Pediatric Patient Blood Management: "A Country Doctor’s View"
Michael J. Eisses, MD, Todd A. Glenski , MD, MSHA and Lynn D. Martin, MD, MBA
Original Article
Murto K, Downey L, Goobie SM. Pediatric Patient Blood Management: Unique Considerations. ASA Monitor 2025; 89(6):15-17.
The focus of today’s PAAD is a review of the unique considerations and challenges of pediatric patient blood management (PBM).1 When asked to review this article by Myron, I (LDM) quickly found myself back in my childhood dreaming about an optimistic 24th century future. Yep, you guessed it, Star Trek™. One of my favorite quotes from Dr. Leonard “Bones” McCoy goes – “I’m not a magician, Spock (insert Myron here), just an old country doctor.” It seems to fit the task at hand. Dr. McCoy relied on advanced, hard to believe technology like tricorders, communicators (cell phones), and computers that he spoke too (A.I. anyone). Even with the universal translator, he often struggled with communication to new species. For this review I have invited Drs. Mike Eisses and Todd Glenski, both pediatric cardiac anesthesiologists, one (MJE) with familiarity/expertise in hematology, lab and transfusion medicine and the other (TAG) a trained expert in evidence-based medicine, to assist me in the translations needed for this review. Lynn Martine MD
Patient blood management (PBM) is an approach using the patient’s hematopoietic system to optimize blood health. The focus of PBM has shifted from the historical transfusion-centered to a patient-centered approach and encompasses the preoperative, intraoperative and postoperative time periods. PBM can be thought of as a 3-legged stool. The first leg (pillar) is improving red blood cell mass by finding and preventing pre-operative and iatrogenic anemia. The second leg minimizes surgical, procedural, and iatrogenic blood loss and optimizes coagulation. The third leg maximizes patient-specific physiologic tolerance of anemia and coagulopathy using restrictive transfusion thresholds.2 This practice is apparently common in adults, but not widely practiced in children. An excellent and up-to-date review of pediatric PBM was recently published to help close this gap.3
With improving blood bank practices, transfusion of blood products is generally considered safe. However, there are still important risks and complications from these products. These can be categorized into infectious and non-infectious complications. Infectious complications include both viral and bacterial organisms. The non-infectious complications list is longer and includes allergic reactions, febrile-non-hemolytic transfusion reactions, hemolytic transfusion reactions, transfusion associated circulatory overload (TACO), transfusion-related acute lung injury (TRALI), iron overload, and transfusion associated graft-vs-host disease. Additional risks include alloimmunization with multiple exposures, and clerical or administration complications. Maintaining a healthy blood supply is critical as there can be new contaminants or pathogens discovered. All of this supports a more restrictive transfusion strategy by avoiding unnecessary transfusions (Pillar 3). Not only are pediatric patients more vulnerable to both short- and long-term complications, but they also reportedly have more transfusion reactions than adults, making the implementation of a pediatric PBM even more relevant.4
Studies evaluating restrictive vs liberal transfusion strategies are not comprehensive but do show that restrictive thresholds do not result in worse outcomes, and in-fact, may show improvement in certain settings.5,6 Therefore, the majority consensus is that restrictive transfusion strategies are preferred given the current data7-9. One major challenge to such recommendations are the wide variability of age, size, and clinical acuity of pediatric patients coupled with clinician treatment variability, again pointing out the need for better consensus and unified approach as described in the article.
A comprehensive pediatric PBM program shares many core principles with Enhanced Recovery After Surgery (ERAS) pathways. Both aim to be evidence-based, span the entire perioperative period, and require the engagement of multidisciplinary stakeholders and institutional support for successful development, implementation, and long-term sustainability. At their core, both aim to reduce unnecessary variation in patient care. Given these shared goals, PBM program development could be integrated into current or developing ERAS pathways.
While most pediatric surgical patients do not require transfusions, PBM principles are especially relevant in high-risk populations (Ex: cardiac or spine surgery). In these settings, there may be two opportunities: first, to develop an ERAS pathway if one does not yet exist, or second, to incorporate PBM components into new or existing pathways. There is currently “a lack of high-quality pediatric-specific PBM research” and a “limited number of evidence-based guidelines.”1 This mirrors the evolution of ERAS programs, where adult pathways gained traction before pediatric pathways.
