[B] OS 216: Hematology
Lec 2: Transfusion in Neonates
Transfusion in Neonates
January 13, 2014
Dr. Eufrosina Marina A. Melendres
TOPIC OUTLINE
I. General Principles and Observations
II. Pathologic Anemia in the Newborn
A. Causes
B. Clinical Symptomatology
C. Laboratory Evidence
III. Red Cell Transfusion
A. Technical Approaches for Small Volume Transfusions
B. Additional Hazards of RBC Transfusions
C. Exchange Transfusion Indicators
IV. Practical Considerations in Administering Blood
Transfusion
V. Reducing Transfusion Reactions
VI. Appendix: Clinical Practice Guidelines for Blood
Component Therapy
GENERAL PRINCIPLES AND OBSERVATIONS
 Transfusion in neonates is different and unique.
o Don't think of the pediatric patient as a small adult.
- Do not transfuse a whole unit; it will lead to toxicity
 Instead, use aliquots (small volume/portion transfusions in
neonates)
 The neonatal period lasts from birth up to four months.
 Fetal Red Cells – at birth
o Contain 53-95% hemoglobin F (α2γ2)
o Shorter half life
- T1/2: 45-70 days in newborn (vs. 90-120 days in adult)
 Reason why testing before 6 mos. is not done
 Blood Volume
o Full-term neonates - ~85 mL/kg
o Premature - ~100 mL/kg
o Larger blood volume attributed to smaller body mass of
prematures relative to full-terms
 The newborn does not compensate for hypovolemia as well as an
adult; it takes longer to recover
 The infant’s bone marrow responds more slowly to anemia than
mature marrow
o Babies need 2-3 weeks to recover while adults only need 4 - 6
days)
 Hypothermia causes adverse metabolic effects so it is important to
maintain normal body temperature in newborn.
o Otherwise, causes increase in the basal metabolism of the
newborn, which may cause: hypoglycemia, metabolic acidosis,
apneic episodes, hypoxia, hypotension, or even cardiac arrest
o Consider inline warmers to avoid hypothermia
o Never allow temperature of newborn to fall beyond normal resuscitation will not work – no. 1 step is to increase temperature
to normal
 The antibody producing mechanisms and cellular immune system of
neonates are immature
o Newborns are considered immunocompromised
o The neonate only has maternal IgG, from placenta (no IgM yet)
 Newborns have immature kidneys and livers which can result in
acidosis, hypocalcemia and hyperkalemia
 We treat only the pathologic type of anemia in the newborn, not the
physiologic one
o NO SYMPTOMS, NO TRANSFUSION
 Hematocrit alone is an imprecise and unreliable laboratory indicator of
anemia in the newborn, so you have to consider other parameters
 The only indication for fresh whole blood (FWB – blood extracted
from donor <5 days ago) is exchange transfusion for neonates;
otherwise only blood components are used
o FWB does not contain platelets
o If you want to avail all the blood components (including platelets)
in FWB, it should be within 6 hours of blood collection. Once the
blood is placed in the refrigerator, the platelets are lost.
o We want FWB because of its higher 2,3-DPG levels
- This allows easier and faster release of oxygen from red cells
PATHOLOGIC ANEMIA IN THE NEWBORN
 Reduction of effective RBC mass limits O2 availability to the tissues
CAUSES
BLOOD LOSS
 Prenatally, during delivery or postnatally (abruptio placenta, placenta
previa, etc.)
MEGGIE, KARL, AHMAD
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OS 216
 Iatrogenic (“physician induced”) blood loss >10% of the blood volume
due to blood extractions [very important] – warrants simple blood
transfusion
o In the NICU, they are supposed to have a record of blood
transfusions/extractions
HEMOLYTIC PROCESS
 Blood group incompatibility (hemolytic disease of the newborn)
 Hemoglobinopathies and thalassemias (defect in hemoglobin)
 Hereditary spherocytosis and elliptocytosis (membrane defect)
 G6PD deficiency (enzyme defect)
IMPAIRED CELL PRODUCTION
 Iron deficiency anemia – due to inadequate Fe stores at birth
o Iron deficient mother = iron deficient baby
 Diamond-Blackfan anemia – “pure red cell aplasia”
 Congenital rubella
 Congenital leukemia
CLINICAL SYMPTOMATOLOGY
 Tachycardia, dyspnea, tachypnea, pallor, decreased activity, tiring at
feeding (due to compensatory mechanisms; in newborns, feeding and
sucking reflex are important)
 Poor weight gain, poor growth (failure to thrive; poor oxygenation)
 Anemia of prematurity – when apneic spells are frequent and
prolonged
 Cardiomegaly on x-ray with tachycardia or tachypnea
 Evidence of hypoxemia
o Already warrant red cell transfusion
Very varied and non-specific!
