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Blood Products & Transfusion in Children - DNH

DNH Intern Orientation 2014

Karin van den Berg

on 14 September 2015

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Transcript of Blood Products & Transfusion in Children - DNH

Blood Products & Transfusion
in Children

Dr Karin van den Berg
SANBS Eastern Cape

Basic Immuno-Haematology
Appropriate Use
Which products are needed?
Small volume transfusions:
Red cell concentrated (packed cells)
Compatible with baby - usually O-neg
Dedicated aliquotes from single donation
Preferably warmed
Depends on the underlying problem:
Exchange Transfusions:
"Fresh" whole blood
Ideally compatible with mom and baby (Usually O-neg)
Monitor K+
Transfusion Thresholds
How much blood should we give?
Final Step (At last!)
Blood Administration
Thank You!!

Massive Transfusions:
"Fresh" red cell concentrate (Not whole blood)
Compatible with baby
Preferably warmed
Basic Immuno-Haematology

Appropriate Use of Blood and Blood Products



Transfusion Reactions
Questions that need answering before transfusion:

Does the patient REALLY need a transfusion:
is there not something else?

When should you consider it:
what should the transfusion threshold be?

What should be given:
which product for which condition?
Is the transfusion really required?
Cause of the anemia?
Can be acute or chronic

Due to decreased production or increased loss/destruction

Whatever the cause, it MUST be identified & treated

Chronic anemia less likely to require transfusion than acute blood loss
Nutritional deficiencies very common
BUT responds very well to replacement therapy
Patients tolerate very low Hb very well

Anemia common in HIV
Responds well to ART
AZT not necessarily contra-indicated,
but can cause / aggrevate anemia

Many drugs cause anemia
Beware: Co-trimoxazole & anti-TB meds!!
Currently no registered blood substitute available in South Africa
However, simple measures is often very effective
* Implementation & adherence to EBM guidelines
* Early diagnosis & appropriate management
* Hematinics
* Erythropoietin
* Effective control of hemorrage
* Early resuscitation
As little as possible
General Guide:
TRICC & PICU studies:
Critically ill patients
Restrictive transfusion policies
As safe as liberal policies
Suggest that:
Hb<7 need reason NOT to transfuse
Hb>9 need GOOD reason to transfuse
There is a “lack of evidence for many transfusion practices in the neonatal period and childhood, making recommendations difficult in a number of areas” (Boulton, 2004)(1)
Only transfuse with symptomatic anemia:

Respiratory irregularities
Poor weight gain
Poor sucking
Congestive cardiac failure
Explaining cost of care is part of informed consent
Red Cell Concentrate R1 440.00

RCC Leucocyte Depleted R2 350.00

RCC Paed. Leucodepleted R1 330.00

Apheresis Platelets R8 330.00

Pooled Platelets R6 960.00

FFP R1 150.00
Pricing is approximate for Public Sector
This presentation is intended as a practical guide
Not a detailed review of available literature
Is rooted Evidence Based Guidelines and Publications
Boulton F. Transfusion guidelines for neonates and older children. British Journal of Haematology. 2004;124:433-53.

Medical Directors of the South African Blood Transfusion Services, editor. Clinical guidelines for the use of blood products in South Africa. 4th ed: Adcock Ingram; 2008.

Lacroix J, Hebert PC, Hutchison JS, Hume HA, Tucci M, Ducruet T, et al. Transfusion strategies for patients in pediatric intensive care units. The New England Journal of Medicine. 2007 19 April 2007;356(16):1609-18.

Hébert PC, Wells G, Tweeddale M, Martin C, Marshall J, Pham B, et al. Does transfusion practice affect mortality in critically ill patients? Transfusion Requirements in Critical Care (TRICC) Investigators and the Canadian Critical Care Trials Group. American Journal Of Respiratory And Critical Care Medicine. 1997;155(5):1618-23.
Conflict of Interest
Employed by SANBS
Have a vested interest:
Try to convince you to use LESS of our products
Has it been addressed?
What volume?
What giving set?
What rate?
What temperature?
General recommended volume 10ml/kg
* Severe malnutrition - 5ml/kg
To raise Hb by 1g/dl you need 3-5ml/kg
* Pediatric RCC = 60-80ml
Children @ increased morbidity and mortality
Susceptible to TACO (Transfusion Associated Circulatory Overload)
Need to carefully consider
* the need for transfusion
* the volume used
in each individual

Active bleeding need transfusion at higher levels transfused quickly

And children with severe malnutrition need lower volumes slowly.
Standard blood giving set
Must be filtered before transfusion
DO NOT need bed-side leucodepletion filter - already leucodepleted
* Platelet giving set for platelets
Patients needing chemotherapy:
* Higher threshold - 10g/dl
Patients with thalassaemia:
* Higher threshold - 9-9.5g/dl.
Exceptions include:
Blood warming NOT routineline indicated
Infants transfused >15ml/kg/hr
*i.e. massive transfusions
Exchange transfusions
High titre cold antibodies
Monitoring & Transfusion Reactions
Most serious reactions occur within first halfhour
Some Public Hospitals:
*Dr to hang first unit
* Ilogical - equal risk with
2nd/3rd Unit
Children at same risk of AHTR
Following is under diagnosed:
TT Bacterial Infections
Probably also TRALI
In Summary:
Blood products in South Africa is a safe as in developed world
BUT blood transfusion is not without risk

Informed consent is critical
Owe patient sufficient info for INFORMED decision making

Give smallest volume transfusion possible
Frequent reassesment
Again - as little as possible
>25 Blood Group Systems
Each contains multiple Ag
Each Ag can elicit Ab response
Most important:
ABO and
Rh Systems
Others can still cause transfusion reactions and HDN
ABO Ab’s called “naturally occuring”

Develops at aroun 4 months of age

Exposure to absent Ag may results in:
Intravascular haemolysis
HDN - Rare, mostly Group O mothers with
Group A babies
Can occur with first pregnancy
Usually not severe
Rh Ab’s are “Red Cell Immune”
Requires pre-exposure
Initial exposre - IgM – Does not cross placenta
Repeat exposure – Increased titre IgG – Crosses placenta

Exposure to absent Ag results in
Red Cell Sensitisation & extra-vascular haemolysis
Most common cause of HDN
Mostly result of anti-D, but also anti-C,c,E,e
Rarely occur with first pregnancy
Progressive severity with subsequent pregnancies
Haemolytic Disease of the Newborn (HDN)
Eg: Mom Rh Neg with a Dad Rh Pos

First pregnancy – Mom is sensitized (IgM)
Second pregnancy – Baby affected (IgG)
Red Cells sensitised
Removed by RE System
Extra-vascular Haemolysis: Raised Bilirubin, etc
Raised Bilirubin,
Severe Anaemia;
Cardiac Failure;

Can occur with any of the Red Cell Antigens
Most common: Rh (D, C, c, E, e) ABO & Kell
Full transcript