ISBT Science Series (2009) 4, 208–215
ª 2009 The Author.
ORIGINAL PAPER AC11
Blood transfusions in neonatal cardiac surgery and ECMO
A. Brand
Sanquin Southwest & Leiden University Medical Center, Leiden, the Netherlands
Background
Patient population
Approximately 6–8 of 1000 newborns have a congenital
heart malformation often requiring surgery. Extracorporeal
membrane oxygenation (ECMO) provides life support to
patients with respiratory and ⁄ or cardiac failure. After car-
diac surgery ECMO is indicated in 0.5–3.5% of infants [1].
Currently, 1–2% of critically ill newborns are treated by
ECMO. The most frequent indications for ECMO in newborns
are meconium aspiration syndrome (MAS) and congenital
diaphragmatic hernia (CDH), together accounting for more
than 50% of ECMO procedures. Other indications are persis-
tent pulmonary hypertension associated with cardiac or
respiratory failure (PPHN), respiratory distress syndrome
(RDS), patients failing to come off from cardiopulmonary
bypass after cardiac surgery and sepsis. An indication for
primary ECMO generally emerges on the second day after
birth and the median duration of treatment is approximately
8 days. The survival rate is, depending on the indication,
60% to over 85% as compared with an estimated mortality
rate of 40–70% should ECMO not have been applied. Long-
term morbidity, after intra-cranial haemorrhage (ICH) or
chronic lung disease is however frequent. Based on a ran-
domized study, the costs associated with ECMO were esti-
mated approximately 75 000 pounds (level 1998) per infant
without disability at 1 year follow-up [2].
Blood usage
Although exact figures are lacking, in high income coun-
tries, infants below the age of 1 year use less than 2% of
Correspondence: A. Brand, Sanquin Southwest & Leiden University
Medical Center, Leiden, the Netherlands
E-mail: a.brand@sanquin.nl
Abbreviations CDH: congenital diaphragmatic hernia; CPB: cardio-
pulmonary bypass; EACA: epsilon amino caproic acid; ECMO: extra-
corporeal membrane oxygenation; FFP: fresh frozen plasma; MAS:
meconium aspiration syndrome; PPHN: persistent pulmonary hyper-
tension associated with cardiac or respiratory failure; PT: platelet
transfusion; RBC: red blood cells; RDS: respiratory distress syndrome;
TRALI: transfusion related acute lung injury; TXA: tranexamic acid.
208
Journal compilation ª 2009 International Society of Blood Transfusion
the blood supply [3,4]. In neonates, approximately 20% of
red blood cell (RBC) and most of the plasma products are
used for surgical procedures, of which cardiac surgery is
the most common indication. The major reason for transfu-
sion in cardiac surgery is because the extracorporeal circuit
(ECC) needs to be primed with blood.
Ten to 25% of neonates admitted to a neonatal intensive
care unit (NICU) receive one or more platelet transfusions
(PT). As compared with critically ill infants not receiving
PT, the mortality rate was reported 10 times higher. In
infants receiving 5 or more PT this risk increased almost 30
times [5]. Infants on ECMO receive almost daily RBC and PT
transfusions. A retrospective survey in the period 2002–
2007 among 12 329 neonates referred to several American
NICU’s, identified 45 infants who had received more than
20 units of PT. Almost half of these, 21 infants, because of
ECMO [6], underscoring that infants on ECMO obviously
belong to a multi-transfused group.
Both cardiac surgery and ECMO are associated with
exposure of the infants to multiple donors.
Technical aspects of extracorporeal circuits
The volume of the ECC in relation to the infant’s circulating
blood volume often requires priming of the system with
blood to avoid unnecessary haemodilution. For cardiac sur-
gery, devices requiring lower priming volumes are becom-
ing available. Reducing the extracorporeal volume from
over 500 ml to less than 300 ml. and even as low as
130 ml, enabled even in small children of 5–10 kg blood-
less cardiac surgery in 55% of the cases [7,8]. Further
downsizing is in progress. A decrease of the extracorporeal
volume will also benefit the extent of inflammation and of
the systemic inflammatory response syndrome (SIRS) fol-
lowing open heart surgery [8,9].
