Error traps in pediatric patient blood management in the perioperative period
Genie Heitmiller MD, Lynne Maxwell MD
Over the past 40 years, efforts to improve the safety of blood products have been successful in reducing infectious risks of transfusion. Because blood products are an extremely valuable, lifesaving, and often scarce resource, and because transfusion can be associated with life-threatening adverse events, transfusion plans require careful decision making. More recent efforts to improve the safety of blood product transfusion include Patient Blood Management (PBM), a patient-centered, evidence-based approach that addresses iron deficiency, anemia, coagulopathy, and blood loss, in both surgical and nonsurgical patients. Implementation of PBM is supported by the World Health Organization, The Joint Commission, and the American Society of Anesthesiologists (ASA).1 Today’s PAAD by Tan et al.2 focuses on the utility of the PBM concept for pediatric patients during the perioperative period to emphasize the importance for multimodal blood conservation strategies. The authors, who are all well-known for their expertise in transfusion therapy, describe five error traps and solutions in blood management for pediatric patients during the perioperative period.
Original Article
Tan GM, Murto K, Downey LA, Wilder MS, Goobie SM. Error traps in Pediatric Patient Blood Management in the Perioperative Period. Paediatr Anaesth. 2023;33: 609-619.
PMID: 37144721.
ERROR TRAP 1: FAILURE TO RECOGNIZE AND TREAT PREOPERATIVE ANEMIA
Anemia is reported to occur in over 40% of children world-wide and in 25% of school-age children in industrialized countries. Since preoperative anemia is an independent predictor of intraoperative blood transfusions and postoperative complications, the Choosing Wisely statement from the Society for the Advancement of Patient Blood Management Pediatric and Neonatal Medicine recommends: Don't proceed with non-emergent major surgery until anemia is evaluated and treated. Additionally, expert consensus guidelines from the Society for the Advancement of Blood Management and the National Blood Authority of Australia recommend screening for anemia at least 3–6 weeks before major elective surgery. Because the Choosing Wisely campaign also recommends to NOT perform routine preoperative testing before low or moderate risk procedures in patients without significant pre-existing disease,3 this screening is pertinent only for patients undergoing surgery expected to have significant blood loss such as elective cardiac, spine, major abdominal, or neuro surgery. In those cases, treating anemia preoperatively (e.g., with erythropoietin) and delaying surgery, whenever possible, until the hemoglobin is optimized is becoming standard of care. The question remains that if the lower limit of normal hemoglobin in children is 11 g/dL, then do we postpone and treat for any hemoglobin less than 11 g/dL in patients scheduled for such surgeries? Guidelines remain vague on this question.
ERROR TRAP 2: FAILURE TO OBTAIN INFORMED CONSENT REGARDING BLOOD CONSERVATION STRATEGIES AND OPTIMAL BLOOD COMPONENT USE
The authors note the importance of obtaining both informed consent and assent for transfusions and for strategies to reduce need for transfusion, such as preoperative treatment with iron and erythropoietin, acute normovolemic hemodilution, cell salvage, and use of tranexamic acid. Consent for transfusion in many institutions is obtained by the surgeon, but the authors suggest that transfusion discussion and consent be the anesthesiologists’ responsibility. Explaining risks, benefits, and alternatives to blood transfusion to pediatric patients and their parents/legal guardians ideally makes sense. How much do we tell them? Although not discussed in the article, do we discuss the possibility of hyperkalemia resulting in cardiac arrest and the possibility of clerical error resulting in a fatal blood transfusion reaction? And what happens if the parents refuse transfusion because of religious beliefs? Do we go ahead anyway or leave it up to state law to decide? And what if the parents agree to transfusion but the pediatric patient refuses?
ERROR TRAP 3: FAILURE TO CONSIDER SPECIFIC INTRAOPERATIVE BLOOD CONSERVATION TECHNIQUES IN CHILDREN
Blood conservation techniques such as acute normovolemic hemodilution (ANH) and cell salvage have been around for decades. Guidelines exist for adults, but not for pediatric patients, which is why these techniques aren’t used routinely in children. Additionally, these techniques are reserved for procedures with substantial blood loss and require resources, technology, and education (especially for ANH) that may not be readily available. Fortunately, the use of tranexamic acid is standard for cardiac, spine fusion and neurosurgical procedures - as long as it’s not on shortage!
ERROR TRAP 4: FAILURE TO RECOGNIZE AND TREAT LIFE-THREATENING HEMORRHAGE IN CHILDREN
Massive hemorrhage protocols (MHP), more commonly termed massive transfusion protocols (MTP), are necessary and lifesaving. The authors list seven key MHP elements and highlight guidelines for administration of RBC’s, but do not include guidelines for transfusion of fresh frozen plasma and platelets as part of the MHP. The American College of Surgeons Children’s Surgical Verification program has a standard (requirement) for Level I pediatric facilities to have a written massive transfusion protocol (MTP) with specific weight-based availability and administration of blood components.
