Blood product prescription


  • Statewide logo

    This guideline has been adapted for statewide use with the support of the Victorian Paediatric Clinical Network

  • See also

    RCH Blood transfusion website 
    RCH Blood transfusion - fresh blood products procedure (intranet only) 
    RCH Massive transfusion and critical bleeding procedure (intranet only)
    The Australian Red Cross Blood Service 

    Key Points

    1. All blood transfusion activity within the RCH and external services must occur in compliance with the relevant hospital procedures and guidelines.
    2. All patients should have consent for blood product administration recorded in the medical record prior to transfusion.
      1. A blood transfusion should only be given when the expected benefits to the patient are likely to outweigh the potential hazards.

      Background

      This guideline is adapted from the National Blood Authority (NBA) Patient Blood Management Guidelines: Module 6 Neonatal and Paediatrics (2016) as well as the British Society for Haematology Guidelines on transfusion for fetuses, neonates and older children (2016). Local procedures or guidelines may vary. 

      Assessment of transfusion requirements

      • A blood product transfusion may be required to treat acute blood loss associated with surgery or trauma, or when the body cannot make enough blood cells in the case of bone marrow failure, cancer or bone marrow suppression.
      • A blood transfusion should only be given when the expected benefits to the patient are likely to outweigh the potential hazards.

      All patients should have consent for blood product administration recorded in the medical record prior to transfusion.

      Indications for Red Blood Cell (RBC) transfusion

      Table 1: Indications for red blood cell transfusion

       Hb Indication 
       Hb <70g/L

       Red Blood Cell (RBC) transfusion is often indicated, however lower thresholds may be acceptable in patients without symptoms (symptoms may include – tachycardia, flow murmur, lethargy, dizziness, shortness of breath and cardiac failure) and where specific therapy (e.g. iron) is available.

       Hb 70 - 90g/L  RBC transfusion may be indicated, depending on the clinical setting e.g. presence of bleeding or haemolysis and clinical signs and symptoms of anaemia.
       Hb >90g/L RBC transfusion is often unnecessary and may be inappropriate  
         

      Transfusion may be indicated at higher thresholds for specific situations:

      • Preterm neonates: Hb thresholds vary depending on post-natal age and respiratory support (See Neonatal Transfusion Recommendations at RCH)
      • Children with cyanotic congenital heart disease or on Extra Corporeal Life Support (ECLS)
      • Children with haemoglobinopathies (thalassaemia or sickle cell disease) or congenital anaemia on a chronic transfusion program

      Indications for Platelet transfusion

      Table 2: Indications for platelet transfusion in neonates

      Platelet count

      (x 10^9/L)

       Indication to trigger platelet transfusions in neonates
      <30 Stable term or preterm neonate with asymptomatic thrombocytopenia and no bleeding 
      30 - 50

      Preterm neonate with thrombocytopenia being treated for sepsis or requiring respiratory support

      <50 Term or preterm neonate with bleeding symptoms (mucocutaneous, gastrointestinal, petechiae/purpura), coagulopathy or prior to surgery
      <100

      Term or preterm neonate with major bleeding (drop in Hb requiring RBC transfusion) or those that require major surgery (e.g. neurosurgery)

      Table 3: Indications for platelet transfusion in infants and children

      Platelet count

      (x 10^9/L)

       Indication to trigger platelet transfusions in infants and children
      <10
      • Clinically stable paediatric patients receiving chemotherapy for leukaemia or post haematopoietic stem cell transplantation (HSCT) (prophylactic)*
      • Clinically stable patients with solid tumours (prophylactic)*
      • Critically ill patients with no bleeding 

      * Transfusions at higher levels may be required for bladder, brain or necrotic tumours

      <20
      • Chemotherapy, HSCT & risk factors (e.g. fever, sepsis, minor bleeding, mucositis, disseminated intravascular coagulopathy (DIC) without bleeding)
      • Critically ill patients with risk factors for bleeding (e.g. sepsis, renal failure, medications)
      • Nasogastric tube insertion
      • Intramuscular injections e.g. Erwinia aspariginase
      • Insertion of a non-tunnelled central venous line
      <30
      • Lumbar puncture (LP) and on-going chemotherapy induced thrombocytopenia
      • Central nervous system (CNS) tumour and:
        • A VP shunt or Ommaya reservoir
        • Has a gross total resection and is receiving chemotherapy and/or radiation
        • Has residual tumour and is receiving chemotherapy and/or radiation
      <50
      • LP and new disease induced thrombocytopenia
      • Patient undergoing invasive procedure (including tunnelled central venous line insertion)
      • Moderate active bleeding (including bleeding associated with DIC)
      • CNS tumour and:
        • A past history of intracranial haemorrhage
        • Is receiving an anti- angiogenesis agent such as bevacizumab

      <75 
      •  Major haemorrhage due to trauma or significant post-operative bleeding 
      <100 
      • Patient undergoing high risk invasive procedure (e.g. neurosurgery/ophthalmology)
      • ECLS (lower platelets may be acceptable in stable patients)

      Platelet transfusion is NOT indicated for the following:

      • Stable patients with chronic, stable, severe thrombocytopenia due to:
        • alloimmunisation
        • immune thrombocytopenia (ITP)
        • thrombotic thrombocytopenic purpura (TTP)
        • aplastic anaemia or
        • myelodysplastic syndrome (MDS)
          These patients should be observed without prophylactic platelet transfusions and should receive platelet transfusions only with clinically significant bleeding