All ECCs, using a roller pump or a centrifugal pump, cause
haemolysis [10]. Haemolysis leads to an increase of plasma-
free haemoglobin (PfHb) and decrease of the haptoglobin
scavenger. Free RBC constituents increase the systemic and
pulmonary vascular resistance, induce platelet dysfunction
and renal tubular damage. The use of special volume
adapted pump systems and coating of tubing and extracor-
poreal surfaces show promising effects reducing haemolysis
and thrombus formation [11]. However, increased degree of
haemolysis and inflammation-induced capillary leakage

can still be expected in young children, extensive surgery,
ventricular assist devices (VAD) and ECMO because blood is
exposed to a relatively large ECC surface [12]. For infants
less than 3 months of age and for premature infants it will
remain difficult to circumvent transfusions.
Besides haemolysis, a fall of approximately 40–50% of
the platelet count is an inevitable consequence of ECC. Both
in cardiac surgery and in ECMO this happens immediately
after connection to the circuit. After ECMO a nadir is
reached after 3 days [13]. Besides, there is dysfunction of
platelets, which become activated and at the same time
show impaired aggregation to agonist. Platelet function
tests such as TEG are disturbed after cardiac surgery and
during ECMO [14]. In combination with heparinization to
prevent clotting in the ECC circuit, this may enhance the
risk for ICH, a severe but frequent complication during
ECMO [15].
In addition to cellular activation and damage, ECMO also
causes biochemical changes. A frequent problem at initia-
tion of ECMO is hypercalcaemia (serum Ca > 11 mg ⁄ dl;
> 2.74 mmol ⁄ l) affecting approximately one-third of neo-
nates and associated with longer ECMO support and more
platelet transfusions [16].
On average, ECMO is applied for 6–8 days, with a wide
range of 2–10 days. The daily need for RBC is 0.5–1 unit
and 0.5–2 units of PT, besides plasma and other fluids.
(ELSO: ExtraCorporealLifeSupport Organization registry).
The use of PT in relation to the vascular access technique
was studied in 234 infants treated for 7.9 ± 6.3 days [17].
Veno-venous (VV)-ECMO was applied in 81 infants requir-
ing daily 1.06 PT, whereas veno-arterial (VA, 138 infants)
or the use of both techniques (15 infants) required an aver-
age number of 1.57 PT ⁄ daily.
Recently, a case comparison study suggested that addi-
tion of continuous haemofiltration to ECMO may result in
less days requiring ECMO (98 h compared with 126 h in
historical controls) and fewer RBC transfusions (0.9 units ⁄
day as compared with 1.8 U ⁄ day), while PT (0.7 unit ⁄ day vs.
0.9 unit ⁄ day), fresh frozen plasma (FFP) usage and mortality
(16%) was equal between the two groups [18].
Specific transfusion problems in cardiac
surgery
Several questions related to transfusion supportive care are
regularly put forward, but few are definitely answered.
No blood, whole blood or fresh blood for priming of
the ECC?
Cases of bloodless open-heart surgery in children
> 3 months by priming of the circuit with crystalloids have
been published in Jehova’s Witness. In cyanotic congenital
 2009 The Author.
Journal compilation  2009 International Society of Blood Transfusion, ISBT Science Series (2009) 4, 208–215
Neonatal cardiac surgery and ECMO 209
heart diseases, in which the haematocrit is high, autologous
blood has been withdrawn (12 ml ⁄ kg) after induction of
anaesthesia prior to the ECC to avoid haemolysis. This
could avoid blood transfusion in 70–80% of cases of repair
surgery [19]. A retrospective survey compared the use of
fresh whole blood with packed red blood cells for priming.
