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Indications for Blood Product Transfusion – Pediatric/Neonatal – Inpatient/Ambulatory

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1
Indications for Blood Product
Transfusion – Pediatric/Neonatal –
Inpatient/Ambulatory
Clinical Practice Guideline
Table of Contents
EXECUTIVE SUMMARY ................................................................................................ 3
SCOPE ............................................................................................................................ 4
METHODOLOGY ............................................................................................................ 5
INTRODUCTION ............................................................................................................. 5
RECOMMENDATIONS ................................................................................................... 6
Administration Of All Products ................................................................................. 6
Red Blood Cells ...................................................................................................... 6
Platelets .................................................................................................................. 8
Cryoprecipitate ........................................................................................................ 9
Plasma Products ................................................................................................... 10
Special Products/Procedures ................................................................................ 11
UW HEALTH IMPLEMENTATION................................................................................ 13
APPENDIX A. EVIDENCE GRADING SCHEMES ....................................................... 14
REFERENCES .............................................................................................................. 14
Note: Active Table of Contents -- Click to follow link
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2015CCKM@uwhealth.org

2
CPG Contact for Content:
Name: Thomas Raife, MD- Pathology- Lab Medicine
Phone Number: (608) 265-8492
Email Address: traife@wisc.edu
CPG Contact for Changes:
Name: Lindsey Spencer, MS- Center for Clinical Knowledge Management (CCKM)
Phone Number: (608) 890-6403
Email Address: lspencer2@uwhealth.org
Coordinating Team Members:
Pamela Kling, MD- Pediatrics- Neonatology
Carol Diamond, MD- Pediatrics- Hematology/Oncology
Benjamin Walker, MD- Anesthesiology- General
Georgios Kirvassilis, MD- Anesthesiology- General
Scott Hagen, MD- Pediatrics- ICU
Kari Nelson, NP- Surgery- Cardiothoracic
Kate Amond, NP- Surgery- Cardiothoracic
Dean Lawler- Clinical Labs- Administration
Robin Grimes- Clinical Labs- Transfusion Service
Anne Rose, PharmD- Pharmacy- Inpatient Services
Zach Tilson- Quality, Safety and Innovation (QSI)
Alison Meier- Population Health
Bradley Ehlenfeldt- Information Services- Clinical Systems
Jennifer Grice, PharmD, BCPS- Center for Clinical Knowledge Management (CCKM)
Kristen Sipsma- Center for Clinical Knowledge Management (CCKM)
Review Individuals/Bodies:
Heather Bartlett, MD- Pediatrics- Cardiology
Sushant Srinivasan, MD- Pediatrics- ICU
Kenneth Desantes, MD- Medicine- Hematology/Oncology
Josh Ross, MD- Pediatric Emergency Medicine
Charles Leys, MD- Surgery- Pediatric Surgery
Sabrina Butteris, MD, FAAP- Pediatrics- Hospitalists
Sharon Bartosh, MD- Pediatrics- Nephrology
Kathleen Montgomery, CNS- Nursing Administration- Children’s Hospital
Laura Konkol, CNS- Nursing- NICU
Committee Approvals/Dates:
Clinical Knowledge Management (CKM) Council (09/24/2015)
Release Date: September 2015
Next Review Date: September 2017
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2015CCKM@uwhealth.org

3
Executive Summary
Guideline Overview
This guideline contains recommendations for the indications of blood product
transfusion and is heavily influenced by recommendations released by the American
Association of Blood Banks (AABB).
Key Practice Recommendations
1. Transfusion rates should be dependent upon the hemodynamic stability of the
patient and disease processes.
2. Transfusing the minimum number of blood product units necessary to relieve
symptoms, or return a patient to safe range or targeted levels, is recommended.
