Consensus Recommendations for RBC Transfusion Practice in Critically Ill Children

The Transfusion and Anemia Expertise Initiative(TAXI)recommendations published in Pediatric Critical Care Medicine provide important clinical guidance and applicable tools to avoid unnecessary RBC transfusion. Earlier, there were no published guidelines to direct RBC transfusion decision-making specifically for critically ill children.

The TAXI consensus conference developed and reached consensus on a total of 102 recommendations (57 clinical [20 evidence-based, 37 expert consensus], 45 research recommendations).

Key recommendations by the committee:

Indications for RBC Transfusion for the General Critically Ill Child Based on Hemoglobin and Physiologic Thresholds

• When deciding to transfuse an individual critically ill child, we recommend considering not only the hemoglobin concentration but also the overall clinical context (e.g., symptoms, signs, physiologic markers, laboratory results) and the risks, benefits, and alternatives to transfusion.


• In critically ill children or those at risk for critical illness, we recommend measuring a hemoglobin concentration before prescribing each RBC transfusion; knowledge of hemoglobin concentration is not required before RBC transfusion if the patient has life-threatening bleeding.


• In critically Ill children or those at risk for critical illness, we recommend an RBC transfusion if the hemoglobin concentration is less than 5 g/dL.


• In critically ill children or those at risk for critical illness, we cannot recommend a specific RBC transfusion decision-making strategy that is based upon physiologic metrics and biomarkers.


• In critically ill children or those at risk for critical illness, who are hemodynamically stable and who have a hemoglobin concentration greater than or equal to 7 g/dL, we recommend not administering an RBC transfusion

Indications for RBC Transfusion for the Critically Ill Child With Respiratory Failure

• We recommend RBC transfusion for critically ill children with respiratory failure who have a hemoglobin concentration of less than 5 g/dL


• In critically ill children with respiratory failure who do not have severe acute hypoxemia, a chronic cyanotic condition, or hemolytic anemia, and whose hemodynamic status is stable, we recommend not administering an RBC transfusion if the hemoglobin concentration is greater than or equal to 7 g/dL.

Indications for RBC Transfusion for the Critically Ill Child With Nonhemorrhagic Shock

• In critically ill children with nonhemorrhagic shock, we recommend considering all possible strategies to augment oxygen delivery and decrease oxygen demand and not RBC transfusion alone.


• In hemodynamically stable critically ill children with a diagnosis of severe sepsis or septic shock, we recommend not administering an RBC transfusion if the hemoglobin concentration is greater than or equal to 7 g/dL.

Indications for RBC Transfusion for the Critically Ill Child With Nonlife-Threatening Bleeding or Hemorrhagic Shock

• In critically ill children with nonlife-threatening bleeding, we recommend that an RBC transfusion should be given for a hemoglobin concentration less than 5 g/dL


• In critically ill children with nonlife-threatening bleeding, we recommend that an RBC transfusion should be considered for a hemoglobin concentration between 5 and 7 g/dL.


• In critically ill children with hemorrhagic shock, we suggest that RBCs, plasma, and platelets be transfused empirically in ratios between 2:1:1 to 1:1:1 for RBCs:plasma: platelets until the bleeding is no longer life-threatening.

Indications for RBC Transfusion for the Critically Ill Child With Acute Brain Injury

In critically ill children with acute brain injury (e.g., trauma, stroke), an RBC transfusion could be considered if the hemoglobin concentration falls between 7 and 10 g/dL.

Indications for RBC Transfusion for the Critically Ill Child With Acquired and Congenital Heart Disease

• In children with cardiac disease, we recommend optimization of all the components contributing to oxygen delivery, including but not limited to achievement/maintenance of normal sinus rhythm and/or heart rate control, optimal preload and contractility, optimal right ventricular and left ventricular afterload, adequate oxygenation, and/or reduction of oxygen demand, as appropriate before initiation of RBC transfusion, except in the case of hemorrhagic shock.


