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Paediatric blood transfusion

Paediatric blood transfusion. Dr. Chitra Rajeswari T Dr. Lokesh Kashyap. www.anaesthesia.co.in anaesthesia.co.in@gmail.com. Why to transfuse blood. Basic physiological function is to ensure adequate oxygenation of the tissues Physiology of oxygen transport. Hypoxic hypoxia.

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Paediatric blood transfusion

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  1. Paediatric blood transfusion Dr. Chitra Rajeswari T Dr. Lokesh Kashyap www.anaesthesia.co.inanaesthesia.co.in@gmail.com

  2. Why to transfuse blood • Basic physiological function is to ensure adequate oxygenation of the tissues • Physiology of oxygen transport

  3. Hypoxic hypoxia Anaemic hypoxia Histotoxic hypoxia Stagnant hypoxia

  4. Anaemic hypoxia

  5. Oxygen delivery • DaO2 =Cardiac output X CaO2 [oxygen content] • Oxygen content [Hb saturation X 1.34 X Hb conc] + 0.003 X PO2 Amount of oxygen carried by 100 ml of blood

  6. Fetal hemoglobin Cardiac reserve Increased metabolism

  7. Fetal hemoglobin • HbF – 70-80% of full term and 97% of premature infants’ total hemoglobin at birth

  8. Fetal hemoglobin • Shorter life span of 90 days (HbA- 120 days) • HbF interacts poorly with 2,3,DPG • P50 with HbF is 19 mmHg • P50 with HbA is 27 mmHg • Leftward shift of ODC

  9. ODC

  10. Hemoglobin for equivalent oxygen delivery Motoyama et al. 1990

  11. 6 months- 6 years 12 7-13 years 13 6 months- 6 years 12 7- 13 years 13

  12. Preoperative hemoglobin • At the time of nadir • Term infant with Hb < 9 g/dl • Preterm infant <7 g/dl • Haemoglobin levels that are adequate for the older patients may be suboptimal in the younger infant

  13. Fetal hemoglobin Cardiac reserve Increased metabolism

  14. Adult vs children - cardiac reserve • Children have a higher cardiac output to blood volume ratio than adults Sandra et al. Pediatric anesthesia 2005

  15. Adult vs children - cardiac reserve • The neonatal myocardium operates at near maximum level of performance as a baseline • The newborn’s heart may be unable to compensate for a decreased oxygen carrying capacity by increasing cardiac output • The neonatal myocardium will also suffer a greater degree of decompensation when exposed to decreased oxygen delivery

  16. Metabolism • Oxygen consumption

  17. When to transfuse blood?

  18. MABL • MABL = Starting – Target hematocrit • Blood loss more than this target value then RBC cell transfusion should be initiated • 65 ml of packed RBC [Hct 70%] = 150 ml of whole blood [Hct 30%] • 0.5 ml of PRBC for each ml of blood loss beyond the MABL • 1 ml/kg PRBC raises the hematocrit by 1.5% X EBV Starting hematocrit

  19. May benefit from higher hematocrit • Preterm and term infants • Cyanotic congenital heart disease • Large ventilation/ perfusion mismatch • High metabolic demand • Respiratory failure

  20. Guidelines for perioperative management of anemia

  21. Guidelines contd… • In an elective setting, anemia should be evaluated and treated,surgery may be postponed for a month or longer • Cumulative record of blood loss should be kept for critically ill infants and loss replaced when it exceeds 10% of blood volume

  22. Guidelines contd… • In an emergency setting, anesthesia administered with extreme caution • Maintain high PaO2 • Adequate cardiac output • Adequate intravascular volume • Avoid factors increasing oxygen consumption • Avoid leftward shift of ODC

  23. Guidelines contd… • Oxygen extraction ratio as hematocrit drops to 15%, OER increases from 38 to 60% • Central venous Po2 • Decline of pVo2 is the most sensitive indicator of anemia • Normal => 38 mm Hg Holland et al. 1987

  24. Pediatric transfusions –guidelines • Platelet transfusions • platelet count less than 50000 in acute bleeding • Less than 1 lakh for intracranial and Subarachnoid or extra corporeal circulation procedures • 5 mL/kg - 10 mL/kg causes a rise of platelets of 50 to 100 * 109/L • Fresh frozen plasma • aPTT or PT > 1.5 times normal • 10-15 ml/kg • Cryoprecipitate • Fibrinogen 100 mg/dl • 1 unit /10 kg BW raises plasma fibrinogen by 50 mg/dl

  25. Transfusion reactions • Acute transfusion reactions ( < 24 hours) • Febrile nonhemolytic reaction • Urticarial/allergic reaction • Acute hemolytic reaction • Bacterial contamination and sepsis • Fluid overload • Anaphylaxis • TRALI • Delayed transfusion reaction • Infection • Delayed hemolytic reaction • Post transfusion purpura • Graft Vs host disease • Iron overload