3. In cases of life-threatening hemorrhage after trauma or during a surgical procedure,
massive transfusion protocols may be implemented to minimize the adverse effects
of hypovolemia and dilutional coagulopathy.1 Per UW Health policy 8.94, blood
products may be ordered as clinically indicated under the Massive Transfusion
Procedure when blood loss of more than one total blood volume is expected in a
short period of time.
Companion Documents
1. UW Health Darbepoetin and Epoetin in Non-Nephrology Patients – Pediatric/Adult –
Inpatient/Ambulatory Clinical Practice Guideline
2. UW Health Massive Transfusion Protocol
Pertinent UW Health Policies & Procedures
1. UWHC 2.04- Blood and Blood Component - OR
2. UWHC 4.32 Caring for Patients Who Refuse Blood Transfusions
3. UWHC 7.03 Human Tissue Standards
4. UWHC 8.12 Blood and Blood Component Transfusion (Requiring Pre-Transfusion
Testing)
5. UWHC 8.37 Donation of Autologous/Directed Blood Products
6. UWHC 8.94 Massive Transfusion Procedure (MTP)
Patient Resources
1. Health Facts For You #6346- Blood Transfusion
2. Health Facts For You #5056- If You Need A Blood Transfusion
3. Health Facts For You #5057- Autologous Blood Donation
4. Health Information: Blood Transfusion
5. Health Information: Blood Transfusions: Should I Bank Blood Before Surgery?
6. Kids Health: Blood Transfusions (Parents)
7. Kids Health: Blood Transfusions (Teens)
8. Kids Health: The Truth About Transfusions
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Scope
Disease/Condition(s): Any disease or condition requiring blood transfusion.
Clinical Specialty: Hematology/Oncology, Transplant, Surgery, Hospitalists, Critical
Care, General Medicine, Pathology, Anesthesiology, Emergency Medicine, Infusion
Center
Intended Users: Physicians, Physician Assistants, Nurse Practitioners, Nursing
CPG objective(s): To outline evidence-based recommendations and indications for
blood product transfusion (including red blood cells, platelets, plasma, and
cryoprecipitate).
Target Population:
Neonatal and pediatric patients (age birth to 17 years) admitted to an inpatient service,
seen within the emergency department, operating room, or HOD clinic.
Major Outcomes Considered:
1. Reduced length of stay (total hospital admission, ICU admission)
2. Improved mortality rates
3. Reduced rates of stroke or myocardial infarction
Guideline Metrics:
1. Retrospective analysis of patient scenario and blood product indication selected
2. Retrospective analysis of blood product indication by service line and/or provider
Copyright © 2015 Univ ersity of Wisconsin Hospitals and Clinics Authority
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Methodology
Methods Used to Collect/Select the Evidence:
Electronic database (i.e., PUBMED) searches were conducted by CCKM and
workgroup members to collect evidence for review. Expert opinion and clinical
experience was also considered during evidence discussions.
Methods Used to Formulate the Recommendations:
The workgroup members adopted recommendations developed by external
organizations and/or arrived at a consensus through discussion of the literature and
expert experiences. All recommendations developed by the workgroup were reviewed
and approved by other UW Health committees as appropriate.
Methods Used to Assess the Quality and Strength of the Evidence:
Recommendations developed by external organizations maintained the evidence grade
assigned within the original source document and were adopted for use at UW Health.
Internally developed recommendations, or those adopted from external sources without
an assigned evidence grade, were evaluated by the workgroup using the Grading of
Recommendations Assessment, Development and Evaluation (GRADE) algorithm (see
Figure 1).
Figure 1. GRADE Algorithm
Rating Scheme for the Strength of the Evidence/Recommendations:
See Appendix A for the various rating schemes used within this document.
Introduction
Blood transfusions should maximize clinical and patient outcomes, while minimizing
cost and potential exposure to infections or other patient risks. Evidence has
demonstrated improved patient outcomes (reduced lengths of stay and mortality)
concurrent with decreasing blood product utilization, as well as improvements in
readmission rates and cost.2 The following guidelines outline key indications for the
transfusion of blood products at UW Health.
