Amina, a 5-year-old girl with a weight of 15 kg, was diagnosed with acute lymphoblastic leukemia . She presented with a fever of 40 °C, severe pallor, and petechiae on her lower limbs. On admission, her hemoglobin level was 5.5 g/dL, the platelet count was 12 × 10⁹/L, and the white cell count 3 × 10⁹/L.

Cancer itself, and cancer treatment, are the main factors that lead to increased blood loss and impaired hematopoiesis . Very often, transfusion with blood products is lifesaving and an indispensable component of supportive care. Advances in supportive transfusion with blood products have significantly improved the management, outcome, and quality of life of children with cancer. However, transfusion is associated with an increased risk of morbidity and mortality when good practice rules regarding the choice of product, prescription, administration, and monitoring are not adhered to (Table 25.1). The decision regarding blood-product transfusion should always take into consideration the benefit/risk ratio for the patient.

From a pathophysiological perspective, anemia and thrombocytopenia may be caused by the following:

Once a decision has been made that a transfusion is required, the doctor has the responsibility of explaining to the child (if he/she is old enough and able to understand) and/or to his parents the indication for, as well as the benefits and potential risks of the transfusion, and to obtain their consent and assent. The doctor should be able to justify the decision and be able to answer any questions about possible alternatives. This process should be documented in the patient file.

The entire healthcare team has the medicolegal responsibility of ensuring that compatibility testing was performed, and that the correct product was ordered and issued for the correct patient. Two appropriately qualified team members (a doctor and registered nurse or two registered nurses) should check the details on the blood product against the patient details at the bedside in order to ensure that the product is administered to the patient it was intended for. Information should be read aloud by one person and checked by the other. The expiry date of the product should also be checked prior to administration, as well as the quality of the product, e.g. temperature, color, etc. All these processes should also be documented on a pretransfusion chart. If any inconsistencies are noted, the blood bank should be informed and the product should be returned.

The transfusion should be initiated in an aseptic manner and should be infused via a blood recipient set (containing a filter) at the correct rate. The patient should then be monitored carefully and frequently (initially every 15 min; then every 30 min). Any reaction should be reported immediately and the transfusion should be stopped, after which supportive care or other treatment should be provided immediately. Furthermore, it is recommended that parallel administration of medications or fluids other than normal saline, calcium-free balanced salt solutions (Plasmalyte, Balsol, modified Ringer’s lactate), 4 % albumin, plasma protein fractions and ABO-compatible plasma should be avoided if possible, otherwise a second intravenous line should be started.

Blood should be warmed when a massive transfusion is being administered (> 50 mL/kg), when infants receive > 15 mL/kg of a blood product, an exchange transfusion is performed, for patients with high-titre cold hemagglutinins and when transfusion occurs via a central line. A specific blood warming apparatus should be used; microwave oven heating may cause extensive hemolysis and can result in a disastrous and potentially fatal transfusion reaction.

In addition to the usual procedures for ordering, checking, and monitoring blood products, the presence of significant immunosuppression in the recipient calls for additional measures, including leukodepletion and irradiation of blood products.

Leukodepletion reduces the incidence of viral infection transmission (in particular cytomegalovirus (CMV)), platelet allo-immunisation, sensitization to transplant antigens in a pretransplant setting and febrile non-hemolytic transfusion reactions. Leukoreduction is recommended in all patients with cancer. Leukodepletion is performed routinely in developed countries, but is only available on request in most countries in Africa due to a significant additional cost. Patients on chronic transfusion programs, those at risk for CMV infection, infants, as well as critically ill, cardiac surgery or severe trauma patients should receive leukodepleted products.

Irradiation of blood products is recommended for patients with severe T-lymphocyte immunodeficiency syndromes, patients receiving a stem cell transplant (from the time of conditioning), before and after stem cell harvest for future autologous transplant, patients receiving HLA-selected platelets or donations from family members, patients with Hodgkin lymphoma, patients receiving fludarabine or cladribine and patients with aplastic anemia receiving anti-thymocyte globulin. This is done in order to prevent graft versus host reactions which may occur in patients with immunosuppression and where the donor and patient share an HLA haplotype. This reaction is mediated by the donor T lymphocytes that proliferate in the recipient and cause cellular damage. It may occur after the transfusion of packed cells, whole blood, granulocytes and platelets. In developing countries where access to radiotherapy is limited, irradiation of blood products is very challenging and sometimes impossible.