Committee Report

National acceptability of American Association of Blood

Banks Pediatric Hemotherapy Committee guidelines for
auditing pediatric transfusion practices
R.G. STRAUSS, J.F. BLAZINA,A.L. WERNER,
H. HUME,G.J. LEVY,L. SCHLOZ,
V.S. BLANCHETTE,
C. BARRASSO,
C. SOTELO-AVILA, AND D. HINES

In 1989, guidelines for the auditing of pediatric transfusion practices were developed
b the Pediatric Hemotherapy Committee of the American Association of Blood Banks
( L B B ) and made available to AABB members. A survey of members who requested
the uidelines w a s conducted to determine how consistent the guidelines were with
locay transfusion practices and how useful they were for the conduct of audits. The
majority of respondents indicated that the recommended audit criteria agreed with
local practices and that most of them could b e applied to their transfusion practice
audits with little or no modification. An exception w a s that criteria for the transfusion
of platelets to premature infants were considered by s o m e to b e too liberal. However,
after review of the comments and the published information available, the committee
elected not to revise the guidelines pertaining to platelet transfusions for premature
infants. Bearing in mind that audit criteria a r e intended to identify circumstances in
which transfusions are acceptable as reasonable therapy without need for further
justification, rather than to serve as indications for transfusions, the AABB Pediatric
Hemotherapy Committee guidelines for auditin pediatric transfusion practices are
fairly representative of national practice. T R A N h S I O N 1993;33:168-171.

Abbreviatlon: AABB = Amerlcan Assoclatlon of Blood Banks.

EARLYIN 1989, guidelines for the auditing of pedia-
tric transfusion practices were made available to Amer-
ican Association of Blood Banks (AABB) members. The
guidelines were developed by the AABB Pediatric Hem-
otherapy Committee, and a detailed discussion of the
rationale for the guidelines and the literature upon which
they were based has been published.' Because pediatric
transfusion practices, particularly those involving in-
fants, are quite c o n t r ~ v e r s i a l , ~the
' ~ Pediatric Hemo-
therapy Committee wished to assess the acceptability of
From the Departments of Pathology and Pediatrics, University of
Iowa College of Medicine, Iowa City, Iowa; the Department of He-
matology-Oncology, Hospital for Sick Children, Toronto, Ontario,
Canada; the Department of Pediatrics, Universite de Montrkal, Mon-
treal, Quebec, Canada; the Louisiana Blood Center, Shreveport, Lou-
isiana; the Mid-South Regional Blood Center, Memphis, Tennessee;
the Department of Pathology, The Ohio State University, Columbus,
Ohio; the Department of Pathology, Children's Hospital of the King's
Daughters, Norfolk, Virginia; the Departments of Pathology and Pe-
diatrics, St. Louis University College of Medicine, St. Louis, Mis-
souri; the Department of Immunohematology, Johns Hopkins Hospital,
Baltimore, Maryland; and the American Association of Blood Banks,
Bethesda, Maryland.
Although support for development and analysis of the questionnaire
was provided by the AABB, the views expressed in this article rep-
resent the opinion of the authors and are not official AABB policy.
Received for publication June 11, 1992; revision received August
10, 1992, and accepted August 12, 1992.
the audit criteria recommended by the guidelines. To this
end, a questionnaire was mailed to all persons who re-
quested the guidelines from the AABB National Office,
to document whether the recommended audit criteria
agreed with local practices and to determine whether
they could be applied to conduct audits with minimal
modification. The results of the survey are presented in
this article.
Materials and Methods
Approximately 1 year after guidelines for auditing pediatric
transfusion practices were made available by the AABB Na-
tional Office, a questionnaire was mailed to all persons who
had requested the guidelines. The objectives of the question-
naire were to assess the acceptability of the recommended audit
criteria and to gather critical input for purposes of modifying
and updating the guidelines. Respondents were reminded that
audit criteria were not intended to serve as indications for trans-
fusion. Rather, they were to identify circumstances in which
transfusions were accepted as reasonable therapy, without a
need for further justification. Thus, not all patients eligible for
a transfusion, according to the guidelines, would invariably
benefit from one. Likewise, transfusions might be warranted
in settings not stipulated by the guidelines. The audit criteria
recommended by the guidelines' in 1989 are summarized in
Table 1.

