What are the guidelines for managing massive blood loss in pediatric patients?

Guidelines for Managing Massive Blood Loss in Pediatric Patients

The management of massive blood loss in pediatric patients requires prompt recognition, a coordinated team approach, and appropriate use of pediatric blood components to minimize morbidity and mortality. 1

Initial Assessment and Resuscitation

• Establish wide-bore peripheral venous access (14G or larger appropriate for patient size) 1

• Restore circulating volume:

  • Use warmed crystalloids initially for volume resuscitation
  • Avoid excessive crystalloid/colloid administration during uncontrolled hemorrhage 1
  • Follow principles of permissive hypotension during active bleeding (except in head/spinal injuries) 1
  • Avoid vasopressors during active hemorrhage 1

• Nominate a coordinator responsible for communication and documentation 1

• Contact key personnel:

  • Clinician in charge
  • Duty anesthetist
  • Blood bank
  • Duty hematologist 1

Pediatric-Specific Considerations

• Blood volume estimation: 70 ml/kg in children, up to 100 ml/kg in newborns 1

• Prescribe blood products by volume rather than units 1

• Transfusion dosing guidelines:

  • Red blood cells: 10 ml/kg (expected to increase Hb by approximately 20 g/L)
  • Platelets: 10-20 ml/kg
  • Fresh frozen plasma: 10-15 ml/kg
  • Cryoprecipitate: 5-10 ml/kg 1

• Use pediatric components when available to minimize donor exposure 1

• Special attention to hypothermia prevention as children are particularly susceptible to temperature drops and electrolyte imbalances during rapid transfusion 1

Laboratory Monitoring

• Send baseline samples immediately:

  • Full blood count
  • Coagulation screen (PT, APTT, fibrinogen)
  • Blood grouping and crossmatch
  • Biochemical profile
  • Blood gases 1

• Repeat testing:

  • Every 4 hours or after 1/3 blood volume replacement
  • After blood component infusion 1
  • Use point-of-care testing when available to guide therapy 1

Blood Component Therapy

• Red blood cells:

  • Consider transfusion when 30-40% of blood volume is lost 1
  • In emergency, use O-negative or type-specific blood 1

• Coagulation management:

  • During active bleeding, use RBC:FFP ratio of 1:1 1
  • Anticipate platelet count <50×10⁹/L after 2× blood volume replacement 1
  • Aim for fibrinogen >1.0 g/L 1
  • Consider early administration of cryoprecipitate as fibrinogen deficiency develops early 1

• Tranexamic acid:

  • Loading dose: 15 mg/kg followed by infusion 2 mg/kg/h 1
  • Administer early (within 3 hours of injury) 1

Equipment Considerations

• Use appropriate-sized equipment for vascular access and rapid administration based on child size 1

• Blood warming:

  • Essential for all massive transfusions in pediatric patients
  • Use approved blood warming equipment with visible thermometer and audible warning 1
  • Available in all emergency rooms and theater suites 1

• Administration sets:

  • Use blood component administration sets with 170-200 μm filter 1
  • For platelet administration, use a clean giving set to prevent platelets sticking to red cells 1

• Rapid infusion devices:

  • Select devices appropriate for pediatric patients
  • Ensure they are CE-marked and verified as safe 1
  • Monitor volume delivered regularly throughout infusion 1

Hemorrhage Control

• Early surgical or obstetric intervention to stop bleeding 1
• Consider interventional radiology when appropriate 1
• Use cell salvage when available and appropriate (not contraindicated by contamination) 1

Common Pitfalls and Caveats

• Blood loss is frequently underestimated in pediatric patients 1
• Hemoglobin and hematocrit values do not fall for several hours after acute hemorrhage 1
• Children <10 kg have significantly greater blood loss per kg and require special attention 2
• Avoid excessive phlebotomy which can contribute to iatrogenic anemia 2
• Monitor for and prevent:
  • Hypothermia (increases risk of coagulopathy and DIC)
  • Acidosis
  • Electrolyte imbalances (particularly during rapid transfusion) 1

By following these guidelines and adapting them to the specific pediatric patient, clinicians can optimize outcomes in cases of massive blood loss in children.