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Neonatal Transfusion Recommendations at RCH

  • The following recommendations apply to neonates at the Royal Children's Hospital
    (About the Royal Children's Hospital Neonatal Unit)

    Transfusion of blood products to neonates should comply with hospital procedures in regard to pretransfusion testingblood administration and management and reporting of adverse effects

    Transfusion of Red Cell Products

    Red Blood Cells

    Red cells may be required for neonatal transfusion for surgery or resuscitation when large volumes are required.

    Red Cell Requirements

    • Group O and Rhesus compatible with infant's group. If infant group identical red cells are used, these must be compatible with any circulating maternal antibody.
    • Leucocyte depleted. All red cell products are leucocyte depleted by ARCBS.
    • Irradiated at time of blood issue
    • Administer using the Baxter Neonatal Set or McGaw 'in-line blood filter IV set' for leucocyte depleted products
    • Commence transfusion within 30 minutes of product receipt and complete transfusion within 4 hours of spiking pack.

    *Note: If an infant is undergoing massive or rapid transfusion, the use of older red cell units may be associated with hyperkalaemia. If this clinical circumstance is anticipated request red cells which are <= 5 days old at the time of crossmatch. 

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    Red  Blood Cells for Exchange Transfusion

    Exchange transfusion is generally carried out for hyperbilirubinaemia and/or anaemia, usually due to haemolytic disease of the newborn (HDN) or prematurity.

    ARCBS produces a red cell product specifically for neonatal exchange transfusion.  This red cell product has the following specifications:

    • Group O
      • CMV Negative
      • Fresh (<= 5 days)
      • Known haematocrit  (<0.6)
      • RhD negative
      • Kell negative
    • Leucocyte depleted
    • Irradiated at time of blood issue
    • Commence transfusion within 30 minutes of product receipt and complete transfusion within 4 hours of spiking pack.

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    Whole Blood

    Whole blood is no longer produced by ARCBS

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    Pedipaks 

    Pedipaks should be used for all red cell top-up transfusions in infants. Pedipaks are available as a stock item in group O Positive and O Negative. They are CMV negative and leucocyte depleted by ARCBS. One blood donation is split into four equal volumes (approximately 50ml). Once a baby receives a pedipak, the remaining segments are reserved for that infant. The use of pedipaks enables us to minimise patient exposure to multiple donors.   

    Pedipack

    Pedipaks should be requested at the time of blood request. Please indicate volume of transfusion.

    Pedipak specifications

    • Available in O Positive and O Negative
    • CMV Negative
    • Leucocyte depleted
    • Irradiated at time of blood issue (RCH)
    • Administer via the Baxter Neonatal Set
    • Commence transfusion within 30 minutes of product receipt and complete transfusion within 4 hours of spiking pack.

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    ASBT Protocol

    What is the ASBT protocol?

    The ASBT protocol enables us to omit repeated crossmatching prior to transfusion for infants during the first 4 months of life. This protocol recognises that the development of antibodies to red cell antigens is very uncommon in the first 4 months of life, and attempts to limit repeated sampling of blood for crossmatching.

    Who?

    Any infant less than 4 months of age who is likely to require more than one
    transfusion.

    The laboratory will make an assessment of suitability according to established criteria;

    • less than 4 months
    • pretransfusion ABO and Rh(D) group performed
    • DAT negative
    • no atypical red cell antibodies detected
    • one continuous admission

    If accepted, the laboratory will issue a report indicating that a further sample will not be required for crossmatch until a date when the baby is 4 months from birth.

    If an infant is discharged and readmitted, they must requalify for ASBT protocol.

    Exclusions?

    Any infants with a positive DAT and/or significant maternal red cell antibody shall be excluded.

    How to request the ASBT protocol?

    Requests: Write "ASBT Protocol" on the request form when the first sample is taken for crossmatch. Indicate any previous transfusion history, in particular intrauterine transfusion, or transfusion outside RCH. Indicate transferring hospital.

    How to order blood for babies on ASBT protocol?

    Once an infant is accepted on the ASBT Protocol, further samples are not required for pretransfusion testing. Blood can be ordered by telephoning the blood bank (ext 5829).

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    Transfusion of Platelet Products

    The platelet products suitable for neonatal transfusion are single units prepared from whole blood donations or apheresis collections split into small packs for paediatric use. All platelet products prepared in Victoria are leucocyte depleted by ARCBS. The words 'leucocyte depleted' will appear on the product label.

    COMPONENT NAME VOLUME ADMINISTRATION
    PLATELETS
    Leucocyte Depleted
    Irradiated 
    40-60ml  

    Baxter Neonatal Set
    (incorporates standard
    200µm filter)

    PLATELETS Apheresis
    Paediatric, Part 1,2,3,4 of 4 
    Leucocyte Depleted
    Irradiated

    40-60ml 

    Baxter Neonatal Set
    (incorporates standard
    200µm filter)

    • Where possible, infants should receive ABO and Rh(D) identical platelets.
    • Avoid giving Rh(D) positive platelets to Rh(D) negative female infants.
    • All Platelets are irradiated by ARCBS
    • Product expires 5 days from collection
    • Administer via the Baxter Neonatal Set (leucocyte depleted products)
    • Commence transfusion within 30 minutes of product receipt and complete transfusion within 4 hours of spiking pack.
    • For neonates or patients <10kg give no more than 10ml/kg or 1paediatric split (which ever is less volume)

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    Transfusion of FFP

    Fresh Frozen Plasma must be compatible with the infants red cell antigens, ie should be group identical or group AB.