For infants < 5 kg body weight, lower transfusion needs the
first 12 h after surgery (64% needed 1 unit) were observed
after priming with fresh whole blood as compared with
85% of infants needing > 2 units, if the pump was primed
with packed RBC [20]. Clinical outcome was similar in both
groups.
There are a few prospective studies comparing priming
of the ECC with fresh whole blood or with reconstituted
blood consisting of fresh or stored RBC and FFP.
A prospective randomized study in 200 infants compared
fresh (< 48 h old) whole blood with reconstituted packed
RBC with FFP for pump priming. No difference in blood
loss, in transfusion needs and clinical outcome was found.
The hospital stay was even shorter when reconstituted
blood (the storage interval of RBC in this study was 6 days)
was used. In this study, 40% of the infants were < 28 days
old [21]. In a prospective study in 30 infants, priming with
reconstituted blood, containing fresh (stored < 5 days) or
old (> 5 days) packed RBC in mannitol and adenine solu-
tion, was compared. Despite there was a storage-dependent
increase in potassium (from 5.4 to 18.4 mEq ⁄ l) in the
packed RBC, already 20 min after mixing and circulation
with other priming constituents this difference had disap-
peared and during surgery and upon arrival at the NICU no
differences in pH, lactate, potassium, and glucose were
observed [22]. Contradictory to the above-mentioned stud-
ies came a randomized study from Canada [23]. In 64
infants, less than 1 month of age, the group transfused with
reconstituted fresh whole blood throughout the whole pro-
cedure (priming, surgery and up to 24 h postoperative
transfusions) had less chest tube blood loss (7.7 vs.
11.8 ml ⁄ kg) and improved clinical outcome with respect to
ventilation (119 vs. 164 h) and hospital stay (12 vs.
18 days) as compared with the group transfused with stored
reconstituted blood.
Antifibrinolytic treatment during cardiac surgery
In adults, a Cochrane analysis summarized over 200 RCTs
that recruited 20 781 patients. The results showed a small
advantage of aprotinin, a serine protease inhibitor, reducing
operative blood loss, number of transfusions and need for
re-exploration as compared with the lysine analogues, epsi-
lon aminocaproic acid (EACA) or tranexamic acid (TXA).
In this analysis, the incidence of myocardial infarction,
stroke and renal failure were not higher in the aprotinin-
treated patients [24].
210 A. Brand
However, in newborns, the coagulation system, in partic-
ular fibrinolysis, differs from older children and adults [25].
On the use of aprotinin, EACA and TXA in newborns and
infants to reduce blood loss in cardiac surgery, few prospec-
tive studies comparing these drugs have been performed.
In a RCT, comprising 320 patients, aprotinin was com-
pared with EACA or a combination in congenital cyanotic
heart diseases. The results showed no difference between
the two drugs with respect to bleeding, transfusion needs,
incidence of re-exploration and clinical outcome [26]. The
same group also compared EACA with TXA or placebo in
150 cyanotic infants and found both drugs evenly superior
to placebo [27].
The three drugs were compared in 100 infants with cya-
notic heart disease equally divided in four groups of 25
patients. No advantage for a combination of aprotinin
(2 · 30 000 KIU ⁄ kg) with TXA (three times 100 mg ⁄ kg)
was observed. TXA alone or aprotinin alone were equally
effective as the combination of both drugs [28].
In a review on this subject, no difference in amount of
bleeding was reported between aprotinin, EACA and TXA.
Almost all studies reported less bleeding with the use of
antifibrinolytics as compared with placebo. However, the
studies did not allow a conclusion on safety [29]. Increased
renal failure using aprotinin could not be confirmed in 200
neonates and, as shown in other studies, the cardiopulmo-
nary bypass time (if longer than 100 min) has the highest
association with renal failure [30].
Recombinant FactorVIIa
Studies examining rVIIa in neonates are limited and ran-
domized studies are not available. In most published cases,
rVIIa was used for uncontrolled bleeding as compassionate
need. Combined case series together comprising 44 infants
below 1 year of age, reported cessation of bleeding in all
cases except one case with surgical bleeding [31–34]. In an
open label study in six infants with postoperative bleeding,
re-operation because of bleeding was prevented [35]. Some
series observed no adverse effects, however, altogether at
least five thrombotic events occurred in these 44 cases, in
particular, in combination with ECMO.
