Is a rapid infuser (RI) suitable for blood transfusions in pediatric trauma cases with significant blood loss?

Rapid Infusers for Blood Transfusions in Pediatric Trauma

Rapid infusion devices should be used for blood transfusions in pediatric trauma cases with significant blood loss, but they must be appropriately sized for children and include blood warming capabilities to prevent hypothermia. 1

Appropriate Use of Rapid Infusers in Pediatric Trauma

Rapid infusion devices are essential tools in pediatric trauma cases with significant hemorrhage for several reasons:

• They allow for the quick administration of blood products when large volumes need to be infused rapidly 1
• Most rapid infusers have flow rates of 6-30 L/h and incorporate blood-warming devices, which is critical for pediatric patients 1
• Children are particularly vulnerable to electrolyte imbalance and hypothermia during rapid blood administration, making proper equipment selection crucial 1

Key Requirements for Pediatric Rapid Infusers:

1. Size-appropriate equipment: Devices must be appropriate for the child's size and the rate of blood loss 1
2. Blood warming capability: All rapid infusers should incorporate warming to 37°C to prevent hypothermia 1
3. Regular monitoring: Volume delivered should be monitored throughout the infusion to ensure the expected volume is delivered at the required rate 1
4. CE-marking: Only use devices verified by the manufacturer as safe for this purpose 1

Blood Product Administration in Pediatric Trauma

When using rapid infusers for pediatric trauma patients, blood products should be prescribed by volume rather than units:

• Blood volume of a child is estimated at 70 mL/kg (up to 100 mL/kg in newborns) 1
• A transfusion of 10 mL/kg of RBCs should increase Hb by approximately 20 g/L 1
• Fresh frozen plasma should be given in doses of 10-15 mL/kg 1
• Platelets should be given in doses of 10-20 mL/kg 1

Critical Threshold for Massive Transfusion:

Recent evidence suggests that transfusion of more than 20 mL/kg of any blood product within an hour should trigger massive transfusion protocols in children 2. This threshold is associated with:

• Higher mortality risk (3.4 increased odds)
• Need for urgent hemorrhage control procedures
• Risk of second bleeding episodes

Special Considerations for Pediatric Patients

Pediatric trauma patients have unique considerations that affect rapid infuser use:

• Hypothermia risk: Children are more susceptible to hypothermia than adults during massive transfusion 1
• Electrolyte imbalances: Rapid administration of blood products can cause significant electrolyte disturbances in children 1
• Accurate dosing: Blood components must be dosed by weight rather than standard adult units 1
• Vascular access: Appropriate-sized vascular access is crucial for effective use of rapid infusers 1

Implementation in Practice

When implementing rapid infusers for pediatric trauma:

1. Use blood component administration sets with a 170-200 μm filter 1
2. Ensure regular maintenance of all rapid infusion and warming devices 1
3. Never warm blood using improvised methods (microwaves, warm water, radiators) 1
4. Follow damage control resuscitation principles during active bleeding 1
5. Consider adjunctive therapies like tranexamic acid (15 mg/kg loading dose followed by 2 mg/kg/h infusion) 1

Pitfalls to Avoid

• Overlooking warming: Failure to warm blood products can lead to life-threatening hypothermia in pediatric patients
• Inappropriate device selection: Using adult-sized equipment without pediatric-specific settings
• Inadequate monitoring: Not regularly checking infusion rates and volumes during resuscitation
• Delayed activation: Failing to recognize when to activate massive transfusion protocols (>20 mL/kg within an hour) 2
• Crystalloid overuse: Avoid excessive crystalloid administration during uncontrolled hemorrhage 1

Rapid infusers are valuable tools in pediatric trauma resuscitation when properly selected and used with appropriate monitoring and warming capabilities. Their use should be integrated into a comprehensive approach to damage control resuscitation in pediatric trauma patients with significant blood loss.