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Recommendations
ADMINISTRATION OF ALL PRODUCTS
Transfusion rates are dependent upon the hemodynamic stability of the patient and
disease processes. Transfusing more than the minimum number of blood product units
necessary to relieve symptoms, or return a patient to safe range or targeted levels, is
not recommended. (UW Health Low quality evidence, strong recommendation)
In general, transfusion of any blood product should be completed within 4 hours. Units
should not be infused after the expiration date or time written on the label, without
exception.
RED BLOOD CELLS
The decision to transfuse red blood cells should always be dependent on patient
presentation and individual characteristics, degree of severity of anemia, presence and
severity of comorbidities, and the clinical judgement of the physician.
PR1 and PR5: Patients exhibiting acute blood loss and signs of shock should receive a
red blood cell transfusion. (UW Health Low quality evidence, strong recommendation)
PR2 and PR6: Evidence has demonstrated no mortality benefit using a liberal
transfusion threshold (hemoglobin levels > 10 g/dL), whereas a restrictive transfusion
threshold (hemoglobin levels of 7-8 g/dL) has demonstrated fewer cardiovascular
events in noncardiac surgery patients.2 Restrictive strategies have also demonstrated
reductions in cost, without negative impacts on patient outcomes. The AABB
recommends adhering to a restrictive transfusion strategy (7 to 8 g/dL) in hospitalized,
hemodynamically stable patients.2-4 (AABB High quality evidence, strong recommendation)
Intensive care patients may receive a transfusion at hemoglobin concentrations of 7
g/dL or less, whereas postoperative surgical patients who are hemodynamically stable
may receive a transfusion at hemoglobin concentrations of 8 g/dL or less or for
symptoms.2
In making transfusion decisions, it is also important to consider clinical signs or patient
symptoms, as well as hemoglobin concentrations.2 (AABB Low quality evidence, weak
recommendation)
PR3: A target hemoglobin of greater than 8 g/dL or hematocrit greater than 24% is
recommended in patients younger than 4 months of age with mild lung disease,
NC/CPAP/NIPPV with FiO2 < 40%, and signs of poor oxygenation. (UW Health Very low
quality evidence, weak recommendation)
PR4 and PR7: Red blood cell transfusion to maintain a hemoglobin above 10 g/dL or
hematocrit greater than 30% is recommended in patients younger than 4 months with
severe lung disease, intubated or nasopharyngeal synchronized intermittent mandatory
ventilation (NPSIMV) with FiO2 > 40%, congenital heart disease, and/or prematurity.
(UW Health Very low quality evidence, weak recommendation)
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PR8: Chronic transfusions of red blood cells are indicated in selected patients with
Sickle Cell Disease or thalassemia syndromes.5 Transfusion is also recommended
during partial exchange or exchange transfusions. (UW Health Very low quality evidence, weak
recommendation)
PR9: In cases of life-threatening hemorrhage after trauma or during a surgical
procedure, massive transfusion protocols may be implemented to minimize the adverse
effects of hypovolemia and dilutional coagulopathy.1 Per UW Health policy 8.94, plasma
may be ordered as clinically indicated under the Massive Transfusion Procedure when
blood loss of more than one total blood volume is expected in a short period of time.