Transfusion support after surgery
Shortly after bypass termination it is important to limit
bleeding and optimize systemic oxygen delivery. Heparin,
hypothermia and inadequate protamine correction are
important factors that contribute to bleeding and should
be adequately treated [36]. Guidelines recommend to aim
at a platelet count > 100 · 10 E9 ⁄ l. Platelets of young
infants (< 2 months of age) with congenital heart disease
are less activated by cardiopulmonary bypass compared
Journal compilation  2009 International Society of Blood Transfusion, ISBT Science Series (2009) 4, 208–215
with platelets from children older than 12 months. The
clinical significance, for instance regarding the trigger for
platelet transfusion for the very small infants is unknown
[37]. Because platelet number and function are impaired
after cardiac surgery, there is concern about volume
replacement with solutes affecting platelet function. In
adults after open heart surgery, the use of hydroxyl ethyl
starch (HES 15 ml ⁄ kg) as compared with albumin did not
result in obvious more chest tube drainage blood loss,
despite HES prolongs clot formation in trombelastography
(TEG) [38].
In a randomized clinical trial, 42 children undergoing
cardiac surgery were assigned to receive HES (130 ⁄ 0.4) or
FFP, both in a volume of 10 ml ⁄ kg after termination of car-
diopulmonary bypass (CPB). Endpoints were APTT, INR,
blood loss and blood product usage until the first postoper-
ative day. Although the INR was significantly longer in the
HES group, postoperative blood loss and transfusion of
blood products were not different between the two groups
[39].
Regarding red cell transfusions it is a general assump-
tion that after cardiac surgery there is a lower margin
of safety for low Hb levels, because stroke volume,
heartbeat and coronary blood flow are major compensa-
tors to maintain tissue oxygenation. In neonates, oxygen
delivery is at near maximal levels and in case of a high
oxygen demand there is a risk of tissue hypoxia. How-
ever, although the relationship may not be causal,
despite improvement of oxygen transport by RBC trans-
fusions, these are also associated with increased postop-
erative complications, in particular infections [40]. More
than 90% of neonatal RBCs contain HbF, having
impaired oxygen delivery by a left shift of the oxygen
dissociation curve [41]. After cardiac surgery, often more
than 50% of the RBCs carry HbA. The consequences of
this shift from HbF to HbA have however not been con-
sidered in setting transfusion targets in newborns.
Given the limited number of studies, firm conclusions for
priming and transfusion in neonatal cardiac surgery can
not be made, but:
• There is no high level evidence to prime the CPB circuit
with fresh whole blood.
• There is still controversy on the limitation of storage
time of erythrocytes for reconstituted RBC and FFP for
priming the CPB circuit.
• Antifibrinolyic treatment reduces blood loss, number of
transfusions and need for re-exploration because of
bleeding.
• Lysine analogues (TXA, EACA) seem as effective as
aprotinin to reduce bleeding.
• CPB bypass time (>100 min) is the major factor contrib-
uting to blood loss, transfusion needs and postoperative
renal failure.
 2009 The Author.

• rVIIa for compassionate need to be balanced in individ-
ual cases between benefit (prevention of re-exploration)
and possible adverse thrombotic effects.
• Rapid degradable hydroxyethylstarch impairs platelet
function tests but is not associated with more blood loss
or transfusions after cardiac surgery in infants.
• Postoperative haemoglobin level may not be an appro-
priate transfusion trigger if HbF ⁄ HbA ratio’s are not
taken into account.
