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D G Markhorst, Paediatric Intensive Care Unit, Vrije Universiteit Medical Center, Amsterdam, The Netherlands; firstname.lastname@example.org
M C J Kneyber, Paediatric Intensive Care Unit, Vrije Universiteit Medical Center, Amsterdam, The Netherlands
Joseph, a 4‐year‐old boy with septic shock, lactic acidosis and multi‐organ failure has been admitted to the paediatric intensive care unit. Mechanical ventilation, vaso‐active support and renal replacement therapy (CVVHD) are initiated. His haemoglobin level is 8.8 g/dl (5.5 mmol/l).
The senior consultant decides to order a red cell transfusion in order to optimise oxygen delivery, but the junior fellow argues that there is no evidence that transfusion improves outcome and that it may potentially be harmful.
In critically ill children [patient] does red cell transfusion to normal haemoglobin levels [intervention] improve survival and reduce incidence of complications or duration of mechanical ventilation [outcome]?
Secondary (Cochrane Library) and primary (PubMed) sources were included in the search.
Secondary sources: Search strategy: ((“Intensive Care” [MeSH]) OR (“Critical Care” [MeSH]) OR (“Critical Illness” [MeSH])) AND ((“Blood Transfusion” [MeSH]) OR (“Erythrocyte Transfusion” [MeSH])) AND systematic: five references, not related to the question.
Primary sources: Search strategy: ((“Intensive Care” [MeSH]) OR (“Critical Care” [MeSH]) OR (“Critical Illness” [MeSH])) AND ((“Blood Transfusion” [MeSH]) OR (“Erythrocyte Transfusion” [MeSH])): 548 references, five relevant to the question.1–5 See table 22.
Anaemia is common among critically ill patients and may have multiple causes. Historically, expert opinion was that haemoglobin (Hb) concentrations should be maintained at levels of at least 10 g/dl (6 mmol/l) to maintain oxygen delivery. Transfusion decisions tend to be driven by individual transfusion triggers rather than by specific physiological triggers or consensus. In paediatric ICU patients, reported transfusion frequencies range up to 30%.6 After careful review of the literature, we found that available reports do not advocate liberal transfusion of red blood cells in critically ill patients. Evidently, critically ill patients are at increased risk of death whether or not transfusions are prescribed. Three studies in adult patients, corrected for predicted risk of mortality, found transfusion to be an independent risk factor. Based on these three studies, the number needed to harm (for death) is 14 (95% CI: 12 to 17). There is also evidence suggesting that red blood cell transfusions are associated with complications including pulmonary oedema4 and nosocomial infection.3
So far, mortality data are limited to adult studies. In the absence of further data, the decision to transfuse critically ill paediatric patients should be individualised and restricted to patients with Hb levels 9 g/dl (5.6 mmol/l) or even lower.