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

Five Things Physicians and Patients Should Question

Released September 22, 2021; Last reviewed 2022

  1. 1

    Don’t proceed with non-emergent major surgery until anemia is evaluated and treated.

    Anemia is a global health problem with an incidence of up to 25% in neonates, infants and children. An independent association between preoperative anemia and postoperative morbidity and mortality has been reported. Expert consensus guidelines recommend screening 3 to 6 weeks before majo elective surgery. Targeted preventative and therapeutic strategies, which may include iron supplementation, to improve the hematologic status of anemic patients prior to surgery could reduce blood transfusions, improve safety, and decrease costs.

  2. 2

    Avoid hemodilution and unnecessary blood draws to avoid dilutional coagulopathy and iatrogenic anemia.

    Excessive fluid administration causing hemodilution and unnecessary phlebotomy reduce hemoglobin levels and may unnecessarily trigger red blood cell transfusions based on a numeric threshold despite adequate oxygen carrying capacity. Replacing blood loss with intravenous fluids which do not contain adequate clotting factors (i.e. crystalloids, colloids and packed red blood cells) may lead to dilutional coagulopathy causing a bleeding diathesis. Routine blood draws should be avoided, and if necessary, blood laboratory investigations should be consolidated when appropriate, using minimal volume withdrawal and closed loop collecting systems.

  3. 3

    Avoid/reduce allogenic transfusion by first using cell salvage for pediatric high blood loss surgery.

    Cell salvage, as a part of a multimodal patient blood management strategy in pediatrics, may reduce unnecessary blood transfusions, improve outcomes and decrease costs. Expert consensus recommendations, observational reports and prospective research suggest that utilizing cell salvage decreases RBC transfusions in infants, children and adolescents undergoing craniosynostosis, spinal and cardiac surgical procedures. While prospective clinical studies are few, the evidence suggests that cell salvage is feasible, effective, and safe. More high-quality trials will further guide optimum use.

  4. 4

    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

  5. 5

    Avoid dependence on standard laboratory values for transfusion decisions; consideration of the patient’s clinical status is requisite.

    Laboratory studies may not accurately portray the individual’s hemostatic status, bleeding risk or need for transfusion; laboratory studies must be assessed in the context of the patient’s overall clinical status. Additional platelet function and viscoelastic testing should be performed to guide blood product transfusions in children with (or at risk for) moderate to severe bleeding. Pharmacologic modalities (i.e. antifibrinolytics, topical hemostatic agents) should be utilized as appropriate. Hemoglobin levels should be assessed in the context of the patient’s fluid status, hemodynamics, and degree of cardiopulmonary reserve; with the goal of restrictive RBC transfusion practices.

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.

The Society for the Advancement of Patient Blood Management (SABM) was founded in 2001 by healthcare providers, nurses and physicians, who saw the need for a new way of thinking about transfusion as a therapy. SABM included thought leaders who promulgated the concept of patient blood management as the new standard of care. The SABM mission is broad, its foundation based on appropriate evidence-based transfusion guidelines, the management of anemia, optimization of coagulation and minimization of bleeding, and utilization of interdisciplinary blood conservation strategies. The goal is improved outcomes for patients of all ages. SABM membership includes numerous practitioners involved in the care of neonates and pediatric patients and SABM has published Standards for PBM practice specific to these patient populations.

Today, SABM is recognized as a key educational resource for patient blood management. SABM is grounded in scientific validation, evidence-based practices and focused on promoting the patients’ best interest through effective and optimal patient blood management.


How This 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.


  1. World Health Organization (WHO) 63rd World Health Assembly. Worldwide prevalence of anemia. 1993-2005. Goobie SM, Faraoni D, Zurakowski D, DiNardo JA. Association of Preoperative Anemia With Postoperative Mortality in Neonates. JAMA Pediatr. 2016 Sep 1;170(9):855-62

    Faraoni D, DiNardo JA, Goobie SM. Relationship Between Preoperative Anemia and In-Hospital Mortality in Children Undergoing Noncardiac Surgery. Anesth Analg. 2016 Dec;123(6):1582-1587

    Australian guidelines ESA Management of severe Perioperative bleeding Eur J Anaesthesiol 2017 Goobie SM, Gallagher T, Gross I, Shander A. Society for the advancement of blood management administrative and clinical standards for patient blood management programs. 4th edition (pediatric version) .Paediatr Anaesth. 2019 Mar;29(3):231-236

  2. Spahn DR, Bouillon B, Cerny V, Duranteau J, Filipescu D, Hunt BJ, Komadina R, Maegele M, Nardi G, Riddez L, Samama CM, Vincent JL, Rossaint R. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Crit Care. 2019 Mar 27;23(1):98

    National Blood Authority Australia: Patient Blood Management Guidelines Module 6: Neonatal and Paediatrics, April 2016.