    • Paediatric FFP is available in group AB as a stock item.
    • Average volume 60ml.
    • Requires 30 minutes notice for thawing
    • Does not require leucocyte depletion or irradiation
    • Administer via the Baxter Neonatal Set
    • Commence transfusion within 30 minutes of product receipt and complete transfusion within 4 hours of spiking pack.
    • Usually infused in a volume of 10-20ml/kg.

    Transfusion of Cryoprecipitate

    • Cryoprecipitate is available in group O and A
    • Average volume 20-30ml.
    • Requires 30 minutes notice for thawing
    • Does not require leucocyte depletion or irradiation
    • Administer via the Baxter Neonatal Set
    • Commence transfusion within 30 minutes of product receipt and complete transfusion within 4 hours of spiking pack.
    • Usually infused in a volume of 5ml/kg.

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    Cytomegalovirus

    The guidelines of the UK Transfusion Services (2002) state that blood transfused in the first year of life should be cytomegalovirus (CMV) seronegative. Other authorities state that products that have been leucocyte depleted to less than 5 x 106/unit have a significant reduction in the risk of CMV transmission. Transfusion recipients at greatest risk of CMV transmission are fetuses, infants weighing less than 1.5kg, immunodeficient patients and stem cell transplant recipients.
    Some clinicians may prefer CMV seronegative components for patients considered to be particularly susceptible to severe CMV infection (patients with cellular immunodeficiency and stem cell transplant recipients). When CMV seronegative products are not available, leucocyte depleted products are an acceptable alternative. Since 60-70% of the adult population are CMV seropositive, CMV seronegative products may not always be available.

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    Irradiation

    Why?

    Cellular blood products may be irradiated to reduce the risk of transfusion-associated graft versus host disease (ta-GVHD).

    Who?

    All neonates at the Royal Children's Hospital.

    Established clinical guidelines for irradiation of cellular blood products in the fetus and neonate include:

    1. Intrauterine transfusion (IUT)
    2. Exchange transfusion (ET)
    3. Top-up transfusion after IUT
    4. When the donor is a first or second degree relative (directed donation) or HLA matched.
    5. When the infant has proven or suspected immunodeficiency

    The 'universal' irradiation policy at RCH is a practical alternative to selecting appropriate patients, and relies on the fact that RCH has a blood irradiator on site. 

    What?

    Cellular products:  Red Blood Cells, Platelets.

    When?

    All platelet products used within RCH are irradiated before issue by Australian Red Cross Blood Service (ARCBS).  Irradiation does not alter expiry time for platelet products.

    Red Cell products will be irradiated by the RCH blood bank immediately prior to issue. The irradiation process takes approximately 5 minutes. If there is a need for immediate transfusion for an exsanguinating infant, emergency blood release of non-irradiated blood is available. Do not delay transfusion in this circumstance.

    Irradiation of blood products

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    Transfusion Support in Necrotising Enterocolitis (NEC)

    Some infants with NEC and/or sepsis develop T activation of red cells. T activation occurs through the action of bacterial neuraminidases and results in exposure of crypt antigens on the red cell surface. T activation was detected in the laboratory by a lectin test, however, this test is no longer available . Infants with NEC and sepsis can develop haemolysis. There are some reports of transfusion exacerbating haemolysis in these very sick infants. Since all adult plasma contains anti-T which could potentially exacerbate haemolysis, some experts advocate special transfusion support for these infants. Practice in this area is varied because of the lack of definitive studies.

    It is reasonable to avoid plasma exposure by requesting washed red cell products in an infant with significant haemolysis. It is reasonable to avoid using FFP/platelet transfusion unless there is significant coagulopathy/thrombocytopenia in the presence of bleeding and/or need for an invasive procedure. Urgent transfusion should not be delayed while waiting for special blood products.
    Transfusion support should be discussed with the consultant on an individual basis.

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    Laboratory specimens and NETS transfers 

    Blood samples (maternal, cord) received with NETS transfers will be accepted by The RCH Core Laboratory when the following criteria are met:

    • The specimen and request form have a minimum of two points of identification:
      1. Firstname and Surname (If first name not yet given, indicate "Baby of" & Surname)
      2. UR or date of birth
    • The two points of identification on the sample and request form are identical
    • The request form is signed by the requesting doctor
    • The request form is signed by the person who collected the sample

    Note that the request form should indicate the type of specimen i.e. maternal or cord sample

    Forward samples to the laboratory immediately where they will be stored appropriately and used as required.

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