Experts address key challenges in paediatric P-PBM, including transfusion strategies, managing anaemia, and overcoming resource limitations
Insights from the WFSA webinar
WFSA recently hosted a webinar on the global implementation of paediatric perioperative patient blood management (P-PBM) as a standard of care: Applying P-PBM Principles in Paediatrics.
The session explored strategies for integrating P-PBM in resource-limited settings and addressed critical challenges, including the impact and management of preoperative anaemia in paediatric surgical patients
During the webinar, participants raised insightful questions, though time constraints prevented all from being addressed in real-time.
To bridge this gap, webinar speakers Dr. Maria Alejandra Echeto, Dr. Susan M. Goobie, and Dr. Heidi Meyer continue the conversation, providing their expert insights.
Q&A
What is your perspective on goal directed transfusion in a resource-limited setup with poor laboratory screening?
Great question! The principles of patient blood management (PBM) are the same everywhere, but resource limitations can make implementation challenging. In surgeries with significant expected blood loss, good communication between anaesthetists and surgeons is key. Laboratory haemoglobin (Hb) testing is usually available, even if point-of-care testing isn’t, but results can take time—so plan accordingly.
Anaesthetists need to be detectives when it comes to blood loss. Keep a close eye on suction volumes, swab weights, and irrigation fluids, while watching for clinical signs like tachycardia, hypotension, and slow capillary refill. Estimate allowable blood loss beforehand to guide transfusion decisions.
PBM strategies—tranexamic acid, meticulous haemostasis, controlled hypotension, and fluid optimisation—help minimise transfusions, especially when blood is scarce. If the risk of major bleeding is high, staged surgery might be the safest way forward. And remember that any opportunity for preoptimisation of preoperative Hb should be used where possible!
Monitoring urine output (<0.5 mL/kg/h) is another practical method for evaluating organ perfusion, while basic haemodynamic assessments, such as blood pressure and persistent tachycardia, provide additional clues. Pulse oximetry, if available, is useful for detecting hypoxaemia but should be interpreted alongside other findings, particularly when Hb levels are low. If there is access to blood gases, then these are also really helpful.
How can we assess tissue oxygenation in neonates and infants to decide on transfusion, rather than just using an HB number?
In neonates and infants, tissue oxygenation matters far more than just chasing a Hb number. The best approach is a combination of clinical signs, metabolic markers, and perfusion monitoring. Look for persistent tachycardia, delayed capillary refill, cool extremities, or respiratory distress, as these can signal poor oxygen delivery.
Blood gas analysis and lactate levels help assess anaerobic metabolism, while venous oxygen saturation (if available) provides insight into overall oxygen extraction. Near-infrared spectroscopy (NIRS) is a great non-invasive tool to monitor cerebral and somatic oxygenation trends, and echocardiography can assess cardiac output when needed.
Instead of relying on an Hb threshold alone, watch the whole picture—if perfusion is compromised despite stable vitals, transfusion may be warranted, but if the child is stable, a more restrictive approach is often safe. It’s all about tailoring the decision to the patient, not just the lab results.
In low-resource settings, assessing poor oxygen delivery to tissues can be challenging and requires a combination of clinical signs and basic bedside tools. Key indicators include altered mental status, tachycardia, hypotension, cool extremities, and delayed capillary refill, all suggesting compromised perfusion.
When should you use fresh frozen plasma (FFP)?
The decision to use FFP really depends on the clinical situation and the availability of other blood products. While FFP contains all coagulation factors, its fibrinogen content is lower than that of cryoprecipitate or fibrinogen concentrate.
Since fibrinogen is often the first coagulation factor to drop in major bleeding, I tend to prefer cryoprecipitate in my practice—especially in septic neonates with a disseminated intravascular coagulation (DIC)-like picture or after cardiopulmonary bypass in paediatric cardiac surgery, where rapid fibrinogen replacement is key.
