2022 Audit of Patient Blood Management in Elective Paediatric Surgery

2022 Audit of Patient Blood Management in Elective Paediatric Surgery

11 February 2025

Key objectives

  • Compare PBM practice against standards in guidelines for a cohort of children at multiple UK Centres undergoing elective surgery where blood loss is expected to be significant.

  • Provide benchmarking feedback to participating Centres on opportunities for improvement.

What did we audit?

  • All hospitals in the UK that perform predefined major paediatric surgical procedures were invited to participate. An initial survey was conducted to ascertain that the audit targeted all appropriate hospitals and types of surgery in the paediatric population.
  • Centres were asked to audit a maximum of 40 cases, with no minimum number of cases. Centres were able to include cases seen during the whole of 2022.

Who took part?

  • 30 centres contributed data
  • 735 patients were analysed

What did we find?

Main findings 

  • 75% (551/735) of children undergoing planned surgery with a significant risk of blood loss had a pre-operative assessment.

  • 90.9% (668/735) children had a full blood count performed preoperatively.

  • 18% (119/653) of all children (where the haemoglobin result was reported) were anaemic on their last haemoglobin check before surgery, with the highest prevalence 27% (54/210) in those under 5 years.

  • 11% (81/735) of all children were given iron preoperatively, majority orally.

  • 81% (17/21) of all children with anaemia were treated empirically with iron without laboratory confirmation of iron deficiency.

  • 29.8% (219/735) of children required a peri-operative allogeneic blood transfusion, 66.1% (158/239) of these transfusions were given intraoperatively.

  • 27/69 (39.1%) of postoperative transfusions were given due to Hb <70 g/L. The majority of the rest were given due to ongoing blood loss, clinical symptoms or haemoglobin <80 g/L with significant comorbidities. In 10/69 cases (14.5%) the reason for transfusion was unknown.

  • Tranexamic acid was given to 68.8% (506/735) of eligible children.

  • Cell salvage was used in 43.8% (322/735) of cases and in 79.8% (257/322) of these the salvaged blood was reinfused.

  • In 38.4% (84/219) of children who received an allogeneic transfusion, cell salvage had not been used.

  • Only half of centres with cell salvage have a specific paediatric protocol.

  • In 77.8% (572/735) of cases there was evidence that the family was informed of the possible need for transfusion but only 16.6% (122/735) had documented written/digital information provision.

     

Our recommendations

  • All children and young people should be offered preoperative health screening for procedures with a significant risk of blood loss, at least 6 weeks pre-operatively, which should include checking the full blood count. Two potential points in the pathway are at booking and in the preoperative assessment clinic.

  • Local policies should clearly define who is responsible for reviewing and acting on results and for follow-up to ensure pre-operative anaemia treatment is effective.

  • Centres should have a clear pathway for investigation and management of pre-operative anaemia in children.

  • The rationale for transfusion should be clearly documented, particularly where the Hb is outside standard triggers.

  • Tranexamic acid must be considered for all children undergoing surgery where there is risk of significant bleeding, unless contraindicated. Centres should update their policies to incorporate the 2022 Joint Royal College guidance and the dosing schedule in paediatrics which now encourage wider usage of tranexamic acid.

  • Centres should have a specific policy for cell salvage in paediatrics. This should be considered for all children weighing at least 10 kg having surgery with a risk of blood loss >10% of blood volume.

  • The risk of transfusion and strategies offered to avoid transfusion should be included in the consent process before major paediatric surgery with a risk of blood loss. Families must be given written information about transfusion. This could be in an electronic format, such as providing the QR code for national resources (NHSBT, 2024)

  • Centres should have a means of recording that written information has been provided, e.g. using a code on electronic records, which can be readily audited.