Indication of Blood Transfusion in Newborns - PowerPoint Presentation

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Indication of Blood Transfusion in Newborns

Dr Bijan Keikhaei

Full Professor of Pediatric

Hematology and Oncology

Research Center for Thalassemia and Hemoglobinopathy, Health Institute, Ahvaz Jundishapur University of Medical Sciences

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Introduction

Blood forms an important part of the therapeutic armamentarium of the neonatologist (

Very small premature neonates

). because of their immaturity, ongoing illness and the need for repeated sampling.

it is essential that one considers the

risk/benefit

ratio and strive to develop treatment strategies that will result in the

best patient outcomes.

Since neonatal physiology varies with the maturity, age, weight and the presence of morbidities, it is

difficult to formulate

one parameter to guide all transfusion decisions.

What specific

pretransfusion processing

is performed before transfusing blood products to neonates? • What are the

indications

for the use of various blood products?

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Introduction

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Introduction

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Introduction

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Blood Transfusion

Benefit

Risk

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Hb Level

Clinical Context

Gestational age&

weight

Blood Transfusion

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TRANSFUSION THRESHOLDS

Transfusion threshold describes the

lower limit of hemoglobin

level at which a transfusion is considered. A balance has to be maintained between

severe anemia

and increasing the

risk of morbidity and mortality

by exposing a patient to donor blood unnecessarily

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Potential benefits of transfusion

Improved tissue oxygenation

lower cardiac output to maintain the same level of oxygenation

Effects of Transfusion Thresholds on Neurocognitive Outcome of extremely low birth weight infants

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Potential Risks of transfusion

Infectious

Non-infectious

I. Immunologic:

Acute Immunologic

Delayed

II. Non-immunologic

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Potential Risks of transfusion

Transfusion-associated Graft versus host disease

Cytomegalovirus infection

CMV seronegative donations and leucodepleted

products should be considered as equally ‘CMV safe’.

PRBC transfusion in preterm neonates should be restricted to minimum to prevent complications which are unique to them such as increased incidence of

retinopathy of prematurity (ROP), CMV infection and even necrotizing enterocolitis (NEC).

Hypoglycaemia.

Transfusion overload

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Immune mediated hemolysis Acute hemolytic transfusion reactions are a common fatality in adult patients, but these

are rare in neonates.

Newborns do not form red blood cell (RBC) antibodies; all antibodies present are

maternal in origin.

Newborns must be screened for

maternal RBC antibodies,

including ABO antibodies if non-O RBCs are to be given as the first transfusion.

If the initial results are negative, no further testing is needed for the initial

4 postnatal months

.

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Blood Transfusion Policies in Newborn

Restrictive transfusion practice

Liberal transfusion practice

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Choosing the blood group for neonatal transfusions

It is preferable to take samples from both, mother and the newborn.

Mother’s sample should be tested for blood group and for any atypical red cell antibodies.

ABO compatibility is essential while transfusing PRBCs. Though ABO antigens may be expressed only weakly on neonatal erythrocytes, neonate’s serum may contain transplacentally acquired maternal

IgG

anti-A and/or anti-B.

Blood should be of newborn’s ABO and

Rh

group. It should be compatible with any ABO or atypical red cell antibody present in the maternal serum.

In exchange transfusions for

Rh

hemolytic disease of newborn, blood transfused should be compatible with mother’s serum. Ideally

Rh

negative blood of the baby’s ABO group has to be used after cross matching with maternal serum. If compatible ABO group is not available then group O and

Rh

negative blood can be used.

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Pre-transfusion Issues

Donor selection

a. Avoid blood donation from first and second degree relatives.

b. In addition to routine screening tests, the donor should be negative of Hb S and seronegative for Cytomegalovirus (CMV).

Pre-transfusion testing of donor blood

a. Blood typing errors can result from

i

. Weak expression of red blood cell(RBC) antigens in neonates

ii. Presence of maternal antibodies that can mask the corresponding antigens.

iii. Umbilical cord samples contaminated by maternal blood/ Wharton’s jelly.

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Irradiated blood

i

.

Intrauterine transfusion

of packed RBC and platelets

ii. Transfusion of packed RBC and platelets (also in

blood exchange transfusion

) after intrauterine transfusion

iii. Transfusion of RBC and platelets in neonates with birth weight

< 1500 grams

and/or gestation at birth

< 30weeks

iv. Donations from

first or second degree relatives

v. Neonates with

congenital or acquired immunodeficiency.

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CMV negative blood

i

. Intrauterine transfusion of packed RBC and platelets

ii. Neonates with birth weight <1500 grams and/or gestation < 30weeks

iii. Neonates with congenital or acquired immune deficiency;

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T activation: T antigens (and the closely related Th,

Tk

and

Tx

antigens)

are present on the neonate’s RBC surface and get activated in certain clinical situations (e.g. Necrotizing enterocolitis and Septicemia) when RBC get exposed to bacterial or viral enzymes (neuraminidase).

This leads to poly

agglutination of the RBCs (unexpected agglutination on testing with sera from ABO compatible donors) and thereby hemolysis.

In high risk situations avoid all plasma or plasma products as most adults have anti T antibodies due to prior exposure to bacteria and vaccines.

If unavoidable use plasma with low

titres

of anti T antibody to prevent hemolysis.

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Recommendations on use of blood products in neonates

Blood for transfusion should be

less than 5 days old,

Irradiated

CMV negative

warmed

HCT of 50 to 60

Reconstituted blood: Reconstituted whole blood is obtained by combining packed RBC with fresh-frozen plasma (FFP). Ideally FFP should be from the same donor bag from which the packed RBC was produced. Otherwise AB group FFP from a different donor may be used. The final product should be used within 24h of reconstitution and has the same characteristics as whole blood except for reduced platelets.

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IUT

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IUT

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Guidelines for packed red blood cells (PRBCs) transfusion thresholds for term neonates

Condition

Hb (g/

dL

)

Severe pulmonary disease

<13

Moderate pulmonary disease

<10

Severe cardiac disease

<13

Major surgery

<10

Symptomatic anemia

<8

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