LABORATORY EVIDENCE
 Hemoglobin
o Below 100 g/L in term infants
o Below 120 g/L in small preterm infants
 Hematocrit – may be unreliable; correlate with other lab findings
o Below 30% in term infant
o Below 40% in sick preterm infants (esp with IRDS, pulm problems)
o Need for higher hematocrit
 Others – not used in PGH
o Red cell mass
o Available oxygen
o Serum EPO (erythropoietin)
RED CELL TRANSFUSION
 Objectives
o To correct anemia – since the patient is symptomatic
- Increase cardiac output
- Decrease metabolic acidosis
- Improve peripheral perfusion
o To enhance oxygen-carrying capacity of the blood
- Replacing HbF with HbA (α2β2)
 Sequesters O2 to tissues more willingly, HbF – “mas matigas”
according to Ma’am thus can’t insinuate on small venules and
capillaries
o Exchanging poorly deformable fetal red cells for more flexible
adult ones
o HbF does not release oxygen as easily as HbA (due to 2,3-BPG)
 Indication
o A combination of clinical and laboratory evidence of pathologic
anemia
TECHNICAL APPROACHES FOR SMALL VOLUME TRANSFUSIONS
 A single donor unit may be divided into several aliquots, with the
added advantage of diminishing the risk of hepatitis and other
transfusion transmitted infections (TTI) by reducing the number of
donor exposures (maximize resources of blood from only one donor)
o Quadruple pack – can provide 1 unit of plasma & three 80mL or
six 40ml aliquots of RBCs (6 babies can share)
- In closed system; consumed in 35 days
- Very expensive
o Half unit donation – using a triple pack can provide two 60 ml
aliquots of RBCs
 Storage duration
o Platelet – 5 days while PRBCs -5 weeks
o * Punctured bag in open method; should be consumed in 24 hours
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Transfusion in Neonates
ADDITIONAL HAZARDS OF RBC TRANSFUSIONS
 Risk of retrolental fibroplasias (retinopathy of prematurity) in infants
who receive simple or exchange transfusions while on oxygen; now
very conscious of this possibility for babies in nursery/in oxygen for a
very long time refer for pediatric opthalmologist
 Possible suppression of erythropoiesis and reticulocytes
 Risk of Cytomegalovirus (CMV) infection
o Give CMV (-) blood, problem – almost all adult blood is CMV (+)
 Risk of transfusion-associated graft versus host disease
o Very rare, but almost uniformly fatal
o Direct donations from first degree relatives
o Relatives share HLA [human leukocyte Ag] that may react with the
baby’s immune system.
- Because of the shared HLA, the donor fails to recognize the
graft as foreign and can’t reject them, however competent T
cells from graft reject the cells of the host [in short, inunahan
lang ng graft cells na i-reject yung host]
o Also, relatives may lie of present condition/illness
o Ideally, blood should be gamma-irradiated, but it is expensive!
(and not available in PGH)
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Meggie: Easiest trans ever. Swerte naman ng block a na nakakuha ng
cardio+gi+renal+etc etc etc lahat ng mahirap na transes natin  good
for them hahaha. Hello to my people. Hello to your people. Yay.
Karl: Hi 2017
[lame ni Karl ni laging walang greeting. haha]
Ahmad: Hello! Hello! Brace Yourselves, Block B! Benign Days are
coming! (minus Neuro). Hello sa RSO peeps, kay Buddy Denzy and
Harj. Sa mga Block A pipol (gudlak talaga sa Renal-Gi-Pulmo
whahahahaha).
Hi Din sa Cardio Elective Peeps! :D And sana Friday na para sa
“Forensic Fridays with Dr. Fortun” Sessions. Sobrang cool lang ni mam
\o/ \o/ \o/
EXCHANGE TRANSFUSION INDICATORS
 Hemolytic disease of the newborn
o ABO incompatibility
- Choice of blood: type O, Rh+ Fresh Whole Blood (FWB) –
usually Filipinos
- Same blood type with mother
o Rh Incompatibility
- Choice of blood: ABO-specific Rh- FWB
- Same blood type with the baby
o Others
- Progressive hyperbilirubinemia
- DIC (disseminated intravascular coagulation-not sure), sepsis
- Choice of blood: ABO, Rh-specific FWB
- same blood type with the baby
.
Figure 1. [Rh incompatibility] You have a Type A of Type B baby;
while the mother has Type O blood. If there is a leakage of blood from
the baby into the placenta, to the mother, the mother is sensitized to the
antigen, then produces anti-A or anti-B antibodies. Antibodies are
brought to the baby, causing hemolysis of blood. In the first 24 hours of
life, symptoms of pallor and jaundice are observed
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PRACTICAL CONSIDERATIONS IN ADMINISTERING BLOOD
TRANSFUSION
Proper typing and crossmatching (avoid human errors - #1 cause!)
Accurate identification of donor unit and recipient
Use proper filter for blood and components
Administer the blood/components as soon as possible after issue.
Return unused blood to the Blood Bank within 30 minutes (Golden
period)
If you return beyond 30 minutes, the blood will be disposed
Only plain NSS should run with PRBC and WB (otherwise blood
will hemolyse)
Drugs should not be injected into the tubing
Infusion time should not exceed 4 hours per unit
Observe the patient closely for the 15 minutes of transfusion for any
adverse reaction. Record vital signs, before, during, and after infusion
REDUCING TRANSFUSION REACTIONS
 Give transfusions only when a definite indication exists
 Observer “eternal vigilance in all aspects of blood banking”.