168
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1993-Vol. 33, No. 2 AUDITING PEDIATRIC TRANSFUSIONS
Table 1. Audit criteria for pediatric transfusions (7989) *
Red cells
Neonatal infants less than 4 months old:
1. Venous hemoglobin level < 130 g/L in neonatal infants
< 24 hours old
2. Hemoglobin level < 130 g/L and severe pulmonary dis-
ease, cyanotic heart disease, or heart failure
3. Acute blood loss 2 10% of total blood volume
4. Phlebotomy losses s5%-10% of the total blood volume
5. Hemoglobin level <80 g/L in stable newborn infants
with clinical manifestations of anemia
Patients 4 months of age or older:
1. Significant preoperative anemia; intraoperative blood
loss 2 15% of total blood volume; postoperativehemo-
globin level <80 g/L, and symptoms or signs of anemia
2. Acute blood loss with hypovolemia unresponsive to
crystalloid or colloid
3. Hemoglobin level < 130 g/L in patients with severe pul-
monary disease requiring assisted ventilation
4. Chronic congenital or acquired anemia without an ex-
pected satisfactory response to medical therapy and a
hemoglobin level <80 g/L, or a hemoglobin level < 100
g/L with symptoms and/or signs of anemia
5. Chronic transfusions to suppress endogenous hemo-
globin production in selected patients with sickle cell
or thalassemia syndromes
6. Induction of immunetolerance before renal transplantation
Whole blood
1. Massive transfusion or acute blood loss (> 1 blood vol-
ume in <24 hrs)
2. Exchange transfusion
3. Cardiovascular bypass surgery
4. Extracorporeal membrane oxygenation
Platelet concentrates
Premature infants (gestational age <37 weeks):
1. Blood platelets <50 x 1OYL in a stable infant
2. Blood platelets < 100 x 10g/L in a sick infant
All other infants and children:
1. Blood platelet count <20 x 109/Land marrow failure
2. Blood platelet count <50 x 1 09/Lwith active bleeding
or an invasive procedure in a child with bone marrow
failure
3. Blood platelet count < 100 x 1OYL with active bleeding
plus disseminated intravascular coagulation or other
coaguiation abnormalities
4. Bleeding with qualitative platelet defect and marked
prolongation of the bleeding time regardless of the
platelet count
5. Cardiovascular bypass surgery with unexplained ex-
cessive bleeding, regardless of the platelet count
Granulocyte concentrates
1. Bacterial sepsis in neonatal infants < 2 weeks of age
with neutrophil plus band cell counts < 3 x 109/L
2. Bacterial sepsis unresponsive to antibiotic in patients
> 2 weeks of age with neutrophil plus band cell counts
<0.5 x 1091~
3. Documented infection unresponsive to antibiotics plus
a qualitative neutrophil defect, regardless of the neu-
trophii plus band cell count
The questionnaire consisted of two major items, each with
several subsections. The first major item asked each respondent
to indicate the strength of his or her agreement or disagreement
with the statement, “The audit criteria are consistent with local
transfusion practices for the following blood components.”
169
Table 1. Continued
Plasma components
Fresh-frozenplasma:
1. Bleeding, or an invasive procedure, in a patient with a
coagulation factor deficiency or a markedly prolonged
prothmbin and/or partial thromboplastin times
2. Replacement therapy in antithrombin 111, protein C or S
deficiency
3. Replacement therapy during therapeutic plasma ex-
change for disorders in which fresh-frozen plasma is
beneficial
Cryoprecipitate:
1. Bleeding, or an invasive procedure, in hemophilia A or
von Willebrand disease
2. Bleeding, or an invasive procedure, in hypofibrinoge-
nemia or dysfibrinogenemia
3. Replacement therapy in factor Xlll deficiency
Clotting factor concentrates:
1. Bleeding, active or anticipated, in patients with docu-
mented coagulation factor deficiencies, such as he-
mophilia A or B
2. Severe or variant forms of von Willebrand disease
Albumin:
1. Acute correction of hypoalbuminemia when clinically
indicated
2. Correction of hypovolemia when colloid infusion is
indicated
3. Replacement therapy in therapeutic plasma exchange
Drocedures
‘Italicized phrases were to be defined by local transfusion
committees.
The question had subsections in which respondents circled a
number from 1 (strongest agreement) to 6 (strongest disagree-
ment) to indicate their opinion about the statement as it applied
to recommended audit criteria for the transfusion o f whole
blood, red cells, platelets, granulocytes, fresh-frozen plasma,
albumin, cryoprecipitate, and other clotting factors.
The second major item sought responses to the question,
“Were they to be used locally, the audit criteria, as written,
would be altered for which blood products?” Respondents were
asked to give a “yes” or “no” response for each of the blood
components mentioned (e.g., whole blood, red cells, etc.). If
the initial response was “yes,” respondents then were asked
to describe criteria that were modified, to identify those that
were deleted, and, finally, to report new criteria that were
added locally.
Questionnaires were returned to the AABB National Office.
Responses were tabulated and analyzed as described in the
following section.
Results
Of 312 questionnairesmailed, 145 (46%) were returned. Of
the 145 persons who returned a questionnaire, 81 (56%) in-
dicated that they had not gained sufficient experience with the
guidelines to permit comment. The remaining 64 respondents
(44%) completed the questionnaire to provide data for analysis.
To determine whether audit criteria recommended by the
guidelines were consistent with local practices, we analyzed
the first major item as follows. All respondents who marked a
score of 1 or 2 were considered to agree strongly that the
recommended audit criteria were consistent with local prac-
tices, whereas those marking a score of 5 or 6 were considered
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170 STRAUSS ET AL. Vol. 33. No. 2-1993

