Page 2054 - Hematology_ Basic Principles and Practice ( PDFDrive )

Chapter 121 Pediatric Transfusion Medicine 1823

TABLE Guidelines for Transfusion of Red Blood Cells in TABLE Guidelines for Transfusion of Frozen Plasma and
121.2 Patients More Than 4 Months of Age 121.4 Cryoprecipitate in Neonates and Older Children
1. Emergency surgical procedure in patient with significant Frozen Plasma
postoperative anemia 1. Support during treatment of DIC
2. Preoperative anemia when other corrective therapy is not available 2. Replacement therapy
3. Intraoperative blood loss ≥15% total blood volume a. When specific factor concentrates are not available, including
4. Hematocrit <2–24% but not limited to, antithrombin, protein C or S deficiency, and
a. In perioperative period, with signs and symptoms of anemia factor II, factor V, factor X, and factor XI deficiencies
b. While on chemotherapy/radiotherapy b. During therapeutic plasma exchange when FFP is indicated
c. Chronic congenital or acquired symptomatic anemia (cryoprecipitate-poor plasma, plasma from which the
5. Hematocrit <21%, hemodynamically stable patients >3 days old in cryoprecipitate has been removed)
the pediatric intensive care unit 3. Reversal of warfarin in an emergency situation, such as before an
6. Acute blood loss with hypovolemia not responsive to other therapy invasive procedure with active bleeding
7. Hematocrit <40% and Note: Frozen plasma is not indicated for volume expansion or
a. With severe pulmonary disease enhancement of wound healing
b. On ECMO Cryoprecipitate
8. Sickle cell disease and 1. Hypofibrinogenemia or dysfibrinogenemia with active bleeding
a. Cerebrovascular accident 2. Hypofibrinogenemia or dysfibrinogenemia, undergoing an invasive
b. Acute chest syndrome procedure
c. Splenic sequestration 3. Factor XIII deficiency with active bleeding or undergoing an invasive
d. Aplastic crisis procedure in the absence of factor XIII concentrate
e. Recurrent priapism 4. Limited directed-donor cryoprecipitate for bleeding episodes in
f. Preoperatively when general anesthesia is planned (target small children with hemophilia A (when recombinant and plasma-
hemoglobin 10 mg/dL) derived factor VIII products are not available)
9. Chronic transfusion programs for disorders of RBC production (e.g., 5. In the preparation of fibrin sealant
β-thalassemia major and Diamond-Blackfan syndrome unresponsive 6. von Willebrand disease with active bleeding: Cryoprecipitate is used
to therapy) in von Willebrand disease only when both of the following are true:
ECMO, Extracorporeal membrane oxygenation; RBC, red blood cell. a. 1-Deamino-8-D-arginine vasopressin is contraindicated, not
available, or does not elicit response
b. Virus-inactivated plasma-derived factor VIII concentrate (which
contains von Willebrand factor) is not available
TABLE Guidelines for Transfusion of Platelets in Neonates DIC, Disseminated intravascular coagulation; FFP, fresh frozen plasma.
121.3 and Older Children
Platelet Count <150,000/µL
1. Platelet count 5000–10,000/µL with failure of platelet production
2. Platelet count <30,000/µL in neonate with failure of platelet adults, and the indications for platelet transfusions do not differ from
production the indications for adults.
3. Platelet count <50,000/µL in stable premature infant
a. With active bleeding, or
b. Before an invasive procedure with failure of platelet production Frozen Plasma and Cryoprecipitate
4. Platelet count <100,000/µL in sick premature infant
a. With active bleeding, or Frozen plasma is used in preterm and term infants most commonly
b. Before an invasive procedure in patient with DIC to treat multiple factor deficiencies or vitamin K deficiency, a condi-
Without Thrombocytopenia tion that can occur in infants not prophylactically given vitamin K
1. Active bleeding with qualitative platelet defect after birth, especially if the mother ingested certain drugs during
pregnancy such as warfarin, cephalosporins, or some anticonvulsants
2. Unexplained excessive bleeding during cardiopulmonary bypass (Table 121.4). Dosing for all pediatric patients is 10 to 15 mL/kg.
3. Patient receiving ECMO with This should result in an increase in all factor activity of 15% to 20%
a. Platelet count <100,000/µL unless there is a marked consumptive coagulopathy. As mentioned
b. Higher platelet counts and bleeding
previously, solvent detergent–treated plasma, Octaplas, may not be
DIC, Disseminated intravascular coagulation; ECMO, extracorporeal membrane safe for neonates as it has low concentrations of protein S and
oxygenation. α2-antiplasmin.
Modified from Roseff SD, Luban NLC, Manno CS. Guidelines for assessing
appropriateness of pediatric transfusion. Transfusion 42:1398, 2002 and Wong Cryoprecipitate is used primarily to treat disorders resulting from
CC, Luban NLC: Intrauterine, neonatal, and pediatric transfusion. In: Mintz PD, a decrease in or dysfunction of fibrinogen or factor XIII deficiency.
editor: Transfusion therapy: Clinical principles and practice, ed 2. Bethesda, These indications are similar to those for adults. Children should
MD, 2005, AABB Press, p 159.
receive 1 to 2 units of CRYO/10 kg patient weight. One unit or less
of cryoprecipitate is usually sufficient to achieve hemostatic levels in
infants and premature infants. The expected rise in fibrinogen should
be 60 to 100 mg/dL.
quite controversial and based primarily on expert consensus rather
than evidence-based medicine. In sharp contrast to adults, who rarely
develop spontaneous severe bleeding until their platelet counts fall Granulocytes
below 10,000/µL, preterm infants with other complicating illnesses
may bleed at higher platelet counts. The increased risk may be sec- Granulocytes, whose efficacy, especially at low doses, is unproven,
ondary to (1) lower levels of plasma coagulation factors, (2) natural may be indicated for neutropenic children with infections unrespon-
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anticoagulants that potentiate thrombin inhibition, (3) intrinsic or sive to standard antimicrobial therapy. In addition, children with
extrinsic platelet dysfunction, and (4) increased vascular fragility. granulocyte dysfunction (e.g., chronic granulomatous disease [CGD])
Platelet counts and function in older children are similar to those of severe infections may also benefit from granulocyte transfusions.