  26. TRALI • TRALI • Acute hypoxemia • Non-cardiogenic pulmonary edema • During or after transfusion • Leading cause of transfusion-related mortality in 2003 – FDA, TRALI conference • Underdiagnosis & underreporting

  27. Incidence • All plasma-containing blood & blood components • 1/5,000 blood & blood component • 1/2,000 plasma-containing component • 1/7,900 units of FFP • 1/432 units of whole blood derived platelets

  28. Pathophysiology • Leukocyte antibodies • Biologically active substance • Lipids & cytokines • Neutrophil priming activity • Leukocyte Antibodies • Neutrophil in pulmonary capillary → pulmonary damage & capillary leak • Antibody to donor leukocyte • Ab to HLA I, II, granulocyte, monocyte, IgA

  29. Management • Supportive • Stop transfusion if timely recognition • Oxygen and ventilatory support as employed in ARDS • Avoid blood from multiparous female donors

  30. Immunologic • Transfusion related graft vs host disease • Lymphocytes in transfused blood component proliferate and cause host tissue destruction • Immunocompromised patient • Premature infants • Children with cancer or severe systemic illness • Acute blood loss • Cardiopulmonary bypass Prevented by irradiated blood

  31. Pediatric transfusions - neonates • Neonates have some specific considerations with respect to anesthesia and blood products. • Major hemolytic reaction (ABO) occurs less frequently in neonates compared with older children and adults. • For the first 3–4 months of life, infants are unable to form alloantibodies to RBC antigens. • After 4 months of age, hemolytic reactions become a potential factor

  32. Massive blood transfusion

  33. Definition • Loss of one or more circulating blood volume in 24 hour • 50% blood volume in 3 hours • Loss occurring at the rate of 2-3 ml/kg/min

  34. Problems of massive transfusion • Hypocalcemia • Hyperkalemia • Hypomagnesemia • Hypothermia • Volume overload • Dilutional coagulopathy • Acid base changes • Shift of ODC curve • Microaggregate delivery • TRALI

  35. Hypocalcemia • Degree of ionized hypocalcemia depends upon • Blood product transfused • Rate • Hepatic blood flow • Hepatic function

  36. Hypocalcemia • Degree of ionized hypocalcemia depends upon • Blood product transfused • Rate • Hepatic blood flow • Hepatic function FFP > 1 ml / kg / min Decreased ability to metabolise by neonate

  37. Hypocalcemia Myocardial depression Inhalational agents Decreased ability to metabolise by neonate

  38. Prevention of hypocalcemia • Rate should be < 1 ml / kg / min • If more than > 1 ml / kg / min calcium should also be transfused • Calcium infusion • Calcium chloride 5-10 mg/kg • Calcium gluconate 15-30 mg/kg • Frequent measurement of ionised calcium

  39. Hyperkalemia • Blood components with high potassium • Whole blood • Irradiated blood • Near the expiry date

  40. Prevention of hyperkalemia • Washing of erythrocytes • Newer blood (< 7 days) • Avoiding whole blood and prefer packed RBC

  41. Treatment • CaCl2 15-20 mg/kg • Calcium gluconate 45-60 mg/kg • 1-2 min intervals until the arrhythmia is resolved • Glucose and insulin • Hyperventilation • Albuterol • kayexalate

  42. Hypomagnesemia • Result of citrate toxicity • Stabilizes the resting membrane potential • Life threatening arrhythmia that dose not respond to exogenous calcium therapy needs magnesium sulphate • 25-50 mg/kg followed by 30-60 mg/kg/24 hours

  43. Acid-base changes • RBC metabloism can elevate the dissolved CO2 to 180-210 mmHg • Anaerobic metabolism increases the lactic acid content • Initial transient combined respiratory and metabolic acidosis • Citrate metabolism leads to metabolic alkalosis

  44. Hypothermia • Shift to left of ODC curve – decreased oxygen delivery • Apnea • Hypoglycemia • Decreased drug metabolism • Increased oxygen consumption • Coagulopathy

  45. Coagulopathy • Massive blood transfusion leads to thrombocytopenia • 40%, 20% and 10% of starting platelet count is seen after 1st, 2nd and 3rd blood volume loss • Dilution and loss of clotting factors • Clotting factor deficiency should be anticipated after one blood volume loss

  46. Recombinant factor VIIa • Retrospective review of use of factor 7a in children undergoing major neurosurgical procedures experiencing massive uncontrollable hemorrhage • Useful adjunct to control life threatening bleeding,but more extensive research is needed Uhring et al Ped crit care med, 2007

  47. Mechanism of action

  48. Blood Conservation • Preoperative Autologous Donation • Acute Normovolemic Hemodilution • Intraoperative Blood Salvage • Preoperative Erythropoietin • Positioning • Hypotensive anaesthesia • Pharmacological enhancement of hemostasis • Artificial blood www.anaesthesia.co.inanaesthesia.co.in@gmail.com

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