Ideally, transfusion decisions should be guided by bedside coagulation tests like viscoelastic testing, which provide a more targeted approach to managing clotting abnormalities. That said, there are cases where FFP is necessary, such as heparin resistance when antithrombin concentrates aren’t available—which is often the reality in my setting.
Ultimately, resource availability plays a huge role in decision-making, particularly in low-resource settings.
How effective is component blood therapy?
Thank you for the question. The effectiveness of component blood therapy is complex and depends on the specific blood component and the clinical indication for transfusion.
The key is timing and tailoring—getting the right product to the right patient at the right time. In settings like trauma or surgery, early use can make a big difference, but overtransfusion comes with risks like TRALI (transfusion-related lung injury) and TACO (fluid overload).
That’s why a restrictive transfusion approach is often preferred, with diagnostic tools like viscoelastic testing helping to guide what’s actually needed. And of course, close monitoring is essential—not just for effectiveness, but also for complications like immune reactions and infections. Ultimately, it’s about striking the right balance between correcting deficits and avoiding unnecessary transfusions.
At what level of HB and HCT (hematocrit) should a paediatric patient’s surgery be postponed or cancelled?
It really depends on the indication, type, and urgency of the surgery – if the procedure is urgent enough, it may be necessary to proceed and even transfuse despite a low Hb.
The cause of the low Hb is also important, whether it’s acute or chronic. For example, patients with chronic kidney disease often have chronic anaemia, and we typically avoid transfusing them unless absolutely necessary.
How long can surgery be postponed while the patient is taking oral iron supplements?
How long surgery can be postponed while using oral iron depends on the severity and type of anaemia, urgency of the procedure, and the patient’s response to supplementation. For elective cases, delaying at least 4–6 weeks allows time for a meaningful Hb increase, but in functional iron deficiency, the response may be minimal.
Ideally, the response should be monitored to guide further management. In urgent cases, surgery may need to proceed while optimising other blood management strategies, such as minimising blood loss and using tranexamic acid. Ultimately, it’s about balancing anaemia correction with surgical urgency.
Can anaphylaxis occur with intravenous iron?
At the paediatric hospital where I work, we sometimes use intravenous iron, and while we haven’t seen anaphylactic reactions, it’s something we stay mindful of. In adults, research shows that iron dextran and ferumoxytol have a 3- to 8-fold higher risk of anaphylaxis compared to iron sucrose, with iron dextran having the highest cumulative risk.
The good news is that the overall risk is very low, with studies reporting only 0.4 to 0.5 cases per 10,000 first doses. In children, second-generation IV iron products like iron sucrose and ferric gluconate are widely used and rarely linked to serious reactions. While the data is reassuring, careful monitoring is still essential, especially in paediatric patients where severe reactions are less well-documented.
For IV iron dosage, I suggest reading this article.
For patient with sepsis and anaemia, would you recommend higher transfusion triggers?
Research, including the TRIPICU trial, has shown that in haemodynamically stable, critically ill children with sepsis, a restrictive transfusion threshold (≤7.0 g/dL) is just as safe as a liberal approach and significantly reduces RBC transfusions. Similarly, the ETTNO and TOP trials in preterm infants support using lower transfusion thresholds than previously recommended.
That said, transfusion decisions shouldn’t be based on numbers alone—it’s about the whole clinical picture. In septic shock, for example, a higher Hb level may be needed to optimise oxygen delivery and organ function. So while restrictive thresholds work in many cases, there are situations where maintaining a higher Hb is the right call. It all comes down to patient-specific factors and real-time clinical judgement.
Can you discuss your recommendations and experience regarding use of cell salvage and erythropoietin (EPO) in your practice, including populations and dosing?
We do use cell salvage in cases where significant blood loss is anticipated, and in our setting, it’s managed by perfusionists, though in many places, it falls under the anaesthesia team’s responsibility. There’s strong evidence supporting its role in reducing allogeneic transfusion in paediatric surgery, particularly in procedures like spinal fusion for scoliosis. However, its high cost remains a major limitation to wider use.
