Anaemia (Severe)

For FFP and platelets see Bleeding protocol, section treatment.

Transfusion Requirement

Hb < 4 g/dL ~ PCV < 12%
Hb < 6 g/dL ~ PCV < 18% AND:
- Dehydration
- Shock
- Significant respiratory distress or acidosis
- Prostration (inability to sit up)
- Heart Failure
- MPS 4+
- BCS less than or equal to 3

Causes

(most common causes written in CAPITALS - always check and treat those in Malawi as their presence significantly increases post-discharge mortality)

Decreased Production	Destruction	Loss
Malnutrition IRON DEFICIENCY (hookworm) HIV Chronic disease ( TB) SEPTICAEMIA/ INFECTION MALARIA Aplastic anemia Leukaemia Parvo B19	Malaria Sepsis (DIC) Thalasseaemia SICKLE CELL DISEASE G6PD Haemolytic Uraemic. Syn. Auto-Immune Disorders	Hookworm Trauma Bleeding disorders Schistosomiasis

Important points in history

Bleeding (tendency) (nose/ gums/ stool/ urine)
Jaundice
Colour of urine
Fever
Previous transfusions
History of painful crises (SCD)
Drug history (G6PD)
Family, social and geographic history

Important Points on Examination

Respiratory
Rate/Pattern
Heart rate/ Cardiac failure
BCS
Jaundice
Malnourished
Dehydrated
Septic/ Shocked
Enlarged Nodes/ Spleen/ Swellings
Bleeding/ haematoma/ trauma
Bone deformities/ frontal bossing

Investigations

In all children check:

MPs + PCV + HIV status
Grouping and Cross-match if transfusion is being considered

If the MPS are negative or if other disease suspected:
- Full Blood Count (look at MCV) + Diff. - take BEFORE transfusion
- Blood Culture if septicaemia considered
If signs of other disease present consider:

Urinalysis
Sickle Cell test
Chest X-Ray
Stool for parasites and/or occult blood
Peripheral blood film (to exclude malignancy) - send to department lab
Consider Bone Marrow Biopsy after FBC results discussed

Management

Blood transfusion (Indicate volume and PCV result on the requesting form), deliver the sample to blood bank, follow up to obtain the crossmatched blood
Oxygen - even with good saturations (will improve O2 delivery to tissues)
Treat cause (e.g. Artesunate, antibiotics, antihelminths etc)
Persistent fever after 48 hrs of Artesunate: consider Salmonella infection

Transfusion and monitoring

	Not malnurished	Malnurished
Volume	Either 10 ml/kg of packed cells or 20 ml/kg of whole blood in 3-4 hours	If stable await senior review If unstable give whole blood (10 ml/kg in 4 hours) If signs of cardiac failure, infuse 5-7ml/kg of packed cells in 3-4 hours (Malnutrition)
Furosemide iv	Only if fluid overload / cardiac failure 1-2 mg/kg, max. 20 mg (give half way through transfusion)	Give in all malnourished children 1-2 mg/kg (give half way through transfusion)
Check PCV and/or Hb + MPs	Consider after 24 h if still signs of symptomatic severe anaemia
Repeat transfusion	Next morning (if necessary) - i.e. Hb 4 g/dL or PCV < 12% and/ or patient still symptomatic	NOT unless Hb/PCV less than pre-transfusion or not increasing after 4 days

Discharge and follow-up

Discharge when child is pink (Hb > 4 g/dL or PCV > 12% and asymptomatic), not vomiting, no oedema
Albendazole treatment to ALL anaemic children > 1 year
Ferrous sulfate and folic acid to all anaemic children except those with sickle cell disease (DO NOT GIVE IRON SUPPLEMENTS TO A CHILD WITH ACUTE MALARIA/ SEPTICAEMIA. WAIT UNTILL THEY ARE DISCHARGED.) FeFol will be needed for 3 months
Check that children have a bed net at home. If not, give one from A&E
Arrange a health centre follow-up 2 weeks after discharge for PCV/ Hb (there is a high risk of recurrence/ death in the first month after transfusion)