Table 1. Indications for Red Blood Cell Transfusion in Neonates and Pediatric Patients
Indication
Codes Reason for Order
Patients younger than 4 months of age:
PR1 (Patient younger that 4 months) Acute blood loss or anticipated surgical blood
loss
PR2
(Patient younger than 4 months) Target Hgb > 7 g/dL or Hct > 21% in stable
patient with signs of anemia (RA or nasal cannula with FiO2 < 25%, and
reticulocyte count < 4%)
PR3 (Patient younger than 4 months) Target Hgb > 8 g/dL or Hct > 24% with mild
lung disease, NC/CPAP/NIPPV with FiO2 < 40%, and signs of poor oxygenation
PR4
(Patient younger than 4 months) Target Hgb > 10 g/dL or Hct > 30% with
severe lung disease, intubated or NPSIMV with FiO2 > 40%, congenital heart
disease, and/or prematurity
Patients older than 4 months of age:
PR5 Acute blood loss or anticipated surgical blood loss
PR6 Target Hgb > 7 g/dL or Hct > 21%
PR7
Signs of poor oxygen delivery or target Hgb > 10 g/dL or Hct > 30% in patients
with severe pulmonary disease requiring assisted ventilation or congenital heart
disease
PR8 Chronic transfusions in selected patients with Sickle Cell or thalassemia
syndromes OR partial exchange or exchange transfusion
PR9 Massive Transfusion Procedure
PR10 Other (specify in comments)____________________________________
Dose:
Suggested guideline = 10 mL/kg
ξ 1 Adsol unit ~ 350 mL with Hct of 60%
ξ 1 CPD unit ~ 250 mL with Hct of 75% (neonates only)
ξ Units may be split (1/2 or ¼)
Note: A dose of 10 mL/kg generally raises Hgb by 1 g/dL, Hct by 3% in adults A dose of 10-15 mL/kg generally raises Hgb by 2-3 g/dL, Hct by 7.5% in neonates
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PLATELETS
The decision to transfuse platelets should be dependent on patient presentation and
individual characteristics, presence and severity of comorbidities, and the clinical
judgement of the physician.
Platelets should not be transfused in patients with thrombotic thrombocytopenic purpura
(TTP) or heparin-induced thrombocytopenia (HIT), unless a life-threatening hemorrhage
has occurred.6 (AFP Grade C)
PP1 and PP5: A target platelet count of greater than 20 K/µL is recommended in a
stable premature infant (gestational age < 37 weeks) and non-bleeding patient with
failure of platelet production and risk factors (e.g., sepsis, fever, coagulopathy, etc.).
(UW Health Very low quality evidence, weak recommendation)
PP2: A platelet count greater than 30 K/µL should be targeted in a sick premature infant
(gestational age < 37 weeks) with minor signs of bleeding (i.e., petechiae).7 (UW Health
Very low quality evidence, weak recommendation)
PP3 and PP6: A target platelet count of greater than 50 K/µL is recommended in
extremely premature patients (gestational age < 37 weeks) at high risk for IVH or
neonatal encephalopathy. This target is also recommended in pediatric patients with a
failure of platelet production who are actively bleeding or in anticipation of an invasive
procedure.7 (UW Health Very low quality evidence, weak recommendation)
PP4: Prophylactic platelet transfusion is recommended to reduce the risk for
spontaneous bleeding in hospitalized patients with therapy-induced hypoproliferative
thrombocytopenia. Patients with a platelet count of 10 K/µL or less should receive a
transfusion to reduce the risk of spontaneous bleeding.8 (UW Health Low quality evidence,
strong recommendation) This recommendation includes patients with a hematological
disorder undergoing chemotherapy or stem cell transplantation.9
PP7: Platelet transfusion is recommended in patients who are significantly bleeding with
a qualitative platelet defect, regardless of platelet count. (UW Health Very low quality
evidence, strong recommendation)
PP8: Although the optimal transfusion threshold remains unknown for ECMO patients, it
is suggested to transfuse platelets to maintain a platelet count greater than 75 K/µL.
(UW Health Very low quality evidence, weak recommendation)
PP9: Platelets are conventionally transfused prophylactically for a preprocedure platelet
count of 80 K/µL to 100 K/µL for adult patients undergoing surgery involving the central
nervous system.10 (UW Health Low quality evidence, weak recommendation) Pediatric patients
undergoing surgery of the central nervous system, ocular surgery, or cardiac surgery
may receive a transfusion, preoperatively or up to 48 hours postoperatively, when
exhibiting a platelet count of less than 100 K/µL.7
(UW Health Very low quality evidence, weak recommendation)
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9
PP10: In cases of life-threatening hemorrhage after trauma or during a surgical
procedure, massive transfusion protocols may be implemented to minimize the adverse
effects of hypovolemia and dilutional coagulopathy.1 Per UW Health policy 8.94,
platelets may be ordered as clinically indicated under the Massive Transfusion
Procedure when blood loss of more than one total blood volume is expected in a short
period of time.