Additional specific transfusion problems in
ECMO: bleeding and thrombosis
Bleeding and thrombosis are major problems in ECMO
treatment and functional coagulation tests, such as
thrombelastography (TEG), shows the whole range
between severe coagulopathies (DIC) to hypercoagulability
[42]. Intracranial haemorrhage is a major cause of neuro-
developmental dysfunction and mortality in children
using ECMO and is reported to occur in 10–52% of the
patients [43]. Risk factors for ICH are low pH, bradycardia
< 80 min, hypotension (MBP < 30 mmHg), difficulties
to maintain the activated clotting time (ACT) between
190–210 s, lower platelet counts and the need of more
transfusions [15]. ICH may also be associated with larger
intravascular volume administration in the first 24 h after
starting ECMO [44]. In comparison to a historical control
group, 42 newborns receiving EACA showed significant
less bleeding and none developed ICH [45]. However, in a
double-blinded randomized study between EACA and pla-
cebo in 29 neonates, five cases of ICH occurred (17.2%),
without a significant difference (EACA 23% and placebo
12.5%) between groups [46].
As compared with slightly older infants subjected to
open heart surgery, the newborn has an increased risk for
bleeding and thrombosis the first week(s) of life [47].
Despite AECA, TXA and activated factor VIIa were
reported to have life-saving effects in individual cases and
effective to reduce bleeding and transfusion needs, a lower
incidence of ICH during ECMO has not been demonstrated
and increased thrombosis at other sites has been reported
after the use of rVIIa. In a retrospective unmatched case-
control study of 12 patients treated with rVIIa for severe
bleeding after cardiac surgery and placed on ECMO, 25% of
patients developed thrombosis of which two with major
thrombotic complications in the ECMO circuit [31]. Four
patients surviving after rVIIa, showed occlusion of the oxy-
genator in two cases, but this was not at variance with con-
trols [48]. Another small report on four patients with
ongoing bleeding despite aprotinin, rVIIa caused cessation
of bleeding without excessive thrombosis [49].
Platelet transfusions still are the major treatment option
to treat and prevent bleeding during ECMO. Trigger levels
 2009 The Author.
Journal compilation  2009 International Society of Blood Transfusion, ISBT Science Series (2009) 4, 208–215
Neonatal cardiac surgery and ECMO 211
used for platelet transfusions in ECMO are 80–110 ·
10 E9 ⁄ l [17,44].
Infants on ECMO receive PT in 30% of the cases
for bleeding symptoms and in 70% for prophylaxis [6].
The mechanism of platelet dysfunction induced by ECMO
is incompletely elucidated. Besides thrombocytopenia
apparently due to consumption, platelets show a decreased
in vitro aggregability with collagen, and in vivo increased
levels of soluble P-selectin and metalloprotease MMP-2.
MMP-2 is released from activated platelets and mediates a
new, nonthromboxane, non-ADP-dependent pathway of
platelet aggregation. It has been shown that exposure to a
large artificial surface and oxidative stress during ECMO
induce release of MMP-2. This MMP-2 is purely derived
from platelets through contact with the artificial surface
without signs of endothelial activation as concluded from
absence of soluble E-selectin or vascular generated nitric
oxide. [50].
Because transfused platelets during ECMO acquire the
same bypass-induced platelet dysfunctions as the patient’s
circulating platelets, the value of prophylactic transfu-
sions to prevent bleeding has been questioned [6,51].
Comparing 1600 thrombocytopenic children (not only
infants on ECMO) in the NICU who –at the same level of
thrombocytopenia-received or not received platelet trans-
fusions the authors concluded that platelet transfusions
themselves were likely responsible for some fraction of
increased mortality in PT receivers [6,51]. The mortality
of patients receiving >20 PT is over 50% and most
patients do not die from bleeding [6]. This poses a crucial
dilemma for future studies.
Concluding (intracranial) haemorrhage of the infant and
thrombosis of the ECMO circuit pose major challenges for
the balance between antifibrinolytic drugs, use of rVIIa and
transfusion support. However, clinical research is limited
and evidence-based conclusions are not possible:
• Antifibrinolytics during ECMO may not reduce the inci-
dence of ICH.
