Transfusion of Blood and Blood Products
Jennifer L. Webb
Yunchuan Delores Mo
Cyril Jacquot
Naomi L. C. Luban
OVERVIEW
Blood Products Utilized in Neonates
1. Red blood cells (RBCs)
2. Fresh or reconstituted whole blood (WB)
3. Platelet concentrates derived from WB or plateletpheresis
4. Fresh-frozen plasma (FFP), plasma frozen within 24 hours (FP24), or thawed plasma
5. Cryoprecipitate
6. Granulocyte concentrates derived from granulocytapheresis
Sources of Blood Products
1. Banked donor blood and blood products
2. Directed donor transfusions
3. Autologous fetal blood transfusions (delayed cord clamping)
Indications, requirements, and transfusion techniques differ for each procedure and component. Simple transfusions are discussed in this chapter. Exchange transfusions are discussed in Chapter 49. Complications common to all blood products are listed later in this chapter.
A. Precautions (1)
1. Whenever possible, obtain informed consent prior to transfusions, delineating risks, benefits, and alternatives to transfusion.
2. Limit use of transfusions to justified indications.
3. Select the blood product appropriate for infant’s condition.
4. Confirm with proper identifiers at bedside that blood product is for correct patient. Maintain all records relevant to collection, preparation, transfusion, and clinical outcome.
5. Avoid excessive transfusion volume or rate for current patient size unless acute blood loss or shock dictates rapid transfusion.
6. Store blood and blood products appropriately. Freezing and lysis may occur if RBCs are stored in unmonitored refrigerators.
a. Use blood bank refrigerator which is continuously monitored and maintained within a specific temperature storage of RBCs, WB, thawed plasma, and thawed cryoprecipitate until the time of transfusion.
b. Temperature should be controlled at 1° to 6°C with constant temperature monitors and alarm systems.
c. Refrigerator should be quality controlled at least daily.
d. Refrigerator should be designated for blood products only.
e. Store platelets at 20° to 24°C with continuous agitation until the time of transfusion.
f. Store frozen plasma at ≤-18°C.
7. RBCs and WB should be out of refrigeration for <4 hours to minimize risk of bacterial contamination and RBC hemolysis.
8. Use approved blood-warming devices for RBCs and WB. Syringes for aliquots must not be warmed in water baths because of the risk of contamination.
9. Stop transfusion if transfusion reaction is suspected. Symptoms may include:
a. Tachycardia, bradycardia, or arrhythmia
b. Tachypnea
c. Systolic blood pressure increases of >15 mm Hg, unless this is the desired effect
d. Temperature above 38°C and/or increase in temperature of ≥1°C
e. Hyperglycemia or hypoglycemia
f. Cyanosis
g. Skin rash, hives, or flushing
h. Hematuria/hemoglobinuria
i. Hyperkalemia
10. Transfuse RBCs cautiously in infants with incipient or existing cardiac failure (2).
a. Monitor heart rate, blood pressure, and peripheral perfusion.
b. Consider partial exchange transfusion if the patient cannot tolerate the increase in blood volume from simple transfusion
(1) With hemoglobin level <5 to 7 g/dL
(2) With cord hemoglobin <10 g/dL
11. Prevent fluctuations in glucose during or after RBC transfusion (3).
a. In infants weighing <1,200 g or in other unstable infants, to prevent hypoglycemia
(1) Do not discontinue parenteral glucose administration
(2) Establish separate IV line for blood administration
b. As transfused blood may have elevated glucose concentration, expect rebound hypoglycemia in infants with hyperinsulinism or after large glucose load from exchange transfusion.
B. Pretransfusion Testing and Processing (1)
1. Blood group and Rh type
a. Maternal ABO blood group and Rh type: Screen maternal serum for unexpected antibodies.
b. Infant’s ABO blood group and Rh type: Screen infant’s serum for unexpected antibodies if maternal blood is unavailable.
c. Cord blood may be used for initial testing.
d. Infant’s blood group is determined from the red cells alone, because the corresponding anti-A and anti-B isoagglutinins are usually weak or absent in neonatal serum.
2. Cross-matching
a. Compatible blood may be low-anti-A, anti-B titer group O Rh-negative blood, or blood of the infant’s ABO group and Rh type (except in alloimmune hemolytic disease of the newborn).
b. Conventional cross-match is not required if the infant is <4 months old and no unexpected antibodies are detected with the initial sample.
c. Compatibility testing for repeated small-volume transfusions is usually unnecessary because formation of alloantibodies is extremely rare in the first 4 months of life.
d. If antibody screen (indirect antiglobulin test [IAT]) is positive in mother or infant:
(1) Serologic investigation to identify antibody(ies) is necessary.
(2) Full compatibility testing is required.
(3) If anti-A or anti-B detected in the infant’s sample, infant should receive RBCs lacking A or B antigen until antibody screen is negative.
e. If infant has received large volumes of plasma or platelets, passive acquisition of antibodies may occur; cross-matching of RBCs is recommended.
f. If directed donor blood from a parent is used, cross-matching is required.
