07.c.i • Paediatric massive blood transfusion

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Definitions

Massive blood loss in children may be defined as:

  1. loss of one blood volume in 24 hours (approximately >80ml/kg in those <40kg) or
  2. loss of 50% blood volume in three hours (approximately 40ml/kg in those <40kg) or
  3. loss of >3ml/kg/min.

The chart below offers volume estimates for children.

Age / weight based estimates of massive blood loss in children
Age Volume estimates
Approx weight 3.5kg
Term Total blood volume
(80ml/kg in 24h) 		280ml
50% blood volume
(40ml/kg in 3h) 		140ml
rate of loss
>3ml/kg/min 		10ml/min
Approx weight 7kg
6 months Total blood volume
(80ml/kg in 24h) 		560ml
50% blood volume
(40ml/kg in 3h) 		280ml
rate of loss
>3ml/kg/min 		20ml/min
Approx weight 10kg
1 year Total blood volume
(80ml/kg in 24h) 		800ml
50% blood volume
(40ml/kg in 3h) 		400ml
rate of loss
>3ml/kg/min 		30ml/min
Approx weight 20kg
5 years Total blood volume
(80ml/kg in 24h) 		1600ml
50% blood volume
(40ml/kg in 3h) 		800ml
rate of loss
>3ml/kg/min 		60ml/min
Approx weight 30kg
10 years Total blood volume
(80ml/kg in 24h) 		2400ml
50% blood volume
(40ml/kg in 3h) 		1200ml
rate of loss
>3ml/kg/min 		90ml/min
Approx weight 40kg
12 years Total blood volume
(80ml/kg in 24h) 		2800ml*
50% blood volume
(40ml/kg in 3h) 		1400ml*
rate of loss
>3ml/kg/min 		100ml/min*
Approx weight 60kg
16 years Total blood volume
(80ml/kg in 24h) 		4200ml*
50% blood volume
(40ml/kg in 3h) 		2100ml*
rate of loss
>3ml/kg/min 		150ml/min*

* Based on blood volume 70ml/kg in over 12 year old



Massive blood loss in children

> 80ml/kg in 24 hours >40ml/kg in 3 hours >3ml/kg/min

*Please see guideline for age/weight blood loss estimates

Contact transfusion

Suspect 40% blood loss if significant source of bleeding suspected and clinical parameters as follows:
Age heart rate Systol. BP
<1
yr 		 >160 <70
1-2 yrs >150 <80
3-5 yrs >140 <80
6-12 yrs >120 <90
>12 yrs >100 <100
Tachypnoea or increased work of breathing
Urine output <0.5ml /kg/hour

Before transfusion

  • Check patient ID
  • Use wristbands
  • Ask parent if present

Primary C-MBL pack

  • Blood 30ml/kg (up to 5 units)
  • FFP 20ml/kg FFP (up to 4 units)

Reassess

  • Re-assess ABC and clinical parameters regularly
  • Document status

Get help

Contact senior member of clinical team. Contact senior ward nurses Contact portering services

Contact Transfusion

Assess ABC

Stop overt bleeding where possible

IV access

2 large cannula (largest possible)

Send blood samples - cross-match, FBC, PT / APTT / Fibrinogen
Biochemistry (U&E, LFT, ionised Ca, phosphate)
Arterial / venous blood gas measurement

Resuscitate

IV warm fluids – crystalloid or colloid
Give oxygen

Give blood

Blood loss >40% blood volume is immediately life-threatening
Give 20ml/kg red cells (up to four units). Aim for Hb>80g/L
Give Group O RhD negative if immediate need
and/or blood group unknown

Blood transfusion lab will provide group specific/
crossmatched red cells as required

Prevent coagulopathy

Anticipate need for platelets and FFP after 20–30ml/kg blood
replacement and continuing bleeding
Give Primary Children’s Massive Blood Loss (C-MBL) Pack
Order Secondary Children’s Massive Blood Loss (C-MBL) Pack
(Secondary pack to be given if bleeding continues)
Correct hypothermia and use fl uid warmer
Correct hypocalcaemia (keep ionised Ca>1 mmol/L)
Contact Haematologist

Maintain stability

Repeat blood gas (including Hb,
ionised Ca, Na, K, glucose) every 30 minutes
Repeat FBC, coagulation after every 40ml/kg blood components given
Monitor HR, BP, capillary refill, saturation, temperature, urine output

Get more help to stop the bleeding

Contact paediatric surgeons, paediatric gastroenterologists,
PICU, radiology as appropriate

Ask transfusion to ‘Initiate children’s massive blood loss (C-MBL) protocol’
Give the weight, age and location of the child

In trauma or surgical bleeding consider Tranexamic Acid Initial bolus 15mg/kg (max 1g) followed by maintenance infusion

Therapeutic aims
Hb >80g/L
Platelets >75 x 109/L
Fibrinogen <1g/L
APTT/PT <1.5x midpoint of normal range
Ionised calcium (on ABG) >1mmol/L
pH >7.2
Core temp >35°C

Secondary C-MBL pack

  • Blood 30ml/kg (up to 5 units)
  • FFP 20ml/kg (up to 4 units)
  • Platelets 15ml/kg (up to 1 unit)
  • Cryo-precipitate 5ml/kg (up to 300ml)


Massive blood loss (C-MBL)
packs for children

Red cells
  • Use O RhD negative until group is known – then use ABO and RhD suitable
  • Move to crossmatch compatible as soon as all investigations are complete
  • Consider age of patient to inform component specification (eg. paediatric red cells)
Platelets
  • Use group A HTN until group is known – then use ABO suitable (A HTN for AB patients)
  • Use apheresis if possible
Fresh frozen plasma
  • Use group AB until group is known – then use ABO suitable
  • Order of preference:
  1. Non-UK methylene blue treated (MB-FFP)
  2. Octaplas (SD-FFP)
  3. Standard FFP
Fresh frozen plasma
  • Use group A until group is known – then use ABO suitable
    (A for AB patients)
  • Order of preference:
  1. Non-UK methylene blue treated cryo-precipitate
  2. Standard cryo-precipitate

Avoid group O for non-O patients where possible
(for platelets, FFP and cryoprecipitate)

Weight Pack
<10kg Primary pack
2 x Red cells
2 x FFP (~400ml)
Secondary pack
2 x Red cells
2 x FFP (~400ml)
1 x Adult platelet dose
3 x MB Cryo-precipitate (~50ml) or 1 adult pool
10kg-40kg Primary pack
4 x Red cells
4 x FFP (~800ml)
Secondary pack
4 x Red cells
4 x FFP (~800ml)
1 x Adult platelet dose
10 x MB Cryo-precipitate (~160ml) or 2 adult pools
>40kg Primary pack
5 x Red cells
4 x FFP
Secondary pack
5 x Red cells
4 x FFP
1 x Adult platelet dose
10 x MB Cryo-precipitate (~160ml) or 2 adult pools