ERROR TRAP 5: FAILURE TO PREVENT UNNECESSARY TRANSFUSION AND RECOGNIZE THE RISKS OF OVER-TRANSFUSION
One of the biggest questions over the years is when is it necessary to transfuse an anemic patient who is stable? If there is no trigger number and the patient has normal vital signs and mentation (in the conscious patient), do we allow the hemoglobin to drop below 6? 5? 4? What is the long-term impact on healing and on postoperative activity level? The authors emphasize the necessity to consider the full clinical context/physiological state, not just the hemoglobin value (assessment of blood pressure, perfusion, shock) in the decision to transfuse. There is no clear consensus on a definitive hemoglobin value (trigger) for transfusion.4 The authors do refer to hemoglobin guidelines published in the pediatric critical care literature5 which recommend clinical correlation for hemoglobin 5-7 g/dL, not transfusing for those who are clinically stable with hemoglobin > 7 g/dL, and not transfusing patients with hemoglobin > 9 g/dL. But they also agree with the Society for the Advancement of Blood Management recommendation: “Avoid dependence on standard laboratory values for transfusion decisions. Consideration of the patient’s clinical status is requisite.” And “In general, recommendations for pediatric patients (excluding neonates) suggests that a hemoglobin threshold transfusion target of 7 g/dL (70 g/L) is appropriate in a hemodynamically stable well compensated patient and for a hemoglobin concentration of > 9 g/dL (90 g/L), red blood transfusion is unnecessary and inappropriate”6, 7
We were concerned that notable and common error traps omitted by the authors that merit serious consideration when transfusing pediatric patients include: 1) the relationship between the duration of blood storage and the incidence of hyperkalemia and associated considerations for washing stored blood before administration, 2) issues of blood irradiation, 3) Association for the Advancement of Blood & Biotherapies requirements for second patient blood samples for blood issuance, 4) need for strict protocols for patient identification and assurance of accuracy of compatibility/matching of supplied blood prior to administration to avoid errors, 5) standards for safe storage of blood products outside of the blood bank, 6) circumstances meriting use of emergency un-crossmatched blood products (O negative) and risks, 7) advantages of and circumstances for use of fresh whole blood, and 8) the failure to discuss errors with transfusion devices including blood warmers, cell savers, rapid infusers, and blood filters.
We think an excellent review of a Pediatric Blood Transfusion Therapy and Patient Blood Management SPA Workshop can be found in the 2019 Fall issue of the SPA Newsletter.8 This review of the workshop held at the 2019 SPA/AAP meeting, and which included a talk on PBM by today’s PAAD senior author, Susan Goobie, provides detail on use of filters and blood warmers, use of low-titer, type O, whole blood, and includes more detail on MTP with regards to transfusion of plasma and platelets.
Finally, in a recent PAAD we reviewed a useful algorithm and weight-based pre-filled table to facilitate calculation of safe and effective volumes for transfusion of red blood cells in children and are working on incorporating it into the Pedi Crisis app.9
PS from Myron: Today’ article and the articles listed in the reference list would make a great journal club and are must reads for new trainees who are starting out their fellowships this month. If you have thoughts about the article or the references please send to me and I will post in a Friday Reader response.
References
1. Practice guidelines for perioperative blood management: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Blood Management*. Anesthesiology. Feb 2015;122(2):241-75. doi:10.1097/aln.0000000000000463
2. Tan GM, Murto K, Downey LA, Wilder MS, Goobie SM. Error traps in Pediatric Patient Blood Management in the Perioperative Period. Paediatric anaesthesia. Aug 2023;33(8):609-619. doi:10.1111/pan.14683
3. Becke K, Eich C, Höhne C, et al. Choosing Wisely in pediatric anesthesia: An interpretation from the German Scientific Working Group of Paediatric Anaesthesia (WAKKA). Paediatric anaesthesia. Jul 2018;28(7):588-596. doi:10.1111/pan.13383
4. Wittenmeier E, Komorek Y, Engelhard K. Current hemoglobin thresholds in pediatric anesthesia - guidelines and studies. Current opinion in anaesthesiology. Jun 1 2023;36(3):301-310. doi:10.1097/aco.0000000000001253
5. Valentine SL, Bembea MM, Muszynski JA, et al. Consensus Recommendations for RBC Transfusion Practice in Critically Ill Children From the Pediatric Critical Care Transfusion and Anemia Expertise Initiative. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies. Sep 2018;19(9):884-898. doi:10.1097/pcc.0000000000001613
6. Downey LA, Goobie SM. Perioperative Pediatric Erythrocyte Transfusions: Incorporating Hemoglobin Thresholds and Physiologic Parameters in Decision-making. Anesthesiology. Nov 1 2022;137(5):604-619. doi:10.1097/aln.0000000000004357
7. Goobie SM, Gallagher T, Gross I, Shander A. Society for the advancement of blood management administrative and clinical standards for patient blood management programs. 4th edition (pediatric version). Paediatric anaesthesia. Mar 2019;29(3):231-236. doi:10.1111/pan.13574
8. Klein NJ. Pediatric blood transfusion therapy and patient blood management. Society for Pediartric Anesthesia Newsletter,. 2019;32(2):1-10. Accessed 07/24/2023. https://www2.pedsanesthesia.org/newsletters/2019fall/blood%20transfusion.html
9. Piekarski F, Noone S, Engelhardt T, et al. Evaluation of a Pre-Filled Table and a Flowchart-Based Algorithm as Cognitive Aids to Reduce Deviations in Dose Calculation for Intraoperative Red Blood Cell Transfusions in Children-An International Web-Based Simulation. Children (Basel). Apr 29 2023;10(5)doi:10.3390/children10050815