Guidelines for assessing appropriateness of pediatric transfusion

R ecent advances in donor screening, blood testing before transfusion, and modifications made to collected components, with irradiation as an example, make the blood supply safer than ever before. Nonetheless, blood components should only be transfused when risks and benefits have been carefully weighed.1-5 Particular consideration is required when transfusing preterm infants, the most heavily transfused patient group in the tertiary care setting, with the greatest potential for longevity.6-9 Recent data have demonstrated that transfusion practices vary tremendously, particularly in preterm infants.10 Establishing criteria for appropriate transfusion practice is important to ensure that clear-cut benefits are derived from the administration of this sometimes limited resource. In addition, the Joint Commission for the Accreditation of Health Care Organizations requires review of the appropriateness of all transfusions to correct transfusion practices that deviate from standard practice and that the use of blood and blood components be reviewed on a continuing basis, as part of a required performance-improvement function.11 Review for under-transfusion should also be considered. This paper has been written to help transfusion services and transfusion committees have a starting point to establish their own audit guidelines. References are included for each institution to evaluate as they embark upon this process. Transfusion medicine specialists who are not well versed in the special needs of neonates, as well as generalists who direct the transfusion service but lack specific expertise, can use this document and its references to initiate guideline development. These guidelines, representing the opinions of the authors and incorporating evidence-based data where it exists, have been designed to facilitate uniform transfusion practice whenever possible. Elements of transfusion practice, which should also be reviewed, include the documentation of informed consent as well as completion of transfusion records.11,12 Transfusion practice guidelines should not serve as medical indications for transfusion, nor can they be all inclusive. The appropriateness for most of these transfusion guidelines has been demonstrated in published reports. It should be pointed out that neonatal transfusion medicine is an evolving discipline. Because of the fragile clinical status of these small patients, it is difficult to design randomized controlled trials with enough statistical power to produce ironclad data. A great majority of the papers written about neonatal transfusion are practice oriented and derived by consensus. Therefore, adapting published literature to be used when creating transfusion audit guidelines for neonates should be done on an individualized basis.13-15 In certain selected clinical situations, transfusion events that deviate from the proposed guidelines may be considered appropriate. Scientific data, as well as a review of the patient’s chart, can be helpful in evaluating the appropriateness of transfusion events that deviate from guidelines.16,17 Physicians should clearly document, in writing, the indication for each transfusion administered and perform an assessment of the efficacy of the transfusion (e.g., relief of symptoms of anemia, cessation of bleeding). Parental informed consent, a process that includes delineating risks, benefits, and alternatives to transfusion, must be obtained in accordance with all applicable local, state, and national regulatory requirements. ObABBREVIATIONS: DIC = disseminated intravascular coagulation; ECMO = extracorporeal membrane oxygenation; ITP = idiopathic thrombocytopenic purpura; PCC = prothrombin complex concentrates; TA-GVHD = transfusion-associated GVHD; UCB = umbilical cord blood; WB = whole blood.