Table 2. Indications for Platelet Transfusion in Neonates and Pediatric Patients
Indication
Codes Reason for Order
Premature infants (gestational age < 37 weeks):
PP1 Target Plts > 20 K/µL in a stable premature infant (GA < 37 weeks)
PP2 Target Plts > 30 K/µL in a sick premature infant (GA < 37 weeks) or minor signs of bleeding
PP3 Target Plts > 50 K/µL and extreme prematurity (GA < 37 weeks) at high risk for
IVH or neonatal encephalopathy
All other infants and children:
PP4 Target Plts > 10 K/µL in a non-bleeding patient with failure of platelet production
PP5 Target Plts > 20 K/µL in a non-bleeding patient with failure of platelet production and risk factors (sepsis, fever, coagulopathy, etc.)
PP6 Target Plts > 50 K/µL with failure of platelet production AND active bleeding OR need for an invasive procedure
PP7 Significant bleeding in a patient with a qualitative platelet defect, regardless of platelet count
PP8 Target Plts > 75 K/µL in a non-bleeding patient on ECMO
PP9 Target Plts > 100 K/µL with major CNS/eye/cardiac surgery (for up to 48 hrs. post-operatively)
PP10 Massive Transfusion Procedure
PP11 Other (specify in comment)____________________________________
Dose:
Suggested guidelines:
Single Donor Platelets- 1 SD unit ~ 250-400 mL and (3.0)x1011 platelets
ξ Patients > 40 kg = 1 SD unit
Note: Platelet transfusions are not routinely indicated for TTP; HUS; HIT unless
actively bleeding
CRYOPRECIPITATE
The decision to transfuse cryoprecipitate should be dependent on patient presentation
and individual characteristics, presence and severity of comorbidities, and the clinical
judgement of the physician.
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PC1:Cryoprecipitate is most commonly administered for prevention or treatment in
patients with hypofibrinogenemia (defined as fibrinogen < 100 mg/dL) or
dysfibrinogenemia.11 (UW Health Very low quality evidence, weak recommendation) Anticipated
major surgery
PC2: Transfusion of cryoprecipitate may be considered in patients with a documented
Factor XIII deficiency.11 (UW Health Very low quality evidence, weak recommendation)
PC3: In cases of life-threatening hemorrhage after trauma or during a surgical
procedure, massive transfusion protocols may be implemented to minimize the adverse
effects of hypovolemia and dilutional coagulopathy.1 Per UW Health policy 8.94,
cryoprecipitate may be ordered as clinically indicated under the Massive Transfusion
Procedure when blood loss of more than one total blood volume is expected in a short
period of time.
Table 3. Indications for Cryoprecipitate Transfusion in Neonates and Pediatric Patients
Indication
Codes Reason for Order
PC1 Active bleeding OR anticipated major surgery/invasive procedure (e.g., ECMO) with fibrinogen < 100 mg/dL or dysfibrinogenemia
PC2 Factor XIII deficiency
PC3 Massive Transfusion Procedure
PC4 Other (specify in comments)____________________________________
Dose: Suggested guideline = 1 unit/10 kg
PLASMA PRODUCTS
The decision to transfuse plasma should be dependent on patient presentation and
individual characteristics, presence and severity of comorbidities, and the clinical
judgement of the physician.
PF1: Transfusion of plasma is recommended with an elevated INR (e.g., INR 1.3 in
surgical patients, 1.5 in stable, non-surgical patients) and if the patient is actively
bleeding or in anticipation of or immediately after a major surgery/invasive
procedure.7(UW Health Very low quality evidence, weak recommendation) It is important to
consider that the INR of fresh frozen plasma is typically 1.5-1.6, therefore transfusion
when the patient’s INR level is equivalent is typically ineffective in lowering the INR.
