Paediatric massive haemorrhage – transfusion guidance

Objectives

Optimize rapid blood product delivery as per NHST paediatric massive haemorrhage policy (weight lower than 50kg).

Challenges: flow rate/mode of delivery

Delivery of warmed blood products rapidly through potentially small IV/IO access. Methods of administration are via the Belmont rapid transfusion device or manual delivery via 60ml Syringe via Buddy Lite portable fluid warmer (Trauma Team Ops Bag)

In general terms if flow rate greater than 100ml/min are required then use Belmont Device. Remember the Belmont can only bolus volumes calculated to the nearest 50ml.

Flow rate lower than 100ml/min then use Buddy Lite warmer and manually push blood products via 60ml syringe.

Cannula/IV access

To use the Belmont infusion device then a minimum cannula size of 20G (pink) is required as maximum flow rate achievable with pressure is 105ml/min

Flow rates Of IV cannulas and intraosseous cannula

IV cannula	Maximum Flow Rate with Gravity ml/min	Maximum flow rate with pressure ml/min
14G	236.1	384.2
16G	154.7	334.4
18G	98.1	153.1
20G	64.4	105.1
22G	35.7	71.4
15G IO	68.2	204.6

Intraosseous access

All intraosseous needles are 15G It may be feasible to administer fluid through the Belmont in the older child but there is likely to be too much resistance causing the high pressure alarm to trigger.

General guide based on age and cannula size

Age (years)	IV access	Mode of delivery
younger than 5	any	60ml syringe and Buddy Lite
at 5 or older	blue cannula (22G)	60ml syringe and Buddy Lite
at 5 or older	pink cannula (20G) or greater	Belmont rapid infuser

ie. Belmont infuser for age greater than 5 years with a pink (20G) cannula or greater. The Belmont can only bolus volumes in increments of 50ml so calculated volume should be rounded up to the nearest 50ml.

References

1) Paediatric Massive Transfusion; BJA Education, 16 (8): 269–275 (2016)