A. Definition of anemia
Significant anemia results in decreased oxygen-carrying capacity of the blood and, thus, a reduction in the oxygen available to the tissues. The hemoglobin concentration is only a rough guide for an individual's adequate oxygen-carrying capacity.
B. Symptoms of anemia
When anemia develops gradually, there may be few symptoms or signs. Common symptoms of anemia include fatigue, dyspnea, inactivity, difficulty concentrating, anorexia, headache, syncope, vertigo, and palpitations. Signs can include pallor, tachycardia, tachypnea, ejection systolic murmur, and gallop rhythm.
C. Specific risks of red cell transfusion
Electrolyte imbalances of potassium or calcium, arrhythmias, post-transfusion purpura, hypothermia, and hemolytic transfusion reactions are more common with red cell transfusion than with other blood component transfusions.
D. Options for the correction/prevention of anemia
Packed red blood cells—AS-1 (Nutricel) or AS-3 (Adsol)— are used as additive solutions to the anticoagulant. Each packed red blood cell unit is approximately 350-380 mL with a hematocrit of 55-60%.
Recombinant erythropoietin has been used successfully in some children with leukemia or solid tumors, giving an increase in hemoglobin and decreasing red cell transfusion requirements. A decreased erythropoietin serum level may help to predict the response to recombinant erythropoietin therapy. This treatment is still experimental.
Consider hemodilution and other methods of decreasing surgical blood loss for children undergoing surgical procedures.
Autologous transfusion in children with solid tumors may be an option. Consult local protocols for autologous donation.
Discourage directed donations from first-degree relatives. Transfusion may sensitize the child and interfere with an allogeneic bone marrow transplant. It is mandatory if directed donations from relatives are used that the blood is irradiated to prevent graft-versus-host disease.
Before deciding to transfuse with red cells, consider symptoms and signs of anemia, not only the hemoglobin level.
E. Indications for red cell transfusion
1. The optimal hemoglobin level for children cannot be precisely defined. The following are prudent guidelines.
a. For a well child recovering from treatment-induced
bone marrow suppression, transfusion is usually indicated if the hemoglobin level is 70-80 g/L and the reticulocyte count is low.
b. For a child with symptoms and signs of anemia and
a hemoglobin level < 100 g/L, a transfusion may be
c. A child beginning a course of chemotherapy with
a hemoglobin level < 80 g/L usually benefits from a
d. A child receiving radiation treatment may require a
hemoglobin level maintained above 100 g/L.
e. A child with acute blood loss of > 10% of blood volume,
ongoing blood loss resulting in a loss of > 10% of blood
volume, or bleeding with a hemoglobin level < 80 g/L
usually benefits from a red cell transfusion.
f. A child with respiratory insufficiency requiring supple-
mental oxygen may benefit from maintaining a hemoglobin level > 120 g/L.
g. A child may require a higher hemoglobin level (> 70
g/L) if undergoing an anesthetic.
h. For a child with a platelet count < 20,000 mL and a
hemoglobin level < 8g/L, a red cell transfusion is usually indicated.
F. Dose of red cell transfusion
1. For a severely anemic child without hypovolemia, use small incremental transfusions of packed cells.
a. For hemoglobin < 30 g/L, transfuse with 5 mL/kg over
b. For hemoglobin 30-40 g/L, transfuse with 6 mL/kg over
c. For hemoglobin 40-50 g/L, transfuse with 7 mL/kg over
d. For hemoglobin > 50 g/L, transfuse the required
amount over 4 hours.
(Note: the length of time over which an individual unit of packed red blood cells can be infused is normally 4 hours. This can be extended to 6 hours under exceptional circumstances.)
e. Unless the child is actively bleeding or hypoxemic, correction of the hemoglobin level can be achieved over
several days for severely anemic children.
For a child with a hemoglobin level of > 50 g/L to achieve an increase of 30 g/L, a red cell transfusion of 15-18 mL/kg is required if transfusing packed red cells with Adsol or Nuricel additive solution. The total volume required is usually infused over 4 hours.
Rarely, an exchange transfusion is required for a safe transfusion in a severely anemic, hypoxic, hypervolemic child with cardiovascular compromise due to congestive heart failure.