• rVIIa may lead to more thrombotic complications in the
ECMO circuit.
• The appropriateness of prophylactic platelet transfu-
sions is questioned, because transfused platelets acquire
platelet dysfunction.
Special blood product requirements
When blood products are transfused as relatively large vol-
umes and at a fast speed, special complications should be
anticipated:
High dose of citrate anticoagulant & preservative solution
Hypothermia due to refrigerated blood
Hyperkalaemia
Depletion of 2,3 DPG in stored blood
212 A. Brand
Metabolic effects of massive transfusions
Many clinicians routinely infuse calcium gluconate in case
of massive transfusions. Hypothermia enhances cardiac
dysrhythmia ⁄ asystole. Transfusion of cold blood has been
associated with apnea, hypotension, and hypoglycaemia.
Moreover, the platelet function and coagulation processes
may be impaired at temperatures below 34 C.
Hyperkalaemia is related to the shelf-life of RBC and
with manipulations (centrifugation, irradiation) of RBC.
During storage of RBC, potassium leaks from the cell and at
the end of shelf-life (35–42 days) the potassium concentra-
tion can be as high as 50–70 mmol ⁄ l. Arythmia’s and
cardiac arrest have been reported after bolus transfusion
of stored blood in at least six case reports (reviewed by
[52]). For this reason, restriction of the storage time of RBC
for 5–12 days is often recommended for (partial) exchange
transfusions for infants and neonates [53]. However, such
serious events are presumably very rare, given the high
potassium load often present in stored RBC. Parshuram
& Joffe measured a potassium concentration above
25 mmol ⁄ l in one-third of the RBC products stored
3–41 days (median 10 days). When measured after an
average interval of 75 min after transfusion in only in three
children the K+-concentration reached > 5 < 6 mmol ⁄ l
without clinical symptoms [52]. Six of 54 transfusions in
this study had been given as bolus of > 5 ml ⁄ kg ⁄ 10 min
without events. A case of cardiac arrest in a 2-month-old
infant undergoing a Blalock-Tausing surgery is worth
mentioning. She received 120 ml over 10 min through a
central line in the inferior vena cava. The RBC had been
stored for 6 days, but had been irradiated 48 h prior to
transfusion. The potassium concentration in the unit was
55.3 mmol ⁄ l and in the patient, withdrawn after observing
ECG changes compatible with hyperkalaemia, 6.3 mmol ⁄ l
[54]. Irradiation enhances potassium leakage, starting >
3 h after irradiation this process starts and reaches a peak
after 3 days. It is prudent to limit the storage time after
irradiation as short as possible. An alternative is to remove
the supernatant and replace it prior to transfusion with
FFP or preservation solution. However, although the
potassium level decreases by saline-wash of RBC, this
turned out to cause more haemolysis in the ECMO circuit
[55].
A transfusion speed of 5 ml ⁄ kg ⁄ h, the usual speed for
top-up transfusions, causes no change in K+ levels, irre-
spective the shelf-life of blood [56].
Immunological effects in newborns
Several studies showed that infants below the age of
4 months hardly produce alloantibodies against red cells
and leukocytes. Half of 53 preterm infants after multiple
Journal compilation  2009 International Society of Blood Transfusion, ISBT Science Series (2009) 4, 208–215
transfusions could be tested 5 months after birth and none
showed RBC antibodies [57]. Ludvigsen found no antibodies
3 months after transfusion of an average 8.9 units of RBC to
90 full-term infants [58]. Exceptions have been described.
An Rh-D negative neonate undergoing cardiac surgery at
17 weeks of age produced anti-D after 2 PT from D+ donors
[59]. Three case reports in newborns reported on allo-anti-E
at the age of 18 days and 11 weeks respectively and one
anti-K detected at the age of 12 weeks [60–62]. Similarly,
Ishibashi et al. evaluated HLA antibody formation in 52
transfused preterm infants and reviewed the literature
comprising > 150 patients, revealing virtually no antibody
formation [63].
