Pediatric Patient Blood Management: Unique Considerations
Myron Yaster MD, Genie Heitmiller MD, Allison Kinder Ross MD, and Susan M. Goobie MD FRCPC
The June 2025 issue of the ASA Monitor has seve ral terrific articles devoted to patient blood and transfusion medicine. In the July 2, 2025PAAD, we reviewed basic information on blood product safety and availability including the use of whole blood to simplify trauma resuscitation and decrease time to transfusion, cold storage of platelets which may offer improved hemostatic function and reduced infection risk while also improving inventory constraints and new fibrinogen replacement products that may improve accessibility while also decreasing waste.
In today’s PAAD, we will discuss the unique considerations of pediatric patient blood management.1 And I would urge all of you in teaching institutions to take advantage of the PAAD while working with students in the OR today. Test your own and their knowledge just as I did in writing this PAAD. I compared the ASA Committee of PBM (COPBM) pediatric recommendations (Murto et al.) to those in the Society for Pediatric Anesthesia’s PediCrisis V 2 app on Massive Hemorrhage Management and found several differences. The former addresses blood conservation and goal-directed transfusion management, and the latter concerns critical bleeding and fixed-ratio transfusion management. Why not do the same when you read it? Myron Yaster MD
Original article
Murto, Kimmo MD, FRCPC; Downey, Laura MD; Goobie, Susan M. MD, FRCPC. Pediatric Patient Blood Management: Unique Considerations. ASA Monitor 89(6):p 15-17, June 2025. | DOI: 10.1097/01.ASM.0001118148.27159.c1
“Patient blood management (PBM) is founded on three key pillars, which aim to optimize and improve red blood cell (RBC) mass by: treating and preventing preoperative and iatrogenic anemia (Pillar 1); minimizing surgical, procedural, and iatrogenic blood loss while optimizing coagulation (Pillar 2); and maximizing patient-specific physiological tolerance of anemia and coagulopathy using restrictive transfusion thresholds (Pillar 3) (figure from article).1
“Pediatric PBM optimizes a child's own blood, minimizes unnecessary transfusions, and employs age/weight-specific conservation strategies. Neonates, infants, children, and adolescents each have distinct physiological responses to blood loss and transfusion, requiring individualized management based on total blood volume, hemodynamic stability, and developmental differences in coagulation and metabolism.2 Pediatric patients are also more vulnerable to both short- and long-term transfusion-related complications, including dose-dependent risks, immunomodulatory effects, and underrecognized noninfectious hazards.”1
Because by design the PAADs are 5-6 minute reads, we will concentrate only on the 2nd pillar, namely, minimizing surgical, procedural, and iatrogenic blood loss while optimizing coagulation. This focuses on blood conservation efforts, goal-directed transfusion management and optimal blood use. This would be a good time to open the PediCrisis app as well.
“Intraoperative blood conservation using evidence-based restrictive transfusion protocols guided by hemodynamic stability and monitoring for impaired end-organ oxygen delivery is a critical component of pediatric PBM. Antifibrinolytic agents, such as tranexamic acid (TXA) and epsilon aminocaproic acid, reduce blood loss and transfusion needs in pediatric trauma and surgical settings including, but not limited to, cardiac, scoliosis, and craniosynostosis repair.3 In high blood loss pediatric surgeries, preemptive, acute normovolemic hemodilution can be used to conserve blood by removing and replacing it with crystalloids or colloids. However, acute normovolemic hemodilution requires an adequate RBC mass to start, making it unsuitable for emergencies, patients with preexisting cardiac or pulmonary disease, or those who are severely anemic or hypovolemic.4 Meticulous use of intraoperative autologous cell salvage has been shown to significantly reduce RBC transfusions in cardiac and noncardiac surgeries in infants and children, although its role in avoiding allogenic blood transfusions has not been demonstrated.5 The debate remains regarding use in cancer surgery or contaminated/infected surgical fields and a leukocyte reduction filter is recommended, while considering the risks and benefits, in these situations. While viscoelastic testing can complement conventional coagulation testing to provide individualized, goal-directed transfusion therapy, no viscoelastic testing devices are currently FDA-approved for pediatric use. Finally, as described in the table, optimizing coagulation through meticulous surgical hemostasis, minimally invasive surgical techniques, use of topical hemostatic agents and/or considering recombinant products such as fibrinogen concentrate can further reduce procedural blood loss and minimize allogeneic blood product transfusion .”1 Patient Blood Management Guidelines can be used in critical bleeding situations to promote Optimal Blood Use (giving the right product, to the right patient, at the right time, for the right reason) together with Massive Hemorrhage Protocols.
The PediCrisis app for massive hemorrhage management recommends the following: After declaring an emergency and calling for help, notify the blood bank, send a blood sample for type and cross, and activate the institutional massive transfusion protocol (consider RBC:FFP:Platelets 2:1:1 or 1:1:1). Use un-crossmatched O negative blood until crossmatched blood is available. Consider intraoperative blood salvage (Cell Saver). Watch for hyperkalemia! If needed, give calcium gluconate 60 mg/kg. Warm the room. Send labs every 30 minutes for hemoglobin, platelets, PT/PTT, rapid TEG, arterial blood gas, Na, K, Ca, and lactate. Use 140 micron blood filter for all products. RBC and FFP should be given through a blood warmer but not platelets. Consider TXA 10-30 mg/kg IV bolus, than 5-10 mg/kg/hour. Activated factor VII is not recommended in either the COPBM ASA pediatric PBM article nor PediCrisis app.
Finally, as we’ve discussed in many previous PAADs, using principles from implementation and quality improvement science to change people’s behavior. “Structured change management process is essential to engage interdisciplinary teams and address site-specific barriers and enablers to determine “who” and “what” needs to be done (or undone).”1 We will discuss this in much greater detail on Monday.
Send your thoughts and comments to Myron who will post in a Friday reader response.
References
1. Murto K, Downey L, Goobie SM: Pediatric Patient Blood Management: Unique Considerations. ASA Monitor 2025; 89
2. 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
3. Goobie SM, Faraoni D: Tranexamic acid and perioperative bleeding in children: what do we still need to know? Curr Opin Anaesthesiol 2019; 32: 343–352
4. Goobie SM, Faraoni D: Perioperative paediatric patient blood management: a narrative review. British Journal of Anaesthesia 2025; 134: 168–179
5. Klein AA, Bailey CR, Charlton AJ, Evans E, Guckian-Fisher M, McCrossan R, Nimmo AF, Payne S, Shreeve K, Smith J, Torella F: Association of Anaesthetists guidelines: cell salvage for peri-operative blood conservation 2018. Anaesthesia 2018; 73: 1141–1150