to disagree strongly. Those marking a score of 3 or 4 were
considered to be equivocal and were not included in calcula-
tions of strong agreement or disagreement. Depending on the
blood component being considered, only 5 to 21 percent of
respondents were equivocal. The percentage of respondents
who strongly agreed or disagreed with the statement that the
recommended audit criteria were consistent with local practices
is presented in Table 2. As can be seen, .the majority of re-
spondents strongly agreed that the recommended audit criteria
were consistent with local practices.
The second item asked whether the recommended audit cri-
teria could be applied directly or whether local modifications
were necessary before transfusion practice audits were con-
ducted. In general, the majority of respondents felt no need to
modify the recommended audit criteria prior to local applica-
tion (Table 3). However, the criteria recommended for auditing
platelet transfusion practices were a notable exception. The
major area of controversy involved the criteria that permitted,
without need for further justification, the transfusion of plate-
lets to sick premature infants, whenever they exhibited a blood
platelet count <lo0 x lo9 per L. Most respondents who dis-
agreed indicated that a more reasonable recommendation would
be to permit platelet transfusions, without need for additional
justification, when the blood platelet count was <20 x lo9
per L in stable infants or when blood platelets had fallen to
between 30 and 50 x lo9 per L in sick infants-but not when
the platelet count was between 50 and 100 x lo9 per L. That
is, respondents believed that a blood platelet count of >50 x
lo9 per L is sufficient, and that a platelet transfusion given
when the platelet count is >50 x lo9per L requires justification.
Two other, somewhat controversial areas, as indicated by a
need for more than one-third of respondents to modify the
recommended audit criteria, were whole blood and red cell
transfusions. Disagreements with the whole blood recommen-
dations seemed to be minor and were concerned with whether
Table 2. Respondents who strongly agree or disagree that
audit criteria are consistent with local practices
Strongly Strongly
Component agree disagree
~
whole blood is ever preferred over reconstituted “whole blood”
(i.e., red cells plus fresh-frozen plasma). Some respondents
felt that whole blood should be used only for exchange trans-
fusions. Disagreements with recommended red cell criteria
consisted largely of minor adjustments-both higher and lower-
of hemoglobin levels in various clinical settings in which trans-
fusions could be given without need for further justification.
In many instances, it seemed that respondents were confusing
audit criteria with actual indications for transfusion.
Discussion
Guidelines for the auditing of pediatric transfusion
practices were developed by the AABB Pediatric Hem-
otherapy Committee in 1989. Because comprehensive
guidelines had not previously been published, and pe-
diatric transfusion practices are controversial, we sur-
veyed individuals requesting a copy of the guidelines to
document how consistent the guidelines were with local
practices and to determine how well they could be ap-
plied to the conduct of audits. The majority of the 64
respondents, who supplied data sufficient for analysis,
agreed that the recommended audit criteria were consis-
tent with local practices. Similarly, respondents indi-
cated that most of the recommended audit criteria could
be applied to their transfusion practice audits with little
or no modification.
The major area of controversy involved audit criteria
for the transfusion of platelets to premature infants. The
AABB Pediatric Hemotherapy Committee felt that a
platelet transfusion was reasonable, without need for fur-
ther justification by the ordering physician, when the
blood platelet count was c50 x lo9 per L in a stable
premature infant or 100 x lo9 per L in a sick premature
infant (Table 1). This decision was originally based on
observations that abnormalitiesof neonatal platelet func-

