Transfusion management of severe anaemia in African children: a consensus algorithm

Department of Infectious Disease, Division of Medicine, Institute of Global Health and Innovation, Imperial College, London, UK. Uganda Blood Transfusion Services (BTS), National BTS, Kampala, Uganda. Department of Paediatrics and Child Health, School of Medicine, Makerere University and Mulago Hospital, Kampala, Uganda. Faculty of Health Sciences, Busitema University, Mbale Regional Referral Hospital, Mbale, Uganda. College of Medicine, Malawi-Liverpool-Wellcome Research Programme, Blantyre, Malawi. Soroti Regional Referral Hospital, Soroti, Uganda. Kenya Medical Research Institute (KEMRI)/Wellcome Trust Research Programme, Kilifi, Kenya. Malawi BTS, Blantyre, Malawi. Liverpool School of Tropical Medicine, Liverpool, UK. Haematology & Transfusion Service, Centre Hospitalier et Universitaire, Yaounde, Cameroon. Medical Research Council Clinical Trials Unit (MRC CTU), University College London, London, UK.

British journal of haematology. 2021
PICO Summary

Population

Children presenting to hospital with both uncomplicated and complicated severe anaemia enrolled in the TRACT trial (n= 3,196).

Intervention

Large volume of whole blood transfusion: 30 ml/kg, (n= 1,598).

Comparison

Recommended blood volume transfusion by current WHO guidelines: 20 ml/kg (n= 1,598).

Outcome

Transfusion volume (20 vs. 30 ml/kg whole blood equivalent) for children with severe anaemia had strong but opposing effects on mortality, depending on fever status. There was no evidence that nutritional status, presence of shock, malaria parasite burden or sickle cell disease status influenced outcomes or modified the interaction with fever status on volume required. Fever status at the time of ordering blood was a reliable determinant of volume required for optimal outcome. Elevated heart and respiratory rates normalised irrespective of transfusion volume and without diuretics. By consensus, a transfusion management algorithm was developed, incorporating three additional measurements of Hb post-admission, alongside clinical monitoring.
Abstract
The phase III Transfusion and Treatment of severe anaemia in African Children Trial (TRACT) found that conservative management of uncomplicated severe anaemia [haemoglobin (Hb) 40-60 g/l] was safe, and that transfusion volume (20 vs. 30 ml/kg whole blood equivalent) for children with severe anaemia (Hb <60 g/l) had strong but opposing effects on mortality, depending on fever status (>37·5°C). In 2020 a stakeholder meeting of paediatric and blood transfusion groups from Africa reviewed the results and additional analyses. Among all 3196 children receiving an initial transfusion there was no evidence that nutritional status, presence of shock, malaria parasite burden or sickle cell disease status influenced outcomes or modified the interaction with fever status on volume required. Fever status at the time of ordering blood was a reliable determinant of volume required for optimal outcome. Elevated heart and respiratory rates normalised irrespective of transfusion volume and without diuretics. By consensus, a transfusion management algorithm was developed, incorporating three additional measurements of Hb post-admission, alongside clinical monitoring. The proposed algorithm should help clinicians safely implement findings from TRACT. Further research should assess its implementation in routine clinical practice.
Study details
Language : eng
Credits : Bibliographic data from MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine