This study has highlighted disparities in care owing to financial, infrastructural and cultural reasons. This study had a significantly high percentage of males (73%). Studies in Bangladesh and south Asia have shown that the sex of a child can influence parental health seeking behaviour and adherence to treatment [14,15,16]. However, these factors were not investigated in this study and hence we cannot determine the reasons for this difference.
Majority of children (76%) underwent major surgery. CMCH being a large tertiary centre receives many complex referrals from less equipped hospitals. The high percentage of major surgery also potentially reflects the culture in rural communities where parents do not seek surgical intervention until significant deterioration of their child’s condition.
Here, 85% of those transfused underwent major surgery which is usually associated with higher risk of blood loss and coexisting medical comorbidities. Forty percentage of patients transfused had not undergone prior blood testing for anaemia, again with a predominance in the major surgery group. In patients with visible features of anaemia undergoing emergency surgery with high risk of blood loss, clinicians did not request preoperative anaemia testing due to the long waiting time for blood results (up to 24 h). Clinicians were also significantly influenced by families’ ability to cover testing costs.
Seventy-five percentage of the patients who underwent haemoglobin testing prior to transfusion had a haemoglobin >80 g/L. Discussion with clinicians outlines reasons such as anticipated volume of blood loss and comorbidities of the patient. Similarly, a Chinese study of 1506 children undergoing intraoperative transfusion found that 45.3% of those transfused had an Hb >80 g/L and 28.8% had Hb >100 g/L. This was attributed to haemodynamic parameters, body size, clinician preference and lack of paediatric perioperative guidelines .
Although preoperative anaemia carries negative outcomes, the haemoglobin threshold to warrant postponement of surgery is unknown. Evidence from the landmark Canadian paediatric ICU trial involving 637 children showed that in stable critically ill children, a threshold of 70 g/L can reduce the transfusion requirements without being associated with adverse outcomes when compared to a liberal threshold of 95 g/L . A Danish study of 210 adolescents undergoing scoliosis surgery also advocated a threshold of 70 g/L .
A review of six studies also concluded that a threshold of 69.3 g/L for children admitted to ICU with burns, sepsis or after general and cardiac surgery was safe (excluding cyanotic heart disease) . Importantly, these studies on restrictive transfusion were conducted in settings well resourced for monitoring and testing. Additionally, they have been done in the context of the critical care and cannot be translated directly to the preoperative setting.
The likelihood of over-transfusion in this study is high because clinical assessment of anaemia can be subjective. Blood transfusion carries several risks including infections, febrile reactions, donor mismatch, lung injury and anaphylaxis. Clinicians at CMCH reported febrile reactions, urticarial, allergic reactions and fluid overload in the last 5 years.
Screening donated blood for HIV, HBV, HCV, syphilis and malaria is mandatory in Bangladesh. However, studies in Bangladesh and India have shown the presence of hepatitis B in donated blood that underwent pre-transfusion screening [21,22,23]. This is potentially due to lack of trained staff and highly sensitive modalities of screening.
Transfusion also poses logistical challenges. Due to the high prevalence of blood borne infections among paid donors, the Safe Blood Transfusion initiative was implemented in Bangladesh, which led to a sharp decrease in the number of paid donors from 70 to 10% in the early 2000s . Hence, blood banks depend on blood donation from relatives, voluntary organisations and hospital staff (when there is a lack of donors and families are unfit to donate).
Blood for donation is usually arranged on demand. For non-urgent cases at CMCH, it can take up to 18 h to carry out donor selection, screening, cross-matching and organising equipment. Written informed consent is taken prior to transfusion.
The health risks and costs highlight the need for titration of transfusion to haemoglobin levels. Bedside point-of-care (POC) haemoglobin testing can increase preoperative anaemia testing. POC testing for perinatal HIV, syphilis and malaria infections have been shown to be very useful in resource-limited settings . POC anaemia testing has been demonstrated to be of comparable accuracy to standard methods . A meta-analysis showed that diagnosing anaemia via POC testing was more accurate than clinical assessment alone .
We propose a prospective study on the clinical impact of POC anaemia testing alongside a restrictive transfusion approach. To conduct the prospective study, we have created a new decision-making guide (Fig. 3). This guide involves a multidisciplinary decision-making approach in aspects such as restrictive blood transfusion, intentional blood pressure control, generous cautery, judicious use of tourniquets and tranexamic acid to reduce bleeding on a case-by-case basis.
Tranexamic acid is a widely available drug at CMCH and is currently considered on an individual basis in the context of trauma and surgery involving significant risk of blood loss (>7 mls/kg). Tranexamic acid has been recommended in paediatric trauma and major surgery as there is evidence that it reduces perioperative blood loss and need for transfusions .
This new proposed guide suggests postponing elective surgery in certain cases, after careful consideration of the patient’s clinical picture and financial circumstances (such as travel and accommodation costs for patients from rural regions). Where postponing surgery will not impact long term health, expedited surgery can be arranged after optimisation of haemoglobin level.
As part of this prospective study, educational awareness regarding transfusion risks and patient blood management strategies is being given to clinicians at CMCH and rural referring hospitals through existing outreach programs.