3. Specifically processed products (4)
a. CMV safe products
(1) Cytomegalovirus (CMV) seronegative or leukodepleted (LD) blood is recommended for infants with birth weight ≤1,200 g born to seronegative mothers or those with unknown serostatus (5) (see “Complications” Section).
(2) Use of universal LD and/or CMV seronegative products is institution specific (6).
b. Irradiation to prevent transfusion-associated graftversus-host disease (TA-GVHD) (7)
(1) WB, PRBCs, previously frozen RBCs, granulocyte and platelet concentrates, and fresh plasma have been implicated in TA-GVHD; LD products have also been implicated.
(2) Clinical indications for irradiated blood components are listed in Table 48.1.
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(3) Some institutions provide irradiated blood products to all neonates to avoid TA-GVHD in patients with undiagnosed immunodeficiency.
C. Equipment
1. Blood product (see Appendix E)
2. Cardiorespiratory monitor
3. Blood and blood administration set: All blood and blood components must be filtered immediately prior to transfusion to remove blood clots and particles that are potentially harmful to the recipient
a. Transfusion services may supply RBCs and occasionally platelets and cryoprecipitate, prefiltered to the neonatal intensive care unit (NICU).
b. If not prefiltered, administration sets with inline filter of 120- to 260-µm pore size may be used for all products (standard size is 170 to 260 µm).
c. Microaggregate filters, 20- to 40-µm pore size are infrequently used in the NICU.
(1) Usefulness questionable and unnecessary if LD and/or additive solution RBCs used
(2) Must follow manufacturer’s instructions
(3) Some only function if product is dripped
(4) Not advisable for syringe administration as they may cause hemolysis
(1) Removes 99.9% of white blood cells (WBCs)
(2) Must follow manufacturers instruction if performing at bedside
(3) Prestorage LD (performed by collecting facility) preferred to poststorage (bedside) LD
(4) Attenuation/abrogation of CMV and other viruses such as Epstein-Barr virus (EBV) and human T-lymphotrophic virus (HTLV) I/II harbored in WBCs
4. Sterile syringe (if blood is not already aliquoted into a syringe)
5. Blood warmer not needed for small-volume transfusions
a. Least hemolysis occurs with peristaltic pumps, but syringe pumps may be used for precise, small volume administration.
b. Vascular access: RBCs may be transfused through 24-, 25-, or 27-gauge needles and short catheters, and there is growing evidence supporting the safety of intermittent transfusions through 24- or 27-gauge PICC lines; however, historically, those have not been the preferred access for transfusion.
c. The amount of hemolysis that results from infusion of RBCs is directly proportionate to the age of the blood and the rate of transfusion, and inversely proportional to needle size.
d. Hyperkalemia, hemoglobinuria, and renal dysfunction may result if hemolyzed blood is transfused.
7. Normal saline flush (1 mL or more) to clear IV solution from line.
RED BLOOD CELL TRANSFUSIONS
A. Indications
1. Guidelines and justifications for transfusions are controversial because there are few studies that address the appropriateness of various transfusion triggers in neonates. Therefore, indications for RBC transfusion vary among different institutions.
2. Current guidelines for neonatal RBC transfusion therapy are given in Table 48.2 (15, 16). In general:
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a. Infants with significant cardiopulmonary disease require more RBC transfusion support.
b. Infants receiving minimal cardiopulmonary support, with acceptable weight gain, and with minimal episodes of apnea and bradycardia, require less RBC support.
3. Liberal versus conservative RBC transfusion
a. Studies on liberal versus conservative RBC transfusion practices have demonstrated mixed results in terms of clinical benefit of liberal transfusion practices toward preventing apneic episodes and immediate neurologic sequelae (17, 18).
b. Long-term neurodevelopmental benefit has not been ascertained for either transfusion practice and evidence is conflicting (19, 20, 21).
c. Observational studies have documented a temporal relationship between RBC transfusions with the occurrence of necrotizing enterocolitis (NEC)
in premature infants; however, prospective studies and meta-analyses have shown a protective effect of transfusions (22, 23, 24, 25, 26, 27, 28).
in premature infants; however, prospective studies and meta-analyses have shown a protective effect of transfusions (22, 23, 24, 25, 26, 27, 28).
d. The relationship between RBC transfusions and NEC in premature infants is being evaluated further.
B. Contraindications
1. None absolute
2. Exert caution in patient with:
a. Volume overload
b. Congestive heart failure
C. Technique
1. Determine total amount of blood needed.
a. Calculate volume of blood for transfusion. Most infants are transfused 10 to 15 mL/kg of RBCs, which will increase the hemoglobin by 2 to 3 g/dL.
b. RBC volume required = (EBV × [Hct desired – Hct observed])/Hct of RBC unit
(1) Hct is hematocrit
(2) EBV is the estimated patient’s blood volume 80 to 85 mL/kg in full-term infants and approximately 100 to 120 mL/kg in preterm infants
(3) RBC units collected in citrate-phosphate-dextrose-adenine (CPDA-1) have an Hct of approximately 70%, RBCs in extended-storage additive solutions (AS) have an Hct ≤60%
2. Include volume of blood needed for dead space of tubing, filter, pump mechanism (varies from system to system; may be as much as 30 mL).
