencies)INTRA-OPERATIVE USE (Where necessary)

Do not use whole blood or red cell suspension transfusion to expand blood volume