Erythropoietin (EPO) is not currently used in our PBM practice in Cape Town, though we do have access to it. The strongest indication remains chronic renal disease, and it’s generally reserved for these patients rather than being routinely used in perioperative blood management. There’s less evidence supporting its use in paediatric PBM compared to adults. Like cell salvage, cost is a major limiting factor, making it less feasible as a standard strategy in resource-limited settings.
Erythropoietin (EPO) dosing in paediatric patients varies based on several factors. Younger children, especially those under one year, often require higher doses than older children. Chronic kidney disease (CKD) stage and whether the patient is on dialysis also influence dosing frequency. Efficacy varies, so response to treatment must be monitored, with adjustments made as needed.
The type of erythropoiesis-stimulating agent (ESA) matters too—most dosing data in children relates to erythropoietin alfa and beta, while evidence for darbepoetin alfa is emerging. Hb levels and rate of Hb increase should guide adjustments, with a gradual rise of 1–2 g/dL per month typically considered safe. However, paediatric dosing varies significantly, and individualised treatment is key to optimising response while minimising risks.
What to do with burn patients who enter the operating room for multiple healing and surgeries?
Great question! At the children’s hospital where I work, we perform around 400-500 burn surgeries annually. I’m not certain many of these would be classified as elective, but after cardiac theatre, it’s the setting where we most frequently administer packed red blood cell (PRBC) transfusions due to significant blood loss during burn debridement.
We typically follow restrictive transfusion triggers whenever possible, aiming for <7.0 g/dL in stable patients and <8.0 g/dL in those actively bleeding. Several factors help estimate expected blood loss, including the burn’s surface area, severity, type, and age of burn injury. But one of the most important factors is the location of the burn—scalp burns, for example, bleed heavily!
Depending on the anticipated blood loss and the patient’s starting Hb, preoperative transfusion may sometimes be the better option. Using a maximum estimated blood loss formula, like Gross’s formula, can also be really useful in deciding whether to group and screen or cross-match before surgery.
How can we implement PBM in children of the Jehovah Witness faith?
The principles of PBM remain the same, but in Jehovah’s Witness patients, early and clear discussions with parents or caregivers are crucial. Some may accept fractionated blood products like albumin, clotting factors, and immunoglobulins, while others may decline all blood components.
Intraoperative cell salvage can be an option if the circuit remains closed, but this varies—so it’s essential to clarify their stance beforehand. Erythropoiesis-stimulating agents may be acceptable alternatives to boost Hb preoperatively.
Consent must be specific and well-documented, ensuring all team members are aligned with the patient’s wishes while providing the best possible care. Essentially, it can be very complex and is highly specific to the individual patient’s or caregiver’s wishes.
Is cancer a contraindication for prophylactic tranexamic acid (TXA)?
Cancer itself isn’t a contraindication for TXA but it does require careful consideration, especially given the increased thrombotic risk in cancer patients. I regularly use TXA in paediatric oncology patients undergoing major surgery, like a laparotomy for nephroblastoma resection, where minimising blood loss is crucial.
In these cases, the benefits of reducing intraoperative bleeding and avoiding transfusion outweighs the risks. That said, I’m always mindful of potential complications, particularly in patients with known thrombotic risks, active clotting disorders, or disseminated intravascular coagulation (DIC) secondary to malignancy. As with any intervention, it’s about balancing risk versus benefit and tailoring the decision to each individual patient.
Can aminocaproic acid be used in neonate as antifibrinolytic?
Where I work, we only have access to tranexamic acid, but aminocaproic acid is another lysine analogue used as an antifibrinolytic in neonates, particularly in paediatric cardiac surgery.
Current literature suggests that both agents appear to be equally effective in reducing blood loss and the need for blood products in this setting.
I’m based in Ghana. Is there a way to join the community to collaborate in studies?
Thank you for your question – you could join the African Perioperative Research Group.
