A 12-year-old girl weighing 35 kg was posted for scoliosis deformity correction. Her Cobb’s angle was 80° and her surgical plan was a D2–S2 instrumentation and fusion. Her preoperative haemoglobin (Hb) was 8.8 gm/dL. As major blood loss was anticipated during the surgery, the surgery was deferred for 1 month to correct her anaemia. She was evaluated and diagnosed to have iron deficiency anaemia and was started on oral iron therapy. One month later, her Hb level rose to 13.2 gm/dL and she was then taken up for surgery. We followed patient blood management (PBM) strategies in this patient, and these included preoperative correction of iron deficiency anaemia, intraoperative and postoperative administration of tranexamic acid, acute normovolemic haemodilution (ANH), intraoperative cell salvage (ICS), and restrictive transfusion strategies. Our plan of anaesthetic management was general anaesthesia with total intravenous anaesthesia (TIVA) for maintenance. Under standard monitoring, she was induced with titrated boluses of intravenous fentanyl and propofol and intubated under atracurium. A central line was placed in the right subclavian vein and arterial line placed in the left radial artery. A Hb level of 10 gm/dL was targeted and a calculated volume of 550 ml blood was harvested. She was monitored intensively during the collection time. The collected volume was replaced with crystalloids. After phlebotomy was completed, all inhalational agents were stopped and TIVA with propofol, dexmedetomidine, and ketamine was initiated and was guided by bispectral index monitoring. Intravenous tranexamic acid was given in a bolus of 20 mg/kg and the infusion was maintained at 5 mg/kg/h. Intraoperative cell salvage was done using the CATS Plus (Fresenius Kabi®) cell saver machine and a volume of 260 ml of red blood cells was salvaged. The haematocrit of the salvaged blood was 65%. Intraoperative blood loss was 1800 mL. The preoperatively collected blood and salvaged red cells were transfused slowly in tandem once the major part of the instrumentation was over, followed by one pint of fresh frozen plasma. One ampoule of calcium gluconate was also administered. She remained haemodynamically stable throughout surgery. After completing all transfusions, her postoperative Hb was 10.5 gm/dL and coagulation parameters were normal. She made an uneventful recovery and was discharged on the fifth postoperative day.
Our report showcases the successful implementation of the principles of PBM in a paediatric patient. Had we taken her up for surgery at her initial Hb level of 8.8 gm/dL and with a loss of nearly 2 L intraoperatively, she would have required multiple allogenic blood transfusions. Preoperative screening and correction of anaemia should be done in all cases associated with major blood loss. Restrictive transfusion strategies have been shown to be safe in paediatric patients of all age groups. Safety of ANH in paediatric patients is well described. The major concerns include the possibility of haemodynamic instability during ANH and the cost and resources required for ICS. Although PBM is well established in adults, the evidence in paediatric patients is still inadequate. The guidelines published by the Society for the Advancement of Blood Management recommend PBM in paediatric patients. PBM is gaining more importance in this era of the pandemic that is witnessing a severe shortage of blood products. The pandemic has also affected the implementation of evidence-based medicine. Nevertheless, we should adopt age-appropriate evidence-based PBM strategies in our routine perioperative management of paediatric patients.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
The authors would like to express their sincere gratitude to Dr Anand M R for his help in the management of this patient.
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