Blood Transfusion In Neonates and Children

1. Blood Transfusion In Neonates and Children Dr Salwa Hindawi MSc, FRCPath, CTM Medical Director of Blood Transfusion Services KAUH, Jeddah Makah 28th April2008

2. Introduction • Blood Transfusion is not without hazards • you should weigh the risk against benefit • use of right products to the right patient at the right time Salwa Hindawi

3. Consider: 1. Child will live long enough to get a long term complication of blood transfusion 2. children has special need 3.Lack of evidence for many transfusion practice in children ,depending on adult experience and clinical judgment. Salwa Hindawi

4. use of clinical guidelines may provide the following: • improvements in outcomes. • improvements in medical practice. • decision support tools for practitioners. • points of reference for medical orientation and • education. • criteria for self-evaluation. Salwa Hindawi

5. Pretransfusion testing in Infants less than 4 month of age Maternal sample: ABO & RhD group & Antibody screen. Infant samples: ABO & RhD group & Direct antiglobulin test (DAT). Antibody screen (if maternal sample unavailable). If no atypical Antibody in maternal & infant serum & DAT on infant red cell is negative, Cross matching is unnecessary. After 4 month Compatibility testing is required as for adults. Salwa Hindawi

6. cross matching within 1st 4 month of age Compatibility testing is required only under the following conditions: • 1. unexpected antibody is detected in the infant's or mother's serum; • 2. the infant has a positive direct antiglobulin test result; or • 3. the infant is to receive RBC transfusion incompatible with the mother's serum Salwa Hindawi

7. For infants with ABO hemolytic disease of the newborn, only group O RBCs should be transfused until compatibility tests are nonreactive with ABO-specific units. • For plasma and platelet transfusions, infants should receive ABO-specific components whenever possible, to avoid transfusing plasma antibody incompatible with the infant's red cell antigens. Salwa Hindawi

8. strategies to reduce donor exposure orRBC transfusions: • delayed clamping of the umbilical cord; • restricting blood sampling • using recombinant human erythropoietin to stimulate erythropoiesis • using iron supplementation or vitamins to minimize the severity of anemia Salwa Hindawi

9. using appropriately collected and stored multipack RBC units • using appropriately screened and handled RBCs from regular or designated donors; and • collecting and transfusing umbilical cord blood (autologous blood transfusion). Salwa Hindawi

10. PRBCs Specification • RBCs administered should be as fresh as possible • group O, or group specific • hemoglobin S negative • CMV-seronegative or leukoreduced • irradiated as indicated. Salwa Hindawi

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19. ABO Selection of Blood Components Salwa Hindawi

20. Administration of blood components Pretransfusion : Recipient identification: The name and identification number on the patient’s identification band must be identical with the name and number attached to the unit. Unit identification: The unit identification number on the blood container, the transfusion form, and the tag attached to the unit (if not the same as the latter) must agree. Salwa Hindawi

21. Component Volumes to be Transfused to Children and Neonates • Red cell concentrates for exchange transfusion: Term Infant 80-160mls/kg Preterm Infant 100-200mls/kg • For top-up transfusion 10-20mls/kg • Platelet concentrates: Children weighing less than 15kg 10-20mls/kg Children weighing more than15kg single Apheresis unit • Fresh Frozen Plasma 10-20mls/kg • Cryoprecipitate 5-10mls/kg Salwa Hindawi

22. Infusion flow rates : RBC: 3-5 mL/kg/hour FFP: within 30 minutes, provided the volume does not exceed 5-10 mL/kg; Platelets: within 30 minutes. It is seldom necessary to reduce the volume of the platelet concentrate if the dose does not exceed 5-10 mL/kg Salwa Hindawi

23. Special Products: • Despite general measures to ensure transfusion safety, there still an added risk to infants and children with underlying hematological, oncologic and immunologic disorders. • Transfusion reaction may be caused by both infectious or non infectious processes. • Special products are blood components collected, processed, and selected specifically to minimize these complications. Salwa Hindawi

24. Leucocytes Reduced Blood Components • Leucocytes in the blood components can lead to many complications • Universal Leucodepletion verses specific indications. Salwa Hindawi

25. Leucodepletion of Blood Components: All neonates and intrautrine transfusion Prevention of Alloimmunization in patients with AML receiving induction chemotherapy. In patients with other types of leukemia and in other cancer patients receiving chemotherapy. Prevention of Febrile Non Haemolytic Transfusion Reaction. Replacement of CMV negative blood components. . Salwa Hindawi

26. CMV negative blood products: • Blood products tested for antibodies to CMV or leukodepleted • Indicated to prevent CMV transmission in select populations: • 1-Immunodeficient or immunosuppressed patients • 2-Neonates • 3-Patients w/ hematologic malignancies • CMV resides in WBCs (leukodepletion), so screening not necessary for FFP, cryoprecipitate, other plasma products. Salwa Hindawi

27. 4-In Oncology/BMT patients, CMV titers are checked If patient is CMV positive, then products do not have to be CMV negative regardless of immune status. If patient is CMV negative, he should receive CMV negative products Salwa Hindawi

28. Irradiation: • -Performed for prevention of transfusion-related • Graft-versus-Host Disease (GVHD) • -Irradiation prevents T-cells proliferation • 25 Gy to blood products effective • Used for cellular products: PRBCs, platelets Salwa Hindawi

29. Indications: • premature infants < 1200g birthweight • 2. infants with known or suspected congenital • immunodeficiency syndromes • 3. infants receiving granulocyte transfusions • 4. infants receiving directed donor blood component from blood relatives • 5. infants receiving HLA-matched or platelet • crossmatch-compatible platelets Salwa Hindawi

30. 6. infants undergoing stem cell transplants (the stem cell product itself must not be irradiated) 7. infants undergoing immunosuppressive therapy, chemotherapy or radiotherapy 8. infants receiving exchange transfusions 9. foetuses receiving intrauterine transfusions 10. infants receiving large volumes of RBCs in association with ECMO. Salwa Hindawi

31. Components negative for Sickle Hemoglobin • Sickle cell trait: Hb A = 60% Hb S = 40% • Hypoxia and acidosis can lead to sickle crisis. • Can donate blood. Salwa Hindawi

32. AABB Recommendations • Define patients populations who should receive red blood cells known to lack hemoglobin S. 1- infants with small blood volume or massive transfusion in neonates. 2- Sickle cell patients Salwa Hindawi

33. Conclusions • Policies, Procedures and Guidelines for Blood Transfusion in Pediatric age group should be in place and implemented. • Training and Education for the hospital staff in policies, and guidelines in pediatric age group are important issues to be considered. • The use of special products is a must for specific patients in pediatric age group to ensure safety. Salwa Hindawi

34. References: • Guidelines for Transfusion Therapy of Infants from Birth to Four Months of age, New York State Council on Human Blood and Transfusion Services, Second Edition 2004. • Pediatric Transfusion, A Physician’s handbook 2nd Edition, 2006. • Prenatal and childhood transfusion, Practical Transfusion Medicine 2001. Salwa Hindawi

35. THANKS Salwa Hindawi