Whyte R, Kirpalani H. Low versus high haemoglobin concentration threshold for blood transfusion for preventing morbidity and mortality in very low birth weight infants. The premature infants in need of transfusion PINT study: A randomized, controlled trial of a restrictive low versus liberal high transfusion threshold for extremely low birth weight infants. Restrictive versus liberal red blood cell transfusion thresholds in very low birth weight infants: A systematic review and meta-analysis.
J Paediatr Child Health ; Neurodevelopmental outcome of extremely low birth weight infants randomly assigned to restrictive or liberal hemoglobin thresholds for blood transfusion. Pediatrics ; Use of Blood Components in the Newborn. NNF India, Guidelines ; Users Online: About us.
Reducing incidence of red cell transfusion among preterm babies in a tertiary care neonatal intensive care unit: A retrospective observational study. J Clin Neonatol ; Figure 1: Neonates who required red blood cell transfusion Click here to view. Figure 2: Gestation in weeks corresponding to the number of red blood cell transfusion Click here to view. Figure 3: Birth weight in grams corresponding to the number of red blood cell transfusion Click here to view. Figure 4: Red blood cell transfusion in neonates who received surfactant, total parenteral nutrition, and mechanical ventilation Click here to view.
Figure 5: Correlation of ventilation days to the number of red blood cell transfusions required Click here to view. Figure 6: Correlation of continuous positive airway pressure days to the number of red blood cell transfusions required Click here to view. A careful risk assessment is essential in malignancy and abdominal injury when the salvaged blood may contain a high concentration of malignant cells or bacteria Association of Anaesthetists of Great Britain and Ireland [AAGBI] Safety Guideline, Cell salvage should be supported by a programme of staff training, accreditation and audit in order to ensure a product of a consistently high quality AAGBI Safety Guideline The preoperative Hb should be optimised by treating iron deficiency anaemia 1C.
Tranexamic acid should be considered in all children undergoing surgery where there is risk of significant bleeding 1B. Red cell salvage should be considered in all children at risk of significant bleeding undergoing surgery and where transfusion may be required, providing there are appropriately trained staff 2C. Children may also bleed during recovery from HSCT and frequently receive prophylactic platelet transfusions.
There are very few descriptive data on patterns of bleeding and use of platelet transfusions in children with haematological malignancies. The optimal safe platelet count for routine lumbar punctures LPs for children on treatment for leukaemia is also uncertain. Chalmers unpublished observation. The precise platelet threshold used for individual patients or patient groups will depend on the presence of other clinical risk factors. Patients with aplastic anaemia may be best managed without routine prophylactic platelet transfusions in order to reduce the risk of alloimmunization, apart from situations of increased risk of bleeding.
Fresh frozen plasma and cryoprecipitate may be administered either therapeutically for the management of bleeding or prophylactically. Although there is little direct evidence in children relating to the appropriate FFP transfusion volume, for example in patients with significant bleeding, higher doses are likely to have a greater effect on reducing the abnormality of coagulation tests.
In the UK, the main source of concentrated fibrinogen is cryoprecipitate, although FFP also contains fibrinogen. Fibrinogen concentrate is only licensed in the UK for treatment of congenital deficiency although it is sometimes used for acquired deficiency on an individual patient basis. There is no evidence of a benefit from prophylactic use of cryoprecipitate.
Recent advances in transfusions in neonates/infants
The major indications for cryoprecipitate transfusion in infants and children are DIC with bleeding, bleeding following cardiac surgery and major haemorrhage. There remains controversy over the fibrinogen transfusion threshold for cryoprecipitate transfusion.
However, care should be taken to avoid volume overload, particularly in vulnerable patients. There is accumulating evidence that this approach is incorrect and that much of this FFP use is likely to be inappropriate and exposes patients to unnecessary risk.
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Data on blood product support in children with DIC are limited and there are no guidelines for paediatric practice. Recommendations are therefore largely extrapolated from adult practice. The primary aim should be reversal of the underlying cause. The evidence for these recommendations is of low quality. Similar recommendations can be applied to children with DIC. In practice, it is necessary to take into account clinical factors including the rate of fall of fibrinogen and severity of bleeding.
