2018 Audit of the use of FFP and cryoprecipitate in neonates and children

Key objectives

  • Ascertain how FFP and cryoprecipitate are used for prophylactic transfusion.
  • Improve understanding of the use of alternatives to plasma transfusion for infants and children.
  • Improve understanding of the management of bleeding episodes in children, including implementation of Major Haemorrhage protocols.
  • Compare practice with national recommendations.
  • Identify clinical areas where further quality improvement initiatives should be targeted.

What did we audit?

  • Each hospital was asked to audit the medical and care records of 20 children receiving FFP and 20 children receiving cryoprecipitate in the prophylactic setting, and a sample of children (target 10) who had a transfusion as part of the management of active bleeding or trauma.

Who took part?

  • 57 sites contributed organisational data
  • 80 sites participated in the clinical audit
  • 675 transfusion events were analysed

What did we find?

Main findings and recommendations

Organisational data
  • Most, but not all sites transfusing the relevant age groups had local transfusion policies/guidelines. 87.3% of sites with a neonatal unit had a policy/local guideline for the transfusion of FFP and cryoprecipitate to neonates. Similarly, 83.3% of relevant sites had a policy/local guideline for the transfusion of FFP and cryoprecipitate to children.
    • BSH guidelines (2016) state that hospitals should have clear guidelines on transfusion thresholds for different paediatric groups.
  • 26.3% of sites had policies of routinely checking coagulation screens on all preterm neonates, which could increase the risk of unnecessary FFP transfusion.
    • BSH guidelines (2016) state that a policy of routine coagulation screening is inappropriate as results are difficult to interpret in neonates and routine testing may lead to increased transfusion of FFP without benefit.
  • 28.1% of sites had no major haemorrhage protocol (MHP) for children.
    • BSH guidelines (2016) state that hospitals which may encounter children with massive blood loss should have a dedicated children’s major blood loss guideline, which would include advice on the correct age-adjusted volumes of blood components in an emergency.
  • For those sites that had an MHP, tranexamic acid use was not included in MHPs for children at 17.5% of sites.
    • BSH guidelines (2016) recommend that tranexamic acid should be used where massive blood loss is anticipated in children presenting with major traumatic injuries, according to the timing and dosage recommended by RCPCH (2012).
  • 40.4% of sites did not have a concessionary release policy for use of acceptable alternatives to ‘paediatric’ blood components in emergencies for major bleeding.
    • In order to avoid delays in blood provision, BSH guidelines (2016) recommend using pre-agreed hierarchies of alternative components in case specific blood components are not available in an emergency.


Clinical audit
  • 76.5% of neonates were transfused prophylactic FFP for ‘abnormal coagulation’, in the absence of surgery/invasive procedure. 23.2% of neonates that had a coagulation test reported within the 24 hours prior to transfusion had an internationalised ratio (INR)/prothrombin time ratio (PTR) of < 1.5, not significantly abnormal.
    • BSH guidelines (BSH, 2016) recommend that there is no evidence to support the routine use of fresh frozen plasma (FFP) to try to correct abnormalities of the coagulation screen alone in non-bleeding neonates.
  • Prevention of intraventricular haemorrhage (IVH) was given as an additional reason for transfusion for around a third of all prophylactic FFP (33.0%; 73/222) and cryoprecipitate (39.1%; 27/69) transfusions given for ‘abnormal coagulation the absence of invasive procedure or surgery’.
    • BSH guidelines (2016) recommend that FFP should not be used for simple volume replacement or routinely for prevention of IVH.
    • The use of cryoprecipitate for this indication was unexpected. BSH guidelines (BSH, 2016) recommend that prophylactic cryoprecipitate should not be routinely administered to non-bleeding children with decreased fibrinogen including prior to surgery. It may be considered for fibrinogen <1 g/l for surgery at risk of significant bleeding or to critical sites.
  • The volume (mL/kg) of neonatal prophylactic FFP and cryoprecipitate transfusions was >20 mL/kg for 13.0% of FFP transfusions and >10mL/kg for 41.5% of cryoprecipitate transfusions where data were available. For all children this was 17.6% for FFP and 31.7% for cryoprecipitate.
    • BSH guidelines (2016) describe suggested transfusion volumes and indicate that care should be taken to avoid volume overload.
  • Volumes of prophylactic FFP and cryoprecipitate were <10mL/kg for 15.4% FFP and < 5mL/kg for 15.9% cryoprecipitate transfusions where data were available.
    • These volumes may be sub-therapeutic and are below those suggested by BSH (2016; for FFP 15-20mL/kg, with higher volumes particularly in bleeding patients; for cryoprecipitate 5-10mL/kg).
  • 59.4% of children transfused with prophylactic FFP and 48.8% with cryoprecipitate who had cardiac surgery as the underlying condition were stated to have ‘normal coagulation’, and the majority were ≥ 1 month old; of these children transfused with FFP, 61.0% were stated to have been given FFP for pump priming/cardiac bypass, and all were > 2 months old.
    • NATA cardiac surgery guidelines (Faraoini et al, 2019) suggest the addition of FFP to the cardiopulmonary bypass (CPB) prime in neonates (<30 days) undergoing cardiac surgery with cardiopulmonary bypass. However, no recommendation could be made for infants and children.
  • Tranexamic acid was used for only 18.2% of cardiac surgery children transfused prophylactic FFP for ‘abnormal coagulation’ and surgery or invasive procedure, and for 64.3% of those transfused cryoprecipitate in the same setting.
    • BSH guidelines (2016) recommend that tranexamic acid should be considered in all children undergoing surgery where there is risk of significant bleeding. NATA cardiac surgery guidelines (Faraoini et al, 2019) recommend prophylactic administration of lysine analogs (either tranexamic acid or epsilon-aminocaproic acid) for all neonates and children undergoing surgery with CPB in order to reduce perioperative bleeding and transfusion.
  • Tranexamic acid was used for 83.3% (10/12) of the cases of trauma within 3 hours of trauma injury, but the numbers were small.
    • According to BSH guidelines (2016), tranexamic acid should be used where massive blood loss is anticipated in children presenting with major traumatic injuries.
  • For children with major haemorrhage, the MHP was only activated in 55.6% of cases.
    • Failure to activate the MHP in situations of major haemorrhage can lead to delayed transfusion and death (Naryan et al, SHOT 2021)