Whole blood 80% 15% tions and clotting proteins might compound the risk of
Red cells 81% 6% serious hemorrhage that was anticipated as a conse-
Platelets 77% 7%
Granulocytes 79% 15% quence of thrombocytopenia during the neonatal period,
Fresh-frozen plasma 69% 10% particularly in premature infant^.',^^^ Respondents ob-
Albumin 86% 3% jecting to these somewhat liberal criteria felt that a blood
Cryopreclpltate 81% 7%
Clotting factors 92% 3% platelet count of 50 x lo9 per L was sufficient and that
platelet transfusions given at higher platelet counts re-
quire further justification. In a preliminary report of a
Table 3. Respondents indicating a need to modify criteria
controlled trial, the need for red cell and fresh-frozen
locallv plasma transfusions in premature infants with blood platelet
counts <60 x lo9 per L was found to be twofold that
Do not
modify Modify in infants with platelet counts maintained at > 60 x lo9
Component (No) Wes) per L, presumably reflecting a greater tendency of the
Whole blood 63% 37% more thrombocytopenic infants to bleed.’ Accordingly,
Red cells 58% 42% when the guidelines for auditing pediatric transfusion
Ptatelets 42% 58% practices were updated and revised in April 1991, the
Granulocytes 71% 29%
Fresh-frozen plasma 82% 18% AABB Pediatric Hemotherapy Committee decided that,
Albumin 79% 21% at least for the present, the recommended criteria for the
Cryoprecipitate 71yo 29% transfusion of platelets to premature infants should not
Clotting factors 97% 3%
be changed. Obviously, individual institutions can mod-
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1993-Vol. 33. No. 2 AUDITING PEDIATRIC TRANSFUSIONS
ify audit criteria to be consistent with local standards of
practice.
As a continuing charge from the AABB Board of Di-
rectors, the Pediatric Hemotherapy Committee annually
revises the guidelines for auditing pediatric transfusion
practices after considering newly published information
and the suggestions of others interested in pediatric
transfusion medicine. Copies of the most recent revision
of the guidelines (April 1992) are available to AABB
members upon written request to the AABB National
Office.
Acknowledgments
The authors acknowledge contributions of members of the AABB
Pediatric Hemotherapy Committee: Ronald Sacher, Naomi Luban,
Suzanne Butch, Asa Barnes, Kenneth Starling, Ann McMican, Phyllis
Warkentin, Samuel Pepkowitz, and Alvin Mauer (liaison to the Com-
mittee from the American Academy of Pediatrics).
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3. Strauss RG, Sacher RA, Blazina JF, et al. Commentary on small-
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