5/5/2024

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A

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D

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Correct answer
C Obtain an initial hemoglobin and repeat if clinically indicated

Clinical factors are the best indicators for repeating a hemoglobin after blunt solid organ injury. An initial hemoglobin is useful, no matter what the clinical condition, as it can be used to predict the need for transfusion and correlates with failure of non-operative management.

Recent literature has suggested that repeat assessments of hemoglobin may not be necessary to identify patients who require transfusion or will fail non-operative management. These are better predicted by hemodynamic instability.

Multiple studies over the last 15 years have evaluated restrictive transfusion protocols in pediatric intensive care unit patients. There is some evidence that children may be at an increased risk relative to adults for morbidity and mortality when undergoing transfusion. A three year review from the PHIS (Pediatric Health Information Systems) database found that 51,720 (4.8%) of pediatric patients received blood product transfusions (most commonly red blood cells and platelets). Of those patients transfused, 492 (0.95%) experienced a complication from the administered blood product - a rate of complications of approximately 1 in 100 units transfused.

A randomized controlled trial analyzed the general surgery subgroup of the TRIPICU (Transfusion Requirements in Pediatric Intensive Care Units) study. Patients with a restricted protocol (i.e. transfusion for Hgb less than 7.0 g/dL) were compared to a more liberal transfusion regimen. The mean Hgb difference was 2.3 g/dL between groups. Several studies have documented no difference in mortality with a restrictive transfusion policy and no difference in duration of mechanical ventilation has been reported.

Given these findings, guidelines are being proposed for determining transfusion criteria in pediatric patients. The Pediatric Critical Care Transfusion and Anemia Expertise Initiative (TAXI) is a group of experts who determined consensus guidelines for transfusion of pediatric patients. In addition to general guidelines, they evaluated 8 subgroups of patients including (1) acute respiratory failure; (2) nonhemorrhagic shock; (3) non–life-threatening bleeding and hemorrhagic shock; (4) acute brain injury; (5) acquired and congenital heart disease; (6) sickle cell and oncologic disease; (7) support from extracorporeal circuit membrane oxygenation (ECMO), ventricular assist devices, and renal replacement therapy; and (8) use of alternative processing of blood products. In most situations, the experts recommend transfusion when the Hgb falls less than 5.0 g/dL. When the Hgb is between 5 and 7 g/dL, transfusion requirements are based upon the clinical scenario. The authors did not recommend transfusion in children with a Hgb greater than 7 g/dL except in specific instances such as sickle cell disease or acute traumatic brain injury. In the setting of an acute traumatic brain injury the expert consensus was for a transfusion threshold between 7 and 10 g/dL, although there was no rigorous data to support this.