Because of the risk of later haemolytic disease of the
newborn of Rh-D alloimmunization, it is advised if Rh-D+-
positive PT are given to Rh-D-negative female infants to
administer anti-Rh-D Ig. A single dose of 250 IU is suffi-
cient to cover five successive PT over a period of 6 weeks
[64]. For FFP and cryoprecipitate it is not necessary to take
the Rh-D factor because of lack of immunization potential
of the small amounts of fragmented cells.
Whereas the antibody formation of newborns is consid-
ered negligible, as result from massive transfusions, passive
immunity can cause adverse effects, such as haemolysis
and transfusion-related lung injury (TRALI).
A review revealed seven cases of severe passive haemol-
ysis due to ABO antibodies in PT reported since 1984 [65].
The age of the recipients ranged from 8 months to 18 years
and three children died from the reaction. SHOT reported
over a period of 10 years, six cases of severe reactions
in blood group A ⁄ B children receiving O platelets. Five
suffered from acute haemolysis and one developed a
positive antiglobulin tests with spherocytes [66].
In 2006, the BCSH published an amendment to the
guidelines for neonates and older children to avoid O plate-
lets for non-O recipients where possible and out of group
platelets, e.g., O to A, B or AB recipients, should test nega-
tive for high titres of anti-A ⁄ B [64].
TRALI is probably underreported in neonates and small
infants. A review found approximately 10 published paedi-
atric cases of TRALI, of which only one in an infant of
4 months of age after cardiac surgery [67]. The authors
warn against the use of maternal blood because of the like-
lihood that the mother possesses anti-leukocyte antibodies
that may cause TRALI. In the SHOT analysis of 1995–2006,
20 paediatric TRALI cases have been recorded, but the
youngest was 2 years old. [66].
To prevent other adverse transfusion effects for which
neonates are particularly susceptible, such as CMV trans-
mission and Graft versus Host disease, it is recommended to
use leukocyte-depleted RBC and PT and to irradiate cellular
blood products with 25 Gy for newborn with a gestational
age < 32 weeks [53].
 2009 The Author.

Transfusion reactions in children
Few transfusion surveillance studies in children are avail-
able. The voluntary system in the UK registering severe
side-effects of transfusion (SHOT), analysed 3239 reported
reactions for a period of 10 years (1996–2005). Among
these 321 (10%) occurred in children < 18 years and 4.5%
(147) in infants < 12 months of age. Per blood product
transfused a severe transfusion reaction occurred in
0.013% in adults, 0.018% in children < 18 years and a three
times higher incidence (0.037%) in infants < 12 months.
Reactions to FFP and PT are approximately 5–6 times more
frequent as after RBC products [66].
In a prospective survey conducted in Canada in a paedi-
atric intensive care unit, 40 of the 2509 evaluated blood
products caused an adverse event, mainly febrile reactions.
Of these, 720 blood products had been given to cardiac sur-
gery patients resulting in eight products causing a non-life-
threatening reaction transfusion reaction. [68].
Again, some practise advices, based on low levels of evi-
dence, can be considered:
• Group O platelet transfusions should not be given to
non-O recipients or, if not available, platelet donors with
low anti A ⁄ B titers should be selected.
• Rh-D+ platelet transfusions if administered to Rh-D neg-
ative female infants should be combined with Rh-D
immunoprophylaxis (250 IU anti-D).
• In case RBC transfusions are administered at a speed >
5 ml ⁄ kg ⁄ h an infant must be monitored for arrhythmia’s.
• TRALI may be underreported in young infants.
• Prospective monitoring of transfusion effects according
to a protocol may help to improve transfusion guidelines
for newborns and small infants.
In conclusion, thorough vigilance and prospective stud-
ies may help making small steps towards improvement of
BT (blood transfusions) treatment. The causality of BT on
postoperative complications is completely unknown and a
challenge for future studies. Major steps forward depend
on technology reducing the extracorporeal volume and
limiting activation of platelets.
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