What are the guidelines for ordering blood in pediatric patients undergoing major abdominal surgery anesthesia?

Blood Ordering Guidelines for Pediatric Major Abdominal Surgery

For pediatric patients undergoing major abdominal surgery, calculate maximum allowable blood loss (MABL) preoperatively and order packed red blood cells at 10-20 ml/kg, fresh frozen plasma at 10-15 ml/kg, and consider cryoprecipitate and platelets based on anticipated blood loss and coagulopathy risk. 1, 2

Preoperative Blood Product Ordering

Red Blood Cell Preparation

• Order packed red blood cells (PRBCs) in volumes of 10-20 ml/kg 1
• Each 10 ml/kg transfusion will increase hemoglobin by approximately 20 g/L (2 g/dL) and hematocrit by 6% 3
• Always prescribe blood by volume (ml/kg) rather than units in pediatric patients 3
• Calculate MABL preoperatively to determine anticipated transfusion requirements 2

Plasma and Coagulation Products

• Fresh frozen plasma (FFP) should be ordered at 10-15 ml/kg doses 1
• Cryoprecipitate dosing: 5-10 ml/kg 4
• Platelet dosing: 10-20 ml/kg 1, 4

Special Neonatal Considerations

• All neonates require CMV-negative blood components 4
• Neonatal blood volume is 70-100 ml/kg (higher than older children at 70 ml/kg) 1, 4
• Order appropriately larger volumes relative to body weight for neonates 1

Intraoperative Blood Management Strategy

Monitoring and Transfusion Triggers

• Use point-of-care viscoelastic testing to guide transfusion decisions when available 1, 5
• Monitor for electrolyte imbalance and hypothermia during rapid blood product administration, as children are at particular risk 1
• Ensure vascular access devices are appropriate for the child's size and anticipated rate of blood loss 1

Hemorrhage Control Protocol

During active bleeding, follow damage control resuscitation principles 1:

• Avoid crystalloid and colloid administration during uncontrolled hemorrhage 1
• Administer RBCs and FFP in a 1:1 ratio while hemorrhage is being controlled 1
• Consider empiric administration of cryoprecipitate (two pools) and platelets (one adult therapeutic dose) until laboratory results are available 1
• Once bleeding is controlled, transition to laboratory-guided component therapy 1

Tranexamic Acid Administration

• Give tranexamic acid loading dose of 15 mg/kg followed by infusion of 2 mg/kg/h in trauma or major surgery with significant bleeding 1, 6
• Do not use adult dosing (1 g) in pediatric patients; weight-based dosing is mandatory 6

Blood Conservation Techniques

Cell Salvage

• Cell salvage can be useful in children even when absolute blood loss is less than 500 ml with appropriate technical refinements 1
• Consider for major abdominal procedures with anticipated significant blood loss 7

Critical Pitfalls to Avoid

• Never attempt to normalize blood pressure during active hemorrhage with vasopressors 1
• Avoid clear fluids for volume resuscitation unless there is profound hypotension and no imminent blood product availability 1
• Children have higher rates of serious adverse transfusion events compared to adults, requiring vigilant monitoring 3
• Rapid transfusion carries specific pediatric risks including electrolyte imbalance (particularly hypocalcemia and hyperkalemia) and hypothermia 1, 8

Age-Specific Ordering Considerations

Neonates and Infants

• Higher blood volume per kilogram (up to 100 ml/kg in newborns) 1
• Mandatory CMV-negative products 4
• Greater susceptibility to metabolic derangements during transfusion 8

Older Children

• Standard blood volume of 70 ml/kg 1
• Same dosing principles apply (10-20 ml/kg for PRBCs, 10-15 ml/kg for FFP) 1
• Consider preoperative anemia correction when time permits 2