FFP contains all the coagulation factors and fibrinogen, so is used in the first instance for DIC with bleeding, reserving cryoprecipitate for persistent hypofibrinogenaemia despite FFP. However, consideration may be given to giving cryoprecipitate as the initial treatment prior to FFP when the fibrinogen is very low e.
Fresh frozen plasma and cryoprecipitate should not be administered on the basis of laboratory tests alone but should be restricted to those with signs of bleeding or where invasive procedures are planned. Patients should also be treated with vitamin K if deficiency is suspected. Where inherited PC or PS deficiency is suspected sometimes in combination with sepsis , initial treatment is usually with FFP as for neonates.
In acquired PF, management of the underlying cause is crucial. Make sure that patients are vitamin K replete; this may mean giving it routinely to sick children. Liver disease may be associated with a variable degree of coagulopathy. Severe liver failure is usually accompanied by profound coagulation derangement, including hypofibrinogenaemia. No RCTs have addressed the use of FFP or cryoprecipitate in this setting although the use of blood product support may have a role in patients with bleeding and prior to interventions with clinically significant bleeding risk.
In liver disease the standard coagulation tests may be misleading and do not reflect bleeding risk. They should generally not be used alone to trigger transfusion with FFP or cryoprecipitate. TTP should be considered in the differential diagnosis in children presenting with microangiopathic haemolytic anaemia MAHA and thrombocytopenia. It is a serious disease with a high mortality if not treated promptly BCSH, b.
It may be considered for HUS with cerebral symptoms. Congenital TTP is a rare disorder that can present at any age e. BPL 8Y and which may also be used for prophylaxis. Where specific coagulation factor concentrates are available, these are the treatment of choice for patients with inherited bleeding disorders. SD FFP is recommended. This is less likely to be an issue in children where the overall risk of thrombosis is low but SD FFP may be used if replacement therapy is required urgently and FXI concentrate is not immediately available.
FFP should not be used in the management of inherited factor deficiencies other than in a few exceptional circumstances where specific factor concentrates are not available 1B. Cryoprecipitate should not be used for congenital hypofibrinogenaemia unless fibrinogen concentrate is unavailable 1C. The exact role of granulocyte transfusions whether derived from whole blood or collected by apheresis therefore remains unclear.
The reaction profile was similar to that with other granulocyte components and all the children recovered. Granulocyte transfusions may be considered for treatment of refractory infections in children with severe neutropenia 2C. The factors contributing to this high blood use include the nature of the surgery and the coagulopathy associated with cardiopulmonary bypass CPB.
Clinically significant bleeding associated with paediatric cardiac surgery may be defined as WHO grade 3—4. Red blood cells RBCs are required during cardiac surgery with CPB, both as part of the priming solution for the bypass circuit to counter the effects of haemodilution and following CPB to replace losses. The primary transfusion threshold for red cells in paediatric cardiac surgery remains the Hb. It is recommended that red cells for neonates and infants receiving large volume red cell transfusions for cardiac surgery should be used before the end of Day 5 see Sections 4.
Electrolyte changes, such as hypocalcaemia, must be closely monitored and corrected and there is concern that older or irradiated blood might be associated with cardiac arrest at the start of CPB in small children due to high serum potassium concentrations.
10.2: Neonatal transfusion
Adult evidence Curley G. However, the current level of evidence in children precludes making firm recommendations. The two groups showed no difference in outcomes including lactate concentration, arteriovenous and arteriocerebral oxygen content and length of hospital stay. There is insufficient evidence to make a recommendation for children with cyanotic heart disease 2C. Blood used for cardiac surgery in neonates and infants should be used before the end of Day 5 see Section 2. Individual paediatric cardiac surgery units should have their own internal guidance on the maximum acceptable potassium concentration in the circuit prior to commencing CPB, and measures to adjust the level if necessary, such as washing or ultrafiltration of the prime.