PF2: Plasma products are used to prime the pump in pediatric open heart surgery as
appropriate for neonates and lower weight pediatric patients (weight < 10 kg).
PF3: Plasma is typically administered to prevent or correct bleeding caused by single or
multiple coagulation factor abnormalities, when a specific coagulation factor concentrate
is not available.7,11 (UW Health Low quality evidence, weak recommendation)
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PF4: Patients with disseminated intravascular coagulation (DIC) who are actively
bleeding should receive a plasma transfusion.7 (UW Health Very low quality evidence, weak
recommendation)
PF5: Administration of plasma is recommended for the reversal of warfarin effect in an
emergent situation or when actively bleeding. (UW Health Very low quality evidence, weak
recommendation) When administering plasma under this indication, vitamin K should also
be administered in most patients. (UW Health Very low quality evidence, strong recommendation)
PF6: In cases of life-threatening hemorrhage after trauma or during a surgical
procedure, massive transfusion protocols may be implemented to minimize the adverse
effects of hypovolemia and dilutional coagulopathy.1 Per UW Health policy 8.94, plasma
may be ordered as clinically indicated under the Massive Transfusion Procedure when
blood loss of more than one total blood volume is expected in a short period of time.
Table 4. Indications for Plasma Transfusion in Neonates and Pediatric Patients
Indication
Codes Reason for Order
PF1 Elevated INR with active bleeding or anticipated major surgery/invasive procedure
PF2 Pump prime in pediatric open heart surgery as appropriate for neonates and
lower weight pediatric patients
PF3 Replacement therapy for hemostatic factor deficiencies if concentrate not available
PF4 Disseminated intravascular coagulation with active bleeding
PF5 Immediate reversal of warfarin effect for emergency surgery or active bleeding
(in combination with vitamin K)
PF6 Massive Transfusion Procedure
PF7 Other (specify in comments)____________________________________
Dose: Suggested guideline = 10-15 mL/kg body weight
SPECIAL PRODUCTS/PROCEDURES11
Component modifications are not medically indicated for all transfusion recipients, but
provide benefit for selected patient populations, as outlined below.
Leukoreduction
ξ Leukocyte-reduced components are indicated to:
1. Decrease the frequency of recurrent febrile nonhemolytic transfusion
reactions
2. Reduce the incidence of HLA alloimmunization
3. Reduce the risk of transfusion-transmissible CMV (i.e., CMV safe)
ξ All blood products are leukocyte reduced (CMV safe)
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CMV seronegative
ξ Transfusion of CMV-seronegative blood is indicated in CMV-seronegative
recipients who are at risk for significant CMV disease
ξ Transmission of CMV infection is associated with cellular blood components
ξ CMV-seronegative blood is selected by performing testing for antibodies to CMV
Irradiation
ξ Irradiated blood is indicated for use in patients that are at risk for Graft-Versus-
Host-Disease (GVHD) from transfusion.
ξ Blood components that contain viable lymphocytes may be irradiated to prevent
proliferation of T lymphocytes, which is the immediate cause of GVHD.
ξ Irradiated blood is prepared by exposing the component to a source of radiation.