• For all children with congenital and acquired heart disease, the benefits and risks of transfusion must be considered before transfusion. Whenever possible, adoption of blood-sparing and conservation procedures and guidelines should be implemented.


• In children undergoing cardiac surgery (repair or palliation) or heart transplants, when deciding to transfuse, we recommend considering not only the hemoglobin concentration but also the overall clinical context (e.g., symptoms, signs, physiologic markers, laboratory results) and the risk, benefits, and alternatives to transfusion.


• In infants and children with congenital heart disease, we recommend investigating and treating preoperative anemia in addition to implementing transfusion/blood management guidelines/blood-conservation practices.

Clinical Recommendations

• In hemodynamically stable critically ill infants and children with uncorrected CHD, we recommend RBC transfusion to maintain a hemoglobin concentration of at least 7.0–9.0 g/dL depending on the degree of cardiopulmonary reserve.


• In hemodynamically stable infants and children with single ventricle physiology undergoing stages 2 and 3 procedures with adequate oxygen delivery, we recommend not administering an RBC transfusion if the hemoglobin concentration is greater than 9 g/dL.


• In infants and children with CHD undergoing biventricular repair who are hemodynamically stable and have adequate oxygenation and normal end-organ function, we recommend not administering an RBC transfusions if the hemoglobin concentration is greater than or equal to 7.0 g/dL.


• Standard issue RBC transfusions should be used in children with acquired or congenital heart disease as there are insufficient data supporting the transfusion of RBCs of shortened storage age in this population.

Indications for RBC Transfusion for the Critically Ill Child With Hematologic and Oncologic Diagnoses

• In children with sickle cell disease who are critically ill or those at risk of critical illness, we recommend RBC transfusion to achieve a target hemoglobin concentration of 10 g/dL (rather than a hemoglobin S [HbS] of < 30%) prior to a surgical procedure requiring general anesthesia.


• In children with sickle cell disease and acute chest syndrome (ACS) who are critically ill, we recommend an exchange transfusion over a simple (nonexchange) transfusion if the child’s condition is deteriorating (based on clinical judgment); otherwise, a simple (nonexchange) RBC transfusion is recommended.

Oncologic Disease

In children with oncologic diagnoses who are critically ill or at risk for critical illness, and hemodynamically stable, we suggest a hemoglobin concentration of 7–8 g/dL be considered a threshold for transfusion.

Bone Marrow Transplantation

In children undergoing hematopoietic stem cell transplant (HSCT) who are critically ill or at risk for critical illness and are hemodynamically stable, we suggest a hemoglobin concentration of 7–8 g/dL be considered a threshold for RBC transfusion.

Selection and Processing of RBC Components in Critically Ill Children

• We recommend the use of irradiated cellular blood components for all critically ill children at risk for transfusion-associated graft versus host disease due to severe congenital or acquired causes of immune deficiency.


• We recommend the use of irradiated cellular blood components for all critically ill children when the blood donor is a blood relative of the child.


• For critically ill children with a history of severe allergic transfusion reaction(s), we recommend considering the evaluation of allergic stigmata (anti-immunoglobulin A [IgA] antibodies in IgA-deficient individuals, anti-haptoglobin antibodies—using a pretransfusion specimen) prior to RBC transfusion.

Indications for RBC Transfusion for the Critically Ill Child With Hematologic and Oncology

• In critically ill children with thalassemia, we recommend undertaking well-designed registries or expanding current initiatives to determine measures and limits of anemia tolerance, examine current practice, and define clinical outcomes to inform future research investigating the risks, benefits, and alternatives of RBC transfusion practice.gic Diagnoses


• In children with sickle cell disease who are critically ill or at risk for critical illness, we recommend a well-designed registry or enhancement of existing network databases to further clarify optimal transfusion management.

For reference log on to 10.1097/PCC.0000000000001613