If the bypass circuit potassium levels are noted to be unusually high such that they cannot be adjusted by normal procedures, an alternative red cell unit should be requested with appropriate specification dependent on availability if the situation is urgent 1C. Cell salvage including collection and washing of the residual bypass circuit contents is commonly used during cardiac surgery in both neonates and children. The transfusion thresholds described in the previous section apply to allogeneic blood; cell salvage is frequently reinfused in theatre at Hbs above these thresholds in order to reduce subsequent allogeneic transfusion.
The risks are low, but adequately trained staff are essential. Red cell salvage is recommended for all neonates and children undergoing cardiac surgery with CPB 1B. The adverse outcomes reported in some adults, including acute kidney injury, have not been reported in children. There was, however, no observed benefit of aprotinin in neonates.
This large but observational study was limited by the lack of data on comparative dosing. Overall, UK paediatric cardiac surgery practice in the use of antifibrinolytics is variable due to a persisting lack of clarity on appropriate dosing Arnold, Fibrin sealants are increasingly used in paediatric cardiac surgery. Consider using antifibrinolytic therapy in neonates and children undergoing cardiac surgery at high risk of significant bleeding 1B. Cardiopulmonary bypass results in reduced platelet numbers and impairs platelet function, predisposing to increased postoperative bleeding.
CPB in neonates and children may result in marked reduction of coagulation factors including fibrinogen, due to haemodilution, loss from the circuit and consumption. This guidance may change in the light of future high quality RCTs. Fibrinogen concentrate is not licensed for this use the UK. Massive blood loss MBL related to trauma is uncommon in children.
Major bleeding is more common in the surgical setting. In clinical practice, haemodynamic changes compatible with hypovolaemia accompanying evidence or suspicion of serious haemorrhage are the usual triggers. Good communication with the hospital transfusion laboratory is essential and should be clearly defined in a massive haemorrhage protocol MHP , which should include a section adapted for children.
Education about the core principles of MHP activation and management in children should be targeted at paediatric trainees and staff in Emergency Departments and theatres.
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Because unit sizes vary for children, the recommended component ratios should be pragmatically given on a volume basis rather than as units. Platelets and cryoprecipitate must be considered if active bleeding persists after initial resuscitation. These aliquots should be repeated in recommended ratios as necessary until bleeding is controlled. Ratios should be modified accordingly once laboratory parameters are available. Careful monitoring for adequacy of resuscitation and for circulatory overload is essential.
Each hospital that may encounter children with massive blood loss should agree and operate a dedicated children's massive blood loss guideline and algorithm including transfusion and clinical guidance. Surgical and trauma teams should have immediate access to emergency RBCs and transfusion laboratories should have plans in place to ensure rapid provision of components for children.
Early use of FFP, platelets and cryoprecipitate is recommended in order to reduce coagulopathy and thrombocytopenia. Tranexamic acid should be used where massive blood loss is anticipated in children presenting with major traumatic injuries, according to the timing and dosage recommended by the Royal College of Paediatrics and Child Health Grade 2C. However, there are a number of circumstances that may place infants and children at particular risk and where particular care is required. Education should be targeted at all clinical staff on all paediatric wards.
In order to reduce neonatal blood testing it is acceptable to use a cord sample as the first grouping sample. The maximum prescribed volume should not be greater than the volume for equivalent adult transfusions. This transfusion formula does not provide a precise prediction of the rise in Hb for a given transfused volume due to variation in the clinical situation and Hct of transfused red cells. Blood components will be provided by hospital transfusion laboratories as units, and it is good practice to liaise with the laboratory in order to ensure that donor exposure is minimized and that the volume ordered and prescribed is not above the maximum normally prescribed for an adult in a similar situation e.
Platelets — 1 pack approx. Consideration should be given to a dedicated prescription chart for blood components in neonatal units and paediatric wards, allowing for the inclusion of prompts for correct prescribing and space for recording multiple units of blood for a single transfusion episode. Hospitals should have clear guidelines on transfusion thresholds for different paediatric patient groups.