 Adhere to the highest standards of pre-transfusion testing. (screen for
HIV, CMV, malaria, Hep B)
END OF TRANSCRIPTION
MEGGIE, KARL, AHMAD
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Transfusion in Neonates
APPENDIX:
Clinical Practice Guidelines for Blood Component Therapy
Transer’s Note: May handout na binigay si mam
CLINICAL PRACTICE GUIDELINES FOR BLOOD COMPONENT
THERAPY
 As recommended by AABB, WHO, ARC, PSHBT, NVBSP, PGH
 Included in the 3rd edition of the PGH Blood Bank manual
 Lecture includes some basic information regarding blood components
INDICATIONS FOR WHOLE BLOOD
 <5 days old (fresh)
 for exchange transfusion in neonates; the only remaining indication for
FWB (Fresh Whole Blood)
o hyperbilirubinemia in infant with IB of 20 mg/dl in first week of life
o hyperbilirubinemia with prematurity and./or other concomitant
illness to include on or more of the ff: prenatal asphyxia, acidosis,
prolonged hypoxemia, hypothermia, sepsis and hemolysis
 Note: Combination of PRBC (Packed Red Blood Cells) and FFP
(Fresh Frozen Plasma) may also be given in WB is not available
PACKED RED CELL
 Aliquots based on weight
1. Hypovolemia from acute blood loss with signs of shock or
anticipated blood loss of >10%
2. Candidates for major surgery and hematocrit <30%
(neonatal <35%)
3. Hypertransfusion for chronic hemolytic anemias (i.e.
Thalassemia)
4. Hemoglobin <13 gm/dl (Hct 40%) in neonates <24 hours old,
severe pulmonary disease, with assisted ventilation,
cyanotic heart disease or heart failure
5. Neonates with phlebotomy losses (Iatrogenic) >10% of total
blood volume
6. Hemoglobin level <8 gm/dl or Hct <25% in stable new born
infants with clinical manifestations of anemia.
 Dose 10 ml/kg BW/transfusion
 Aim: to restore or maintain the oxygen-carrying capacity of the blood
minimal expansion of the blood volume
 Advantages: Less transfusion reaction, Less fluid overload (Because
you don’t give plasma)
 Rest period post transfusion is 8-10 hours (As recommended by Dra.
Melendres)
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FRESH FROZEN PLASMA
 Indications
1. Significant multiple coagulation factor deficiency or acquire
factor deficiency (e.g. dengue shock syndrome)
2. Significant congenital factor deficiency
3. Anti-thrombin III deficiency
4. Bleeding in exchange transfusion or massive transfusion (>1
Blood Volume)
 Contains all clotting factors, labile and stable.
 Transfuse within 24 hours after thawing, within 6 hours to avail of
the labile factors
 Should be ABO-compatible
 Dose: 15 ml/kg/transfusion
CRYOPRECIPITATE
 Prepared within 6 hours of collection
1. Factor VIII Deficiency
2. Von Willebrand’s Disease
(There were two others that were mentioned, hanapin nyo na lang
tenks. Basta any disease that lacks these clotting factors)
 Contains labile factors = I, V, VIII, XIII, VWF
 Contains approx.. 80-100 units of F. VIII per bag, and approx.. 250 mg
fibrinogen per bag.
 Arbitrary doses: a minimum of 3 bags/transfusion, 1 unit/6 kg
CRYOSUPERNATE
 Indications
1. Liver disease
2. Disseminated Intravascular Coagulation
3. Hemophilia B (Factor IX deficiency)
 Contains Stable factors = II, VII, IX, X (Vitamin K dependent factors)
 Preferably ABO compatible
SMALL VOLUME TRANSFUSIONS IN NEONATES AND CHILDREN
 Technical approaches:
o Quadruple Pack – a single donor unit can provide one unit of
plasma and three 80-ml aliquots of packed red cells.
o Half-unit donation – using a triple pack, will provide two 60-ml
aliquots of packed red cells
o Transfer bad
 N.B. The neonatal period extends from birth up to 4 months
PLATELET CONCENTRATE
 Indications
1. Active Bleeding and thrombocytopenia <50 or at risk for
intracranial hemorrhage
2. Active bleeding and qualitative defect
3. Prophylaxis for severe thrombocytopenia <20 or associated
qualitative defect
4. Scheduled invasive procedure and thrombocytopenia <70 or
associated qualitative defect.
 No crossmatching needed (Only red cells need crossmatching not
platelets!!!!)
 Use ABO-specific or type O platelets
 Dose: 5-8 units/M2; be guided clinically
 May also use apheresis platelet concentrates
o Single-donor platelets
o Equivalent to 6-8 units of platelet concentrates
 *Apheresis platelet concentrates
o From one donor
o Blood circulates thru machine 6-8 times
o Machine harvests only platelets
o Does not have much effect on donor
o Expensive (12k pesos), not all hospitals have apheresis machines
MEGGIE, KARL, AHMAD
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