A lack of definitive research or guidelines should not prevent institutions or physicians from acting. Downey et al1 refers to multiple studies/guidelines that provide a foundation for beginning a PBM initiative. For example, in 2024 the World Health Organization (WHO) revised its guideline hemoglobin cutoffs using a standardized approach that included input from content experts, structured PICO (Population, Intervention, Comparison, Outcome) question development, and transparent reporting of findings. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology, considered the gold standard in guideline development, was used to assess the quality of available evidence and determine the strength of each recommendation. Unfortunately, and a good example of lacking recommendations in the pediatric world, the WHO guideline did not address patients less than six months of age. Many of the recommended components, such as preoperative anemia screening, minimizing blood draws, or intraoperative TXA, can be integrated into existing Pre-Admission Testing clinics and/or ERAS pathways.
Starting a PBM program from scratch may feel overwhelming, but a phased, multidisciplinary approach focused on reducing unnecessary variation in care is an important first step. Like ERAS pathways, small, coordinated efforts may lead to big overall improvements. Over time, such efforts will not only improve patient care but also help generate the data and experience needed to advance pediatric PBM research and assist in guideline development.
I (LDM) was particularly happy to see the final section focused on how to implement guidelines and many implementation science (IS) references for those with interest in this field. I worry that the science of implementation ‘gets lost in translation’ for the very busy front-line physician, so please allow me to translate into what I hope is a more user-friendly summary. I personally like using Kotter’s 8-steps change management framework.10
1. CREATE a sense of urgency: The leader of the change project must clearly communicate the evidence in the literature that there is a problem and find and share data that shows WE HAVE THIS PROBLEM. Lean into every physician’s professional commitment to ‘first do not harm’ and their desire to provide the best care possible. You need to talk about why this is important and the right thing to do. Sadly, this step is commonly overlooked, and allowing complacency to win the day.
2. BUILD a strong guiding coalition: You empower a multidisciplinary team composed of all stakeholder roles for the impacted process (for PBM: preop APN/RN, blood bank/hematology, anesthesiologist(s), surgeon(s), OR nursing, intensivist(s) and ICU nurses, postoperative hospitalists/APNs) to lead the improvement efforts. Ideally all team members are motivated (i.e., I like asking for volunteers for each role). This team agrees on the ideal (end vision) state and next studies the current state of practice and the gaps from the goal. This current state review must include internal data and the variability in practice (disclosure: LDM is a part-time employee of AdaptX, a software tool designed for QI work such as this). This assessment may identify providers within the system and all its associated constraints who are performing better (i.e., positive deviants or best practice providers). The team must study these positive deviants to understand what they do differently to achieve this better performance. Now the team knows their goal (ideal state) and where they are at (current state).
3. FORM a clear, easy-to-understand vision: The next step is to develop a feasible, incremental roadmap for improvement. I encourage small test of change with a focused pilot (i.e., perhaps cardiac first rather than everyone who gives blood products). Using PDSA cycles of improvement, the first target is to simply replicate the positive deviant practice. This approach is a much easier pill to swallow as you are simply learning a colleague’s methods to better navigate the challenges within your system. The next target could be to close a gap with (a) a new process or (b) improve an existing process, continuing these cycles until you reach the goal (ideal state) for your pilot. Next you scale to additional areas (i.e., spines, craniofacial, etc.) until you have a guideline that works for most patients and services. We have published our ERAS implementation using these methods and more recently a multicenter pediatric perioperative example of this positive deviance approach.11,12
4. ENLIST front-line by communicating this vision: Throughout this entire process above the team is now communicating regularly (weekly) and in various formats (information boards, emails, daily huddles, staff meetings, etc.) with front-line staff impacted by these improvement efforts.
5. ENABLE (engage) front-line to act on vision: In these communications the team seeks trial feedback from the frontline staff on (1) changes the work, (2) those that don’t, and (3) ideas to make it better. Let the team and front-line staff figure out how we will improve. Make it easier to follow the new rather than the old process through point of use supplies, equipment, and EMR order-sets with decision support. When staff are engaged and feel heard, they come to feel part of the process and take pride and ownership as things improve. This front-line engagement is the secret sauce that will sustain the improvements.
