J. McArdle1, N. Ladak2, B. Clevenger3

1Newcastle-upon-Tyne NHS Foundation Trust, UK

2Sheffield Children's NHS Foundation Trust, UK

3Royal National Orthopaedic Hospital, UK


Patient blood management (PBM) during the peri-operative period is well established in adult practice; however, it has lagged behind in paediatrics. Considering this, a national comparative audit of patient blood management in elective paediatric surgery was carried out across 31 hospitals in the UK in 2022. The aim was to compare PBM practice against standards in guidelines for children undergoing elective surgery where blood loss was expected to be significant and provide opportunities for improvement.


All hospitals in the UK that perform predefined major paediatric surgical procedures were invited to participate. Sites audited a maximum of 40 cases, with no minimum number of cases, undertaken during the whole of 2022.

Inclusion criteria were; patients greater than 4 weeks old and less than 18 years old undergoing elective non-cardiac surgery where blood loss was expected to be significant and a group and screen sample was taken, or the patient cross-matched for the procedure.

Specific patient groups were excluded from the audit; these included: children with haemaglobinopathies and any form of haematological malignancy, children undergoing urgent or emergency surgery and any re-do or second side surgery.

The audit standards were:

Full blood count (FBC) measured at least six weeks preoperatively [1]

Optimising pre-operative haemoglobin by treating iron deficiency [2,3]

Transfusion threshold of 70 g/L in stable patients without co-morbidities or ongoing blood loss [3]

Tranexamic acid given where there is a risk of significant bleeding [3]

Consideration of using red cell salvage [3]

Patients at risk of blood loss should be informed about the risk of blood transfusion preoperatively [2].


Across 31 hospitals there were 735 patients’ data analysed. 89.4% (n=657) of patients had a pre-operative FBC measurement. 17.7% (n=116) of patients were anaemic on their last FBC check before surgery and of this group only 19% (n=22) were investigated with haematinics. 11.2% (n=81) received iron therapy. There was a total of 226 transfusions in 213 patients, giving an overall transfusion rate of 30%.

71% (n=505) of patients in whom it was not contra-indicated received tranexamic acid.

Cell salvage was used in 44% (n=320) of cases. There were 84 cases (39% of all transfused patients) where cell salvage was not used but the patient received an allogeneic transfusion. 16.6% (n=122) of patients had documented evidence of written information about blood transfusion pre-operatively.


This audit reviewed a range of standards relating to practice in PBM in the elective paediatric setting, with significant numbers of children receiving blood transfusions in the peri-operative period. Better implementation of the standards of PBM may reduce the rate of peri-operative blood transfusions.


[1] International Consensus Statement on the perioperative management of Anaemia and Iron deficiency Anaesthesia Dec 2016 DOI: 10.1111/anae.13773

[2] NICE quality standard QS138: Blood transfusion 2016 https://www.nice.org.uk/guidance/qs138/chapter/Quality-statements

[3] British Society of Haematology: Guidelines on transfusion for fetuses, neonates and older children 2016  https://doi.org/10.1111/bjh.14233

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