Hospitals are recommended to develop paediatric prescription charts to aid correct prescribing of blood components. Monitoring during the transfusion process is essential, especially as neonates and younger children may be less able to communicate symptoms of a transfusion reaction. Prescribers must take particular care in calculating paediatric transfusion volumes using a transfusion formula, noting particularly the recent changes to reporting Hb 1C. As for recommendations in adults BSCH, b , a second sample collected at a different time should be tested for confirmation of the ABO group of a first time patient prior to transfusion unless secure electronic patient identification systems are in place, as long as this does not delay urgent transfusion 1C.
For children whose parents refuse to consent to transfusion, for example Jehovah's witnesses, a full and timely discussion between the consultant and the family is crucial. The discussion should include optimising any cardiovascular or respiratory disease, investigation and correction of anaemia, and nutritional advice including information on ensuring adequate iron in the diet. Individual component types have additional special features, which are described in more detail in Appendix 1.
However, the selection of HT negative platelet components does not totally eliminate the risk of haemolysis. An additional indirect antiglobulin test is performed to screen donor blood for clinically significant red cell antibodies. These measures further reduce the risk of transmission of infectious agents via the blood supply. This means if the collection date is Day 0, the component must be transfused before midnight of Day 5.
It is considered good practice for hospitals to have a robust stock rotation mechanism to ensure that the freshest paedipack units are available for resuscitation, especially if they are irradiated. Emergency blood should be available for maternity and specialist neonatal units. If maternal and neonatal blood units are stored in the same refrigerator, they should be separated and clearly labelled to prevent accidental selection of the wrong component. There should be a locally agreed concessionary release policy for acceptable alternatives for emergency use including a process for communication between the clinical area, the laboratory and the Blood Services see also BSCH, Alternatives are dependent upon the reason for transfusion, availability of components routinely held in stock, timescales for delivery from the Blood Centre and proximity of the local blood storage to the clinical area.
Hospitals should agree a protocol outlining the hierarchy for acceptable alternatives if specific components are not available in an emergency, and the communication pathway between the clinical area, the hospital transfusion laboratory and the Blood Services.
Neonatal transfusion guideline
The antibody screen should be undertaken on the maternal sample when available. It is easier to obtain a sufficiently large sample from the mother to allow for screening and antibody identification if required. Sample collection from the infant exacerbates the anaemia of prematurity. If the maternal sample is unavailable or the baby was born in another hospital, the maternal group and antibody status and the transfusion history of both mother and baby should be sought from the referring hospital transfusion laboratory.
It is vital to remember that sick neonates may be transferred between multiple hospitals: a full transfusion and testing history should be obtained. Investigations on the infant sample: ABO and D forward group: if transfusion is required or likely to be required the infant's blood group should be verified on two samples unless a secure electronic patient identification system is in place collected at different times, where this does not impede the delivery of urgent red cells or other components BSCH, b. One of these samples can be a cord blood sample.
Prior transfusion can affect blood group interpretation so any transfusion history needs to be taken into account. In the absence of maternal plasma, screen the infant's plasma for atypical antibodies. Caution when interpreting neonatal ABO grouping is required because fetal or neonatal transfusion prior to sample collection may lead to mixed field results, or misinterpretation of the blood group due to presence of transfused cells. Ensure that the neonate's transfusion history is considered when interpreting and reporting ABO and D grouping. Is there ABO incompatibility between mother and infant?
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Nationwide, many NICUs continue to use red blood cells less than 10 days old in neonates, despite an increased emphasis on reducing donor exposure because of risk of transfusion Tx transmitted diseases. In the past, we have demonstrated that the donor exposure is reduced significantly after instituting a Dedicated Donor Transfusion Program DDTP [One unit of red cells is dedicated to each baby for the life of the unit - 35 days] in our NICU.
We compared the annual donor exposure and number of transfusions in infants in the year of introduction of DDTP and 3 years later. We also reviewed the blood pH, post-transfusion serum potassium and hematocrit. Presently, the clinical status of the infant determines the need for transfusion.