Transfusion in critically ill children: Indications, risks, and challenges

Critical care medicine (Impact Factor: 6.31). 03/2014; 42(3):675-90. DOI: 10.1097/CCM.0000000000000176
Source: PubMed


To provide a concise review of transfusion-related issues and practices in the pediatric patient population, with a focus on those issues of particular importance to the care of critically ill children.
Electronic search of the PubMed database using the search terms "pediatric transfusion," "transfusion practices," "transfusion risks," "packed red blood cell transfusion," "white blood cell transfusion," "platelet transfusion," "plasma transfusion," and "massive transfusion" either singly or in combination.
All identified articles published since 2000 were manually reviewed for study design, content, and support for indicated conclusions, and the bibliographies were scrutinized for pertinent references not identified in the PubMed search. Selected studies from this group were then manually reviewed for possible inclusion in this review.
Well-designed studies have demonstrated the benefit of "restrictive" transfusion practices across the entire age spectrum of pediatric patients across a wide spectrum of pediatric illness. However, clinician implementation of the more restrictive transfusion practices supported by these studies is variable. Additionally, the utilization of both platelet and plasma transfusions in either a "prophylactic" or "therapeutic" setting appears to be greater than that supported by published data.
The preponderance of prospective, randomized trials and retrospective analyses support the use of a restrictive packed RBC transfusion policy in most clinical conditions in children. Neonatal transfusions guidelines rely largely on "expert opinion" rather than experimental data. Current transfusion practices for both platelets and coagulant products (e.g., fresh-frozen plasma and recombinant-activated factor VII) are poorly aligned with recommended transfusion guidelines. As with adults, current transfusion practices in children often do not reflect implementation of our current knowledge on the need for transfusion. Greater efforts to implement current evidence-based transfusion practices are needed.

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    ABSTRACT: Nucleic acid testing (NAT) for human immunodeficiency virus (HIV) and hepatitis C virus (HCV) was introduced for blood donation screening in the United States in 1999. This study analyzes temporal trends of these two infections since NAT introduction. Donation data from 1999 to 2008 were analyzed; each donation was tested for antibodies and viral RNA for HIV and HCV. Incidence for first-time (FT) donors was derived by multiplying that among repeat (RP) donors by the ratio of NAT yield rates between FT and RP donors. Incidence for all donors was the weighted mean based on percentage of FT and RP donors. Residual risk (RR) was determined using the window-period model. During the 10-year period approximately 66 million donations were screened with 32 HIV (1:2 million) and 244 HCV (1:270,000) NAT yield donations identified. HCV prevalence among FT donors decreased by 53% for 2008 compared to 1999. HIV and HCV incidence among RP donors increased in 2007 through 2008 compared to 2005 through 2006. During 2007 through 2008, HIV incidence was 3.1 per 10(5) person-years (py), with an RR estimate of 0.68 per 10(6) (1:1,467,000) donations; HCV incidence was 5.1 per 10(5) py, with an RR estimate of 0.87 per 10(6) (1:1,149,000). The increase in HIV incidence was primarily among 16- to 19-year-old, male African American donors and that in HCV was primarily among Caucasian donors of 50 or more years. Donors from the Southern United States had higher incidence rates. HCV prevalence decreased significantly since NAT introduction. The increase in HIV and HCV incidence in 2007 through 2008 warrants continued monitoring and investigation.
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