6. GENERATE and highlight (celebrate) early wins: The team leader must publicly share and celebrate every win. The first win is critical. Honestly, I (LDM) commonly set it up so that I am throwing a ‘batting practice’ fastball down the middle of the plate to my best hitter to get the early home run. Then you celebrate and get the snowball rolling downhill before moving on!
7. SUSTAIN momentum and consolidate gains: Use all means possible to build on your early success. Have team members providing care when trialing the new processes first, then the team members train carefully selected front-line staff and slowly spread training until most staff have been engaged. Recognize that not all trials will achieve the desired improvement. Monitor closely and move on if you have good protocol compliance and are not seeing any improvements. Ending trials is a clear signal to the front-line that you are watching, listening, and learning.
8. INSTITUTE new practice change into the culture (‘this is how we do it here’): Once you have achieved your goal and scaled to all impacted services, you must seal your success by building it into your culture. This translates into the improvement team and clinical champion handing off ownership of the new and improvement practice guideline to a clearly designated local owner. This operational owner is responsible for monitoring compliance, learning why non-compliance occurs and responding as needed, educating new staff, monitoring the literature for emerging new technology or medications, and regulating new ideas for improvement and their trialing. Improving is never done!
In conclusion, there is clear and compelling evidence that we all should be looking into the development and implementation of pediatric PBM guidelines of care. What is your current practice? Are there gaps in this practice? What is stopping you from addressing these gaps and implementing new, better practices? Let us know, we want to hear what you think. Send your thoughts and comments to Myron (myasterster@gmail.com) 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(6): 15-17. https://doi.org/10.1097/01.ASM.0001118148.27159.c1
2. Goobie SM, Gallagher T, Gross I, et al. Society for the advancement of blood management administrative and clinical standards for patient blood management programs. Paediatr Anaesth 2019; 29: 231-6. (PMID: 30609198)
3. Goobie SM, Faraoni D. Perioperative paediatric patient blood management: a narrative review. Brit J Anaesth 2025; 134(1): 168-79. https://doi.org/10.1016/j.bja.2024.08.034. (PMID: 39455307)
4. McCormick M, and Delaney M. Transfusion Support: Considerations in pediatric populations. Seminars in Hematology. 2020; 57(2): 65-72. (PMID: 32892845)
5. Redlin M, Kukucka M, Boettcher W, et al. Blood transfusion determines postoperative morbidity in pediatric cardiac surgery applying a comprehensive blood-sparing approach. J Thoracic and Cardiovascular Surgery. 2013; 146(3): 537-542. (PMID: 23228399).
6. Curley A. Stanworth SJ, New H. Randomized Trial of Platelet-Transfusion Thresholds in Neonates. NEJM. 2019; 380(3): 242-251. (PMID: 30387697)
7. Deschmann E, Dame C, Sola-Visner MC, et al. Clinical Practice Guideline for Red Cell Transfusion Thresholds in Very Preterm Neonates. JAMA Network Open. 2024; 7(6):e2417431. (PMID:38874929)
8. Carson JL, Stanworth SJ, Guyatt G, et al. Red Cell Transfusion: 2023 AABB International Guidelines. JAMA. 2023; 330(19):1892-1902. (PMID: 37824153)
9. Valentine SL, Bembea MM, Muszynski JA, et al. Consensus Recommendations for Red Blood Cell Transfusion Practice in Critically Ill Children from the Pediatric Critical Care Transfusion and Anemia Expertise Initiative. Pediatr Crit Care Med. 2018; 19(9):884-898. (PMID:30180125)
10. Kotter JP. Leading Change. Boston: Harvard Business School Press, 1996.
11. Martin LD, Chiem JL, Hansen EE, et al. Completion of an Enhanced Recovery Program in a Pediatric Ambulatory Surgery Center: A Quality Improvement Initiative. Anesth Analg. 2022; 135(6): 1271-1281. https://do.orgi/10.1213/ANE.0000000000006256. (PMID: 36384014)
12. Low AB, Maresh JR, Jarvi T, et al. Perspectives in Perioperative Quality Improvement: Case Studies in Positive Deviance Using Real-World Data. Pediatr Anesth 2025. http://doi.org/10.1111/pan.15143. (PMID: 40525583)