3. Obtain blood product (see Appendix E).
a. Several studies have documented the safety of using PRBCs stored in extended-storage AS for small-volume, intermittent transfusions (30, 31, 32).
b. Transfusions of ≤15 mL/kg of CPDA-1 or AS RBCs stored to maximum outdate (35 or 42 days) deliver approximately 0.3 mEq/kg of K+ which does not pose a significant risk to most neonates when transfused slowly over 2 to 4 hours (2, 3).
c. A randomized controlled trial showed no benefit to using ≤7-day-old blood as compared to standard-of-care transfusion practice for intermittent transfusions in premature infants (33).
d. Use of split RBC packs effectively limits donor exposures, and these are safe for use in neonatal small-volume transfusions up to the outdate (2, 34, 35). This practice requires sterile connecting devices, and either transfer packs or syringe sets that permit multiple aliquots to be removed (Figs. 48.1 and 48.2).
e. Avoid use of old RBCs for large-volume transfusions (including massive and exchange transfusions as well as extracorporeal membrane oxygenation [ECMO] circuit priming), unless the additive is removed by inverted storage or centrifugation; risks of hyperosmolality, hyperglycemia, hypernatremia, hyperkalemia, hyperphosphatemia are postulated (3, 31, 36).
f. Despite concerns about AS, infants on ECMO have tolerated RBCs stored in AS well (37).
4. Verify whether cross-matched product is necessary or un-cross-matched product is adequate.
5. Verify appropriateness of blood selected for infant by comparing blood product and unit tag (integral to blood unit) information, patient identification, and orders. Barcode reading devices are advisable.
a. Confirm informed consent has been obtained (if possible)—Note: Should obtain informed consent even if two physicians sign for initial transfusion (emergency situation). Refer to institutional policy.
b. Confirm recipient identity using two identifiers.
c. Verify information on blood unit tag and blood bag/syringe.
 FIGURE 48.1 Neonatal syringe set with filter. (Courtesy of Charter Medical Ltd., Winston-Salem, North Carolina.) This system, when used with sterile connection technology, provides a closed delivery system that maintains primary unit outdate. Syringe blood aliquots (PRCBs, plasma) must be administered to the patient within 24 hours and syringe platelet aliquots within 4 hours. |
 FIGURE 48.2 Use of a sterile connecting device. A: An adult RBC unit is shown along with a set of pediatric transfer bags. The transfer bags can be attached by spiking the unit, causing it to expire in 24 hours; alternatively, the transfer bags can be connected using a sterile connection device. B, C: The separate tubings are loaded into the tubing holders of the device. The covers are closed. D: A welding wafer heated to about 500°F melts through the tubing. The tubing holders realign and the welding wafer retracts allowing the tubing ends to fuse together. E: The unit can now be aliquoted as needed. Because a functionally closed system has been maintained, the expiration date of the blood has not changed. |
d. Blood group and type of both donor and recipient
e. Expiration date and time of product
f. Product meets restrictions as ordered by physician or by institutional guidelines
6. Restrictions that may be evident on the blood product and transfusion tag include:
a. CMV: Tested/untested
b. Irradiated: Yes/no
c. Directed (familial) donation: Yes/no
d. RBC antigen-negative: Yes/no
e. Sickle tested-negative: Yes/no
f. Other restrictions specified: Yes/no
7. Warming RBCs.
a. There is no need to warm small-volume RBC aliquots, particularly if the transfusion is given over 2 to 3 hours.
b. RBCs may be warmed by placing the syringe beside the infant in the warm-air incubator for 30 minutes prior to transfusion.
c. Inappropriate warming by exposure of blood to heat lamps or phototherapy lights may produce hemolysis. Shielding the RBC component and tubing from UV light (used for phototherapy) are recommended (38, 39).
8. Adhere to aseptic technique throughout procedure.
9. If prefiltered RBCs are provided by the blood bank in a syringe, attach tubing directly to syringe.
10. If RBCs are provided in a bag, use large-bore needle (18 gauge or larger) to withdraw volume into syringe. Filter should be placed between bag and syringe (Fig. 48.1).
11. Prime tubing with blood. Clear syringe and tubing of bubbles, and mount into infusion device.
12. Verify patency of vascular access.
13. Clear line into patient with normal saline.
14. Record and monitor vital signs.
15. Determine spot glucose test. Repeat hourly as needed.
16. Begin transfusion at controlled rate: 3 to 5 mL/kg/hr.
17. Gently invert container of blood every 15 to 30 minutes to minimize sedimentation if RBCs are provided in a bag. This step is not required for syringes since they contain prefiltered RBCs.
18. Stop transfusion if any adverse change in condition occurs.
19. At end of infusion, clear blood from line with saline.
20. Check recipient hemoglobin and hematocrit, if necessary, at least 2 hours after transfusion.
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