PRBC Transfusion Criteria for Infants with Acyanotic Congenital Heart Disease
For infants with acyanotic congenital heart disease, transfuse PRBCs when hemoglobin falls below 7-8 g/dL in stable patients without significant respiratory support, or below 9-11 g/dL in those requiring respiratory support, with higher thresholds during acute decompensation, sepsis, or hemodynamic instability.
Age-Specific Transfusion Thresholds
Preterm Infants (<30 weeks gestational age) with Acyanotic CHD
Use restrictive transfusion thresholds based on postnatal age and respiratory status 1:
For infants on respiratory support (mechanical ventilation, CPAP, or nasal cannula ≥1 L/min) 1:
- Postnatal week 1: Hemoglobin <11 g/dL (Hematocrit <33%)
- Postnatal week 2: Hemoglobin <10 g/dL (Hematocrit <30%)
- Postnatal week ≥3: Hemoglobin <9 g/dL (Hematocrit <27%)
For stable infants without significant respiratory support 1:
- Postnatal week 1: Hemoglobin <10 g/dL (Hematocrit <30%)
- Postnatal week 2: Hemoglobin <8.5 g/dL (Hematocrit <25%)
- Postnatal week ≥3: Hemoglobin <7 g/dL (Hematocrit <21%)
Term Infants and Older Children with Acyanotic CHD
For stable acyanotic cardiac patients, maintain hemoglobin above 70-80 g/L (7-8 g/dL) 2. This threshold applies to hemodynamically stable patients without acute decompensation 2.
Clinical Situations Requiring Higher Thresholds
Increase transfusion thresholds in the following circumstances 1:
- Sepsis or necrotizing enterocolitis: Use higher thresholds from the respiratory support category
- Requiring vasopressor or inotropic support: Transfuse at higher hemoglobin levels to maintain oxygen delivery
- Acute decompensation or acute bleeding: These recommendations do not apply; transfuse based on clinical assessment 1
- Previous exchange transfusion: Consider higher thresholds 1
- Hemodynamically unstable patients: The optimal threshold is unknown; err toward higher hemoglobin targets 2
Important Caveats and Pitfalls
Do not use hemoglobin thresholds lower than those validated in clinical trials, as safety data below these levels is lacking 3. The restrictive strategy shows no difference in mortality, bronchopulmonary dysplasia, severe intraventricular hemorrhage, necrotizing enterocolitis, or neurodevelopmental impairment at 2 years compared to liberal strategies 1.
Avoid routine phlebotomies to maintain predetermined hemoglobin levels in patients with acyanotic CHD, as this can lead to iron deficiency and microcytosis 1. Iron deficiency-induced microcytosis is the strongest independent predictor for cerebrovascular events in cardiac patients 1.
For iron-replete anemia (hemoglobin inadequate for oxygen saturation), blood transfusion may be required 1. Ensure iron stores are adequate (MCV >80 fL) before attributing anemia solely to cardiac disease 1.
Transfusion Administration
Transfuse PRBCs at 2 cc/kg/hour as a continuous infusion for children with severe anemia of gradual onset 4. This rate is safe and effective, resulting in approximately 1% hematocrit increase per 1 cc/kg of PRBCs transfused 4.
Monitor heart rate throughout transfusion; expect a mean decrease of 28% from pretransfusion heart rate by completion, indicating improved oxygen delivery 4.
Use irradiated blood products for immunocompromised patients to prevent transfusion-associated graft-versus-host disease 5.