Transfusions in the Critically Ill Pediatric Patient

Jelena Roganovic

Disclosures

Pediatr Health. 2010;4(2):201-208. 

In This Article

Transfusion Alternatives

Comparatively low erythropoietin levels have been found in critically ill, low birthweight neonates and infants with anemia of prematurity, providing a theoretical rational for the use of recombinant human erythropoietin (r-EPO) therapy.[22] Since the late 1980s, a number of trials and reports have focused on r-EPO's ability to prevent or treat anemia of prematurity with the goal of eliminating or reducing RBC transfusions. The studies differed markedly from one another in multiple ways, producing variable results that could not be explained.[19,20] The ability of r-EPO to enhance RBC production in neonates is well established and may reduce RBC transfusion requirements. However, the effect of r-EPO appears to be relatively modest and does not reduce transfusion requirements within the first 2 weeks of life, when sick neonates are most transfusion dependent owing to frequent blood sampling. It has been demonstrated that in the presence of restrictive guidelines for blood transfusion in very low birthweight infants with adequate protein and iron supplementation, the number of RBC transfusions and volume transfused were not influenced by the administration of r-EPO. Side effects of r-EPO include the rare report of sudden infant death syndrome and the more common induction of iron deficiency. Thus, treatment with r-EPO must be accompanied with oral or parenteral administration of iron. A possible increase in the prevalence of retinopathy of prematurity has been described in infants who were administered r-EPO compared with matched controls.[16,20]

In conclusion, although r-EPO is effective in stimulating erythropoiesis in preterm neonates, clinical studies offer little support for its generalized use in this patient group. In the Cochrane review, no demonstrable benefits were reported of early versus late administration of r-EPO with regard to reduction in the use of RBC transfusions, the number of transfusions, the amount of RBCs transfused or the number of donor exposures per infant.[23] Nevertheless, in individual cases of severely ill neonates with ongoing needs for RBC transfusions, r-EPO may be a consideration. The optimal dose, timing and nutritional support required during r-EPO therapy has yet to be determined. If administered, r-EPO will take at least 2 weeks before any benefit is seen.[4,23]

Iatrogenic anemia should be minimized in hospitalized patients. In the past years, improvements made in test ordering practices, phlebotomy techniques and instrumentation have significantly reduced the amount of blood drawn from critically ill pediatric patients. Improved laboratory test utilization driven by managed care may further reduce the risk of iatrogenic anemia and the need for blood transfusions, thereby increasing the child's safety and reducing the cost of care.

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