      • Bone marrow aspirate and trephine biopsy
      • Intravenous cannula insertion

       Indications for Fresh Frozen Plasma (FFP)

      FFP is appropriate for the following:

      • Acute bleeding in the setting of significant coagulopathy
      • Warfarin reversal, in the presence of significant or life-threatening bleeding or prior to emergency surgical procedures
        • Given in addition to vitamin K
        • NOTE: Vitamin-K dependent clotting factor concentrates (e.g. prothrombinex) may be given instead of FFP for bleeding secondary to warfarin or emergency warfarin reversal.
      • Liver disease, with clinically significant bleeding in the context of coagulopathy post liver transplantation.
      • Acute disseminated intravascular coagulopathy (DIC) with bleeding and significant coagulopathy
      • During massive transfusion or cardiac bypass for the treatment of bleeding
      • Plasma exchange for the treatment of TTP
      • Specific factor deficiencies where a factor concentrate is not available

      FFP is NOT indicated for the following:

      • The correction of minor coagulation abnormalities (minor prolongation of the INR/APTT) in the non-bleeding child
      • Liver disease when there are minor coagulation abnormalities and no-bleeding
      • For reversal of a INR <2.0 in patients undergoing minor procedures
         

      Indications for Cryoprecipitate

      Cryoprecipitate is indicated for:

      • Active bleeding and fibrinogen level <1.5g/L 
      • During massive transfusion or cardiac bypass, for the treatment bleeding when the  fibrinogen level <1.5g/L or there is hyperfibrinolysis
      • Acquired fibrinogen deficiency or acute DIC when there is significant bleeding and the fibrinogen <1.0g/L
      • Prior to an invasive procedure when the fibrinogen <1.0g/L and there is a risk of significant bleeding associated with the surgery or it is at a critical site (e.g. neurosurgery or eye surgery)

      Cryoprecipitate is NOT indicated for the following:

      • Non-bleeding children with mildly reduced fibrinogen levels
      • Liver disease when there are minor coagulation abnormalities and no active bleeding 

      Management - Transfusion volumes and rates

      • In neonates and children less than 20kg, transfusion volumes should be calculated based on weight and prescribed in mLs
      • In children greater than 20kg, calculate and prescribe the transfusion volume with consideration to pack sizes 
      • For RBC transfusion, prescribe a single unit followed by clinical reassessment to determine additional transfusion requirements
      • For platelet transfusions, the usual platelet dose in an adult is one adult unit
      • All transfusions must be completed within 4 hours of spiking a pack

       Table 4: Transfusion volumes and rates

       Blood product

      RBC 

       Platelets

      FFP  Cryoprecipitate

      Formula for calculating transfusion volume (mL)

      Children <20 kg:

       

      mL = wt (kg) x Hb (g/L) rise (desired Hb – actual Hb) x 0.5

       

      e.g.10 kg child requiring Hb to rise from 60 to 80g/L:

       

      10 x 20 x 0.5 = 100mL

         

      Children >20 kg:

      1 unit for > 20 kg child

      Children <20 kg:

       

      Pooled platelets        10 mL/kg                               

       

      Apheresis platelets     5 – 10 mL/kg                                

                                                 

      Children >20 kg:

      1 unit for > 20 kg child

      10 – 20 mL/kg  

      5 – 10 mL/kg 

      Typical unit volume

      Red cell unit ~ 258 ml  


      Paediatric red cells (pedipak) ~ 61 mL

      Pooled platelet ~ 334 mL


      Apheresis platelet ~181 mL 

      FFP ~284 mL


      Paediatric FFP (pedipak) ~69 mL

       Cryoprecipitate ~ 36 mL 

      Transfusion rate 

      5 mL/kg/hr        

       

      Commence at a slower rate (e.g. half the prescribed rate) for the first 15 minutes

      (Usual maximum rate 150 ml/hr) 

      10 – 20 mL/kg/hr

      Faster infusion rates (e.g. given over 30 minutes) may result in a transfusion reaction

      10 – 20 mL/kg/hr 

      10 – 20 mL/kg/hr 

      Blood product modifications

      Request the appropriate blood component and special requirements:

      • Irradiated blood products should be given to: 
        • All immuno-compromised patients, including all immunology patients, oncology patients, neonates, preterm and low birth weight neonates, neonates with cardiac disease and directed blood donations to prevent graft-versus host disease.
      • CMV negative products:
        • Leucocyte depleted blood products, are considered an acceptable alternative to CMV seronegative products at RCH
        • CMV negative products are only indicated for neonatal exchange transfusion, transfusions to preterm and term neonates up to 28 days post term, pregnant women and patients with Severe Combined Immunodeficiency Disease (SCID) who are CMV negative. 
      • Phenotype matched red blood cells:
        • Indicated for chronically transfused patients or patients with red cell alloantibodies
      • Cryodepleted FFP
        • May be requested for patients with Thrombotic Thrombocytopenic Purpura (TTP), although FFP may be as effective.
      • IgA deficient products
        • Patients with IgA deficiency who have developed an anti-IgA antibody 
      • HLA matched
        • For children with immunological refractory thrombocytopenia 

      Parent information sheet

      Kids Health Info Factsheet - blood product transfusions

      Information specific to RCH

      Consult the RCH clinical haematology team for further information 

      Last updated March 2018