Paediatric transfusion Paediatric transfusion
Cross-matching § <4 months old § No further sampling once blood group established provided no alloantibodies and DAT negative and no transfusion reaction § If received large volume or fresh blood, repeat testing recommended
Blood component volumes § Red cells § Exchange: 170ml/kg § Top-up: 15-20ml/kg § <1year and cardiac surgery = fresh (<5 days old blood) § Platelets § <15kg: 10-20ml/kg § >15kg: standard adult dose § Apheresis if <16 years § FFP § 10-20ml/kg § Methylene blue and non-UK sourced for children under 16 years § Cryo § <15kg: 5ml/kg § 15-30kg: 1 pool (5 units) § >30kg: 2 pools (10units)
§ Paedipaks should be used to minimise donor exposure
ABO haemolytic disease of the newborn § Mother group O and baby group A
Neonates and children 1. Leukocyte depleted products (< 5 x 106 per unit in 99% of units with 95% confidence) 2. MB treated FFP sourced from US for children under 16 3. Components for children under age of 1 and fetal transfusion must be from repeat donors 4. CMV negative in the first year of life 5. Irradiated products for a. IUTs including top up and exchange transfusions b. Donations from relatives (1st / 2nd degree) c. Suspected immunodeficiency d. All granulocytes e. Stem cell transplant (7d pre harvest, 2 weeks pre transplant, 3-6 months after if auto / indefinitely if allograft) 6. Screening transfusions in the first 4 months of life a. Screen maternal sample for ABO and atypical red cell antibodies b. ABO on neonatal sample c. DAT on neonatal sample d. If maternal sample not possible perform ABO and atypical red cell antibodies on neonatal sample 7. Selection of blood in the first 4 months a. ABO matched / compatible for the neonates own group b. Compatible with any maternal or fetal ABO or atypical antibodies c. NOT an electronic crossmatch
Intrauterine transfusion § Aim to prevent fetal hydrops to allow the fetus to progress a gestational age that will ensure survival of the neonate with the minimal number of procedures § Start transfusion as late as is safely possible § Infuse maximum safe number of cells § Dose = Fetal blood volume x Rise in PCV / (Donor – Fetal PCV) § Cell counting should be available close to fetal sampling to allow immediate haematocrit/Hb estimation. § Red cells § O- or ABO identical RhD- K- § Crossmatch compatible with mother § <5 days old (minimises risk of hyperkalaemia) § CMV neg § Irradiated § PCV Up to 0.75 § Warmed carefully § Transfused at 5-10ml/min § Dose calculated (Rise in PCV/Difference between donor and fetal PCV x Fetoplacental BV § Platelets § Dose = Fetal blood volume x Increment / Count in product § O RhD negative tested for high titre ABO antibodies § HPA compatible § Apheresis § Irradiated § Concentrated to a count of >2000 § Warmed § Transfused at 1-5mL/min § Dose = Fetal blood volume x Desired increment / Platelet count of product
Sampling should be done with Teflon coated needles – less volume
Exchange transfusion § Single volume exchange removes 75% whereas a double volume exchange removes 90% § Usually done for HDN (also for icterus and severe anaemia with heart failure) § Plasma reduced red cells with an HCT 0.5-0.6 § Crossmatch compatible with the mother by IAT § <5 days old § Collected into CPD anticoagulant § CMV negative § Ideally irradiated but not strictly necessary § Warm § Dose 80-160ml/kg for a term infant / 100-200ml/kg for a preterm infant
Transfusion triggers § Anaemia in NICU / first 24h Hb<12 § >10% blood loss § Chronic oxygen dependency Hb<11 § Late anaemia in a stable patient Hb<7
FFP § Clotting times often prolonged (reduced hepatic production / increased effects of citrate due to the high HCT) § Should be corrected with FFP 15ml/kg if INR/APTTR >1.5 and there is a significant risk of bleeding or about to undergo a procedure. § Should be group AB or compatible with the patients own group § Virally inactivated / sourced outside the UK
Platelets § Aim to keep platelet count >20 in term infants – higher threshold generally recommended for preterm infants § NAIT platelet count usually kept >30
T-activation § NEC and pneumococcal sepsis may be infected with neuraminidase producing organisms § Strips sialic acid from surface of red cells § Exposes T-crpto antigens = T activation § Haemolytic transfusion reaction § Most plasma contains antibodies to T-antigens and hence there is a risk of haemolysis following transfusion of plasma containing products § If severe reaction to standard products § Washed red cells, washed platelets, low titre FFP
Haemoglobinopathies § CMV negative if a candidate for a transplant § Extended Rh phenotype and Kell phenotype § Sickle § Top up § Splenic / hepatic sequestration § Aplastic crisis § Exchange transfusion § Chest syndrome § Stroke § Priapism § Hepatic failure § Mesenteric syndrome § Hypertransfusion § Stroke – to prevent recurrence § Renal failure § Chronic sickle lung disease § Osteonecrosis § Leg ulcers § Thalassaemia § Start when Hb falls below 6 § Aim average Hb 12 with a pretransfusion Hb of 9-10 § Transfusion should be aimed to prevent marrow hyperplasia, skeletal changes and organomegaly § Requirements need to be adjusted to compensate for growth and hypersplenism
Cardiac surgery § Iron status of child preop § Consider whole fresh blood (<48h) if the child is under 2 years old § Infants going onto bypass are effectively having an exchange transfusion § Fluid in the circuit dictated by the size of the patient and starting Hb § Should try and use blood <10d old § Children older than 6 months can have blood collected in normal additive solution. § DDAVP can be used to minimise blood loss § Tranexamic acid § Vitamin K deficiency should be corrected § Cell salvage should be used § Cold reacting antibodies are of no significance even if the child is being cooled § Irradiate products if any concerns the patient might have Di George syndrome (who have interrupted aortic arch)
ECMO § Similar rules to exchange transfusion § Whole blood may be useful as has higher factor levels
Problems with blood handling in babies 1. Confusion between maternal and baby samples 2. Confusion between multiple births – blood taken from the wrong placenta 3. Failure to apply wrist bands 4. Failure to communicate special transfusion requirements | ||||||||||||||||||||||||||||||||||||||||||||||||
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