    Valentine SL, Bateman ST. Identifying factors to minimize phlebotomy-induced blood loss in the pediatric intensive care unit. Pediatr Crit Care Med. 2012 Jan;13(1):22-7

    Haas T, Mauch J, Weiss M, Schmugge M. Management of Dilutional Coagulopathy during Pediatric Major Surgery. Transfus Med Hemother. 2012 Apr; 39(2):114-119

  3. Goobie SM, Gallagher T, Gross I, Shander A. Society for the advancement of blood management administrative and clinical standards for patient blood management
    programs. 4th edition (pediatric version).Paediatr Anaesth. 2019 Mar;29(3):231-236

    Faraoni D, Meier J, New HV, Van der Linden PJ, Hunt BJ. Patient Blood Management for Neonates and Children Undergoing Cardiac Surgery: 2019 NATA Guidelines.
    J Cardiothorac Vasc Anesth. 2019 Dec;33(12):3249-3263

    Patient Blood Management evidence based guidelines: Module 6 Neonatal and Paediatrics

    Cholette JM, Powers KS, Alfieris GM, Angona R, Henrichs KF, Masel D, Swartz MF, Daugherty LE, Belmont K, Blumberg N. Transfusion of cell saver salvaged blood in
    neonates and infants undergoing open heart surgery significantly reduces RBC and coagulant product transfusions and donor exposures: results of a prospective,
    randomized, clinical trial. Pediatr Crit Care Med. 2013 Feb;14(2):137-47

    Stone N, Sardana V, Missiuna P. Indications and Outcomes of Cell Saver in Adolescent Scoliosis Correction Surgery: A Systematic Review. Spine (Phila Pa 1976). 2017
    Mar 15;42(6):E363-E370

    Kozek-Langenecker SA, Ahmed AB, Afshari A, Albaladejo P, Aldecoa C, Barauskas G, De Robertis E, Faraoni D, Filipescu DC, Fries D, Haas T, Jacob M, Lancé MD, Pitarch
    JVL, Mallett S, Meier J, Molnar ZL, Rahe-Meyer N, Samama CM, Stensballe J, Van der Linden PJF, Wikkelsø AJ, Wouters P, Wyffels P, Zacharowski K. Management of
    severe perioperative bleeding: guidelines from the European Society of Anaesthesiology: First update 2016. Eur J Anaesthesiol. 2017 Jun; 34(6):332-395

  4. 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


  5. Carson JL, Guyatt G, Heddle NM, Grossman BJ, Cohn CS, Fung MK, Gernsheimer T, Holcomb JB, Kaplan LJ, Katz LM, Peterson N, Ramsey G, Rao SV, Roback JD, Shander A, Tobian AA. Clinical Practice Guidelines From the AABB: Red Blood Cell Transfusion Thresholds and Storage. JAMA. 2016 Nov 15;316(19):2025-2035

    American Society of Anesthesiologists Task Force on Perioperative Blood Management. Practice guidelines for perioperative blood management: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Blood Management*. Anesthesiology. 2015 Feb;122(2):241-75

    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

    Valentine SL, Bembea MM, Muszynski JA, Cholette JM, Doctor A, Spinella PC, Steiner ME, Tucci M, Hassan NE, Parker RI, Lacroix J, Argent A, Carson JL, Remy KE, Demaret P, Emeriaud G, Kneyber MCJ, Guzzetta N, Hall MW, Macrae D, Karam O, Russell RT, Stricker PA, Vogel AM, Tasker RC, Turgeon AF, Schwartz SM, Willems A, Josephson CD, Luban NLC, Lehmann LE, Stanworth SJ, Zantek ND, Bunchman TE, Cheifetz IM, Fortenberry JD, Delaney M, van de Watering L, Robinson KA, Malone S, Steffen KM, Bateman ST; Pediatric Critical Care Transfusion and Anemia Expertise Initiative (TAXI); Pediatric Critical Care Blood Research Network (BloodNet), and the Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network. Consensus Recommendations for RBC Transfusion Practice in Critically Ill Children From the Pediatric Critical Care Transfusion and Anemia Expertise Initiative. Pediatr Crit Care Med. 2018 Sep;19(9):884-898