Society for the Advancement of Patient Blood Management: Pediatric and Neonatal Medicine

View all recommendations from this society

September 22, 2021

Avoid transfusing older RBC units (>7 days) in infants <10 kg or < 1 year of age requiring massive transfusions to prevent hyperkalemic cardiac arrest.

Transfusion-associated hyperkalemia resulting in cardiac arrest (TAHCA) has been recognized as a complication of massive RBC transfusion in children. During storage, potassium in the extracellular fluid of RBC units stored in additive solutions increases linearly over time. Transfusion of older RBC units (≥7 days) should be avoided when large volume/ massive transfusions are expected in neonates and children, such as in craniosynostosis and spinal surgeries, neonatal CPB prime, and cannulation for ECMO or trauma. Although potentially limited in supply, the use of fresh RBC units (<7 days) should be used in large volume/ massive transfusions in neonates and children to prevent hyperkalemic cardiac arrest

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

How The List Was Created

The Executive Committee and Board of Directors (BOD) of the Society for the Advancement of Patient Blood Management (SABM) had a strong desire to participate in the Choosing Wisely® campaign. Participation allows SABM to align with the national Choosing Wisely® team and other specialty societies to further the mission of collaborative physician-patient healthcare delivery and responsible use of resources.

A Task Force composed of specialists in neonatal and pediatric medicine and surgery was appointed at the suggestion of the SABM Educational Oversight Committee. With SABM BOD approval, this Task Force drafted an initial set of statements. Evidence-based recommendations were based on our Society’s foundational pillars and structured around published SABM Standards. For this particular list, the SABM Standards, Section 13, 5th edition for neonatal and pediatric patients were critical for statement development. An essential element was the review of relevant literature for supporting evidence applicable to each statement. Ultimately, the draft recommendations were vetted by the Task Force. This resulted in the final five statements for which evidentiary materials and pertinent references were written. The Educational Oversight Committee and the BOD approved the materials prior to submission to the Choosing Wisely® national team.

Working with this initiative, our selected recommendations and integrated materials will be further honed based on subsequent Campaign review. The list and supporting evidence, once approved, will form the basis of a manuscript for publication in a peer-reviewed journal. We foresee this as a vehicle for outreach to other professional societies, healthcare providers and patients.


Yamada C, Edelson M, Lee A, Saifee NH, Bahar B, Delaney M. Transfusion-associated hyperkalemia in pediatric population: Prevalence, risk factors, survival, infusion
rate, and RBC unit features. Transfusion. 2021 Apr;61(4):1093-1101
Strauss RG. RBC storage and avoiding hyperkalemia from transfusions to neonates & infants. Transfusion. 2010;50(9):1862-1865

Lee AC, Reduque LL, Luban NL, Ness PM, Anton B, Heitmiller ES. Transfusion-associated hyperkalemic cardiac arrest in pediatric patients receiving massive transfusion.
Sesok-Pizzini D, Pizzini MA. Hyperkalemic cardiac arrest in pediatric patients undergoing massive transfusion: unplanned emergencies. Transfusion. 2014 Jan;54(1):4-7

Cardigan R, New HV, Tinegate H, Thomas S. Washed red cells: theory and practice. Vox Sang. 2020 Nov;115(8):606-616

New HV, Berryman J, Bolton-Maggs PH, Cantwell C, Chalmers EA, Davies T, Gottstein R, Kelleher A, Kumar S, Morley SL, Stanworth SJ; British Committee for Standards
in Haematology. Guidelines on transfusion for fetuses, neonates and older children. Br J Haematol. 2016 Dec;175(5):784-828