Embed Size (px)
Citation preview
Dr Gopal Agrawal
PHOTOMD (Peds), DM Neonatology (PGI, Chandigarh)
Consultant Neonatologist, Cloudnine Hospital, Gurgaon
Neonatal Transfusion Guidelines
Outline
Thresholds for transfusion
Discuss evidenced based
policy
Complications to be aware of
When not to transfuse
Detailed work up of
neonatal anemia
IUT
Partial Exchange, DVET
Erythropoietin use
Not covered
What’s the fuss about transfusions??
Benefits Harms
Complications
expected
Infections:
• HIV, Hep B, Hep C, Syphilis, Malaria
Non-Infectious:
Acute
Immunologic
•Hemolytic: Incompatibility of donor RBCs with recipient plasma Ab
•Allergic: Reaction of plasma AB to donor proteins
•TRALI: Reaction of Donor Ab to recipient HLA Ag
•FNHTR
•TA-NECNon-immunologic:
•Volume overload
•Hypocalcemia: citrate
•Hypothermia
•Hyperkalemia
Chronic
TA-GVHD: Reaction of donor lymphocytes to patient tissues
Basic Principles
Avoid whole blood
Use components as far as possible
Guidelines simply provide a list of acceptable clinical
situations
Should not serve as absolute indications for transfusion
Physician should take into account the general
condition of the infant
Consideration of the risk-benefit ratio for the individual
PRBC
Why are preterms prone?
↓ RBC mass, ↓ Iron stores
↓ RBC survival
↑ Growth rate, ↑ Demand
↑ Phlebotomy
Erythropoietin stimulated at lower nadir
Nearly 40% of preterm below 1500 grams and 95% below 1000
grams would receive a PRBC transfusion
When to transfuse
Bell study (2005):
Restrictive transfusion associated with more apneic episodes, intraparenchymal brain hemorrhage, and PVL
PINT (2006):
Liberal practice resulted in more infants receiving transfusions
Restrictive strategy not associated with adverse outcomes
PINTOS (2009):
NDO at 18 to 21 months CGA
All adverse outcomes (death or serious neurodevelopmental disability, cerebral palsy, cognitive delay) more frequent in the restrictive group (Non-significant)
British Committee on Standards in
Hematology (BCSH), 2016
How much to transfuse
Volume: 15-20 ml/kg
Rate: 5 ml/kg/hour
Top-up transfusions > 20 mL/kg not recommended
Risk of transfusion – associated circulatory overload (TACO)
Which Blood Group?
Fresh (≤7 days) or Old (> 7 days)
Age of Red Blood Cells in Premature Infants (ARIPI) trial:
Fresh RBC transfusions did not demonstrate an improvement
Composite outcome measure of major neonatal morbidities (NEC, IVH, BPD], and ROP) or death at 30 and 90 days
Strongly recommended against the use of fresher PRBCs
as a routine in preterm neonates
Warming the blood
RBC units stored at 4° to 6° C
Hypothermia can develop after massive transfusion
Inline blood warmers should be used for all RBC transfusions (preferably)
Radiant heaters should be avoided
Can result in hemolysis of the RBC component
CMV Protection
CMV seronegative components:
For IUTs
Neonates up to 28 d post-expected date of delivery (i.e.
44 weeks CGA)
Dual Inventory:
CMV seronegative + Leukoreduction
The 'belt and suspenders' strategy
Advisory Committee on the Safety of Blood, Tissues and Organs. 2012
Leuko-reduction
Decreased CMV transmission
Decreased febrile reactions
Use of third-generation leukoreduction filters at the time of collection of cellular products recommended
American Association of Blood Banks:
Must contain < 5 × 106 total WBCs per unit
Irradiation
Prevents proliferation
of lymphocytes
Decreases TA-GVHD
Dose of 25-50 gray
Designated blood “Satellite packs”
Blood donated by relatives
Higher risk of GVHD, increased immune response against HLA
Controversial in RHDN, NAIT
A dedicated single-donor system
RBCs are collected from unrelated donors preferably
Able to supply all small volume RBC transfusions needed by individual
88% of transfused preterm infants received RBCs from only one donor
Hospitals should develop policies that help to minimize
exposure of infants to multiple donors
Strauss RG, Transfusion 2000
TANEC
Withhold enteral feeding in preterm neonates’ receiving a PRBC
transfusion beginning 2 to 3 hours prior to beginning the
transfusion and continuing for the duration of the transfusion
Prevention – “Better than Cure”
Delayed cord clamping
Enteral iron supplementation of 2 to 4 mg/kg/day
Reduce phlebotomy loss
Use micro-containers for lab testing
Use of cord blood for initial blood tests
Summary – PRBC Transfusion
Follow Restrictive policy – Use pre-decided thresholds
Transfuse 10-15 ml/kg
Use old PRBC, satellite packs – Reduce donor exposure
Irradiated, Leukoreduction, CMV seronegative – Recommended
Withhold feeds 2-3 hours before and during transfusion
Optimize “Preventive” strategy
Platelet
When to
transfuse?
BCSH, 2016
How much to transfuse?
Each unit of RDP (50 ml) = 5*1010 platelets
1 unit of RDP raises the platelet count by 50,000-100,000/mm3
One unit of SDP (250 ml) = 3 × 1011 platelets
Equivalent to approximately 6 units of RDPs
BCSH, 2016: 10-20 ml/kg, Rate 10-20 ml/kg/hour
Which Blood
Group?
Platelets express intrinsic
ABO antigens, but not Rh
antigens
They should be ABO-group
specific whenever possible
Platelets do not routinely
require cross-matching
FFP
When to transfuse?
To correct coagulopathies
“Clinically ill” infants or infants weighing <1,500 g: PT or PTT ≥2
times normal for age
Disseminated intravascular coagulation (DIC)
Vitamin K deficiency associated bleeding
Prior to invasive procedures with a risk of significant bleeding
and with abnormal coagulation profile
Not indicated for volume expansion
A policy of routine coagulation screening is inappropriate
Cryoprecipitate
Useful in infants who require higher concentrations of factors
VIII, XIII, vWF, or fibrinogen levels
Cryoprecipitate is the most practical source of fibrinogen or
factor XIII for neonates until a specific diagnosis is made
1-2 units per 10 kg
“Carry Home”
Use components wherever feasible/ available
Having a blood transfusion policy reduces the number of transfusions
Follow transfusion thresholds
Treat patient/ not lab values
Be aware of complications of BT