Indication
Codes Patient Characteristics
Blood Product
Characteristics
CMV
Seronegative Irradiation
S1 Patients during the first four months of life X X
S2 Patients < 1 year of age with unexplained illness such as growth
failure, persistent diarrhea, recurrent or unusual infections, etc. X
S3 Heart/lung transplant candidate/recipient X
S4 Patients with aplastic anemia or unexplained cytopenias, particularly if treated with antilymphocyte or antithymocyte globulin X
S5 Patients with lymphopenia (absolute lymphocyte count < 500/mL) and bone marrow suppression X
S6 Peripheral stem cell/bone marrow transplant candidate/recipient X
S7 Hematological malignancies including Hodgkin’s disease,
lymphoma, leukemia and myelodysplastic syndromes X
S8
Severe immunosuppression- non-hematologic cancer patients
treated with multiagent chemotherapy or combined
chemo/radiotherapy within the past year
X
S9
Immunodeficient patients (e.g., congenital immunodeficiency who
exhibit defective cell medicated immunity, DiGeorge syndrome,
Wiscott Aldrich syndrome, SCID)
X
S10 Intrauterine transfusions X X
S11 Patients receiving donor units from blood relatives X
S12 Recipients of HLA matched or crossmatched platelets X
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UW Health Implementation
Potential Benefits:
ξ Improved oxygen carrying capacity
ξ Improved clotting
Potential Harms:
ξ Delayed hemolytic reaction (DHTR)
ξ Hepatitis B, Hepatitis C, HIV-AIDS infection/transmission
ξ Transmission of other infectious diseases (i.e., cytomegalovirus, HTLV-1, malaria)
ξ Iron overload
ξ Transfusion-associated Graft vs. Host Disease
Implementation Plan/Tools
1. Guideline will be housed on U-Connect in a dedicated folder for CPGs.
2. Release of the guideline will be advertised in the Clinical Knowledge Management
Corner within the Best Practice newsletter.
3. Links to this guideline will be updated and/or added in appropriate Health Link or
equivalent tools, including:
EAPs
Red Blood Cells (Pediatric) [BLB0013] Red Blood Cells (Neonatal) [BLB0023]
Plasma (Pediatric) [BLB0010] Plasma (Neonatal) [BLB0024]
Platelets (Pediatric) [BLB0011] Platelets (Neonatal) [BLB0025]
Cryoprecipitate (Pediatric) [BLB0012] Cryoprecipitate (Neonatal) [BLB0026]
Order Sets/Smart Sets
OP – Blood Transfusion – Pediatric [2641]
IP – Blood Transfusion – Neonatal – Supplemental [5033]
IP – Blood Transfusion – Pediatric – Supplemental [1267]
IP – BMT - Blood Transfusion – Supplemental [4179]
IP – Apheresis – Pediatric – Procedure [3527]
IP – Comprehensive Donor Blood Product/Transfusion Orders [4069]
Delegation Protocols
Blood and Bone Marrow Transplant (BMT) Service Transfusion – Adult/Pediatric [50]
Disclaimer
CPGs are described to assist clinicians by providing a framework for the evaluation and
treatment of patients. This Clinical Practice Guideline outlines the preferred approach
for most patients. It is not intended to replace a clinician’s judgment or to establish a
protocol for all patients. It is understood that some patients will not fit the clinical
condition contemplated by a guideline and that a guideline will rarely establish the only
appropriate approach to a problem.
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Appendix A. Evidence Grading Schemes
GRADE Ranking of Evidence
High We are confident that the effect in the study reflects the actual effect.
Moderate We are quite confident that the effect in the study is close to the true effect, but it is also possible it
is substantially different.
Low The true effect may differ significantly from the estimate.
Very Low The true effect is likely to be substantially different from the estimated effect.
GRADE Ratings for Recommendations
Strong for using/Strong against using The net benefit of the treatment is clear, patient values and
circumstances are unlikely to affect the decision.
Weak for using/ Weak against using The evidence is weak or the balance of positive and negative effects
is vague.
American Family Physician Grading Scheme
A Consistent, good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, disease-oriented evidence, usual practice, expert opinion, or case series
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5. Genetics SoHOCo, Pediatrics AAo. Health supervision for children with sickle cell
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Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised: 09/2015CCKM@uwhealth.org

15
9. Estcourt L, Stanworth S, Doree C, et al. Prophylactic platelet transfusion for prevention
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transplantation. Cochrane Database Syst Rev. 2012;5:CD004269.
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