Blood component therapy in newborn and children jyoti
Dr. Jyoti prajapati Guided by dr. S.S. Yadav
INTRODUCTION Blood transfusion is one of the oldest forms of therapy. Critical care frequently requires the urgent use of large numbers of blood component, often as a lifesaving supportive measure Blood component transfusion plays a very important role in modern transfusion. Through modern medical methods, many kinds of blood components are separated from whole blood.
The routine separation of donor blood into components and plasma fraction has made it possible for blood banks to provide the specialized blood products required for the support of patients in multiple treatment modalities. The infusion of blood component is called component transfusion or blood component therapy.
Fresh Whole Blood o Light spin, C(within 8 hrs)Packed Red Cells Platelet Rich Plasma o Heavy spin, C Platelet Concentrate Fresh Plasma o Store at C Freeze(FFP)
In some special cases, whole blood, usually in the form of reconstituted whole blood, can be used. However, in most cases blood components are preferred because each component has specific optimal storage conditions and component therapy maximizes the use of blood donations.
WHOLE BLOOD contains RBCs and plasma clotting factors. Few units are stored as whole blood. can be reconstituted from a unit of RBCs and FFP. stored at 1°C to 6°C and coagulation factors decay at this temperature. should be no more than 5 to 7 days old. Platelets in are cleared rapidly following transfusion. reconstituted whole blood lacks significant quantities of plateletsIndications. Exchange transfusions. Surgery Massive transfusion, trauma can be used as a substitute for blood components.
Packed Red Blood Cells (PRBCs) After plasma is separated from red cells by centrifugation of 350 ml whole blood, the RBC component has a volume of about 200 ml and Hct of about 80 %. The whole blood is spun to sediment out the RBCs, and most of the plasma is removed by pushing it into a pre- attached satellite bag. Genarally 100 to 110 mL of a nutrient additive solution is added back to the packed RBCs, creating an “additive RBC” product that has a final hematocrit of 55% to 60%. These solutions prolong the shelf life of the RBC product from 21 days (packed RBCs in CPD) to 42 days (additive RBCs).
Available forms of RCCsThe following forms of RCCs are available for the treatment of anaemia. RBC concentrates. RBC concentrates deprived of the buffy coat. RBC concentrates with additive solutions. RBC concentrates deprived of the buffy coat and re suspended in additive solutions. Washed RBC. Leucodepleted RBC. Frozen RBC. Apheretic RBC. Irradiated RBC.
PRBCs are the most commonly used blood product in neonatal transfusions. Red blood cells (RBCs) are transfused to increase the oxygen-carrying capacity of the blood and, to maintain satisfactory tissue oxygenation. Guidelines for RBC transfusions in children and adolescents are similar to those for adults.
Indications for transfusion of PRBCs are mainly resolution of symptomatic anemia and for improvement of tissue oxygenation. Tissue oxygenation depends on cardiac output, oxygen saturation and hemoglobin concentration. Once cardiac output and oxygen saturation are optimal, tissue oxygenation can only be improved by increasing the hemoglobin level. The guidelines for transfusion of PRBC vary according to age, level of sickness and hematocrit.
Factors other than hemoglobin concentration to be considered in the decision to transfuse RBCs include: (1) Patients symptoms, signs, and functional capacities,(2) The presence of cardiorespiratory, vascular, and central nervous system disease(3) The cause and anticipated course of the anemia(4) Alternative therapies, such as recombinant human erythropoietin (EPO) therapy, which is known to reduce the need for RBC transfusions and to improve the overall condition of children with chronic renal insufficiency and preterm infants.
Blood component therapy in newbornThe total blood volume of neonates is small, although the volume is higher per kg of body weight than that of older children or adults. (85 ml/kg for full-term and 100 to 105 ml/kg for pre-term). .
Blood transfusion in pre-term infants, is often given for the anaemia of prematurity, associated with delayed renal production of erythropoietin due to decreased sensitivity to lower haematocrit levels. These neonates may require multiple transfusions, increasing the risk of infectious disease transmission, through multiple donor exposures. alloimmunization Studies have shown that multiple transfusion from multiple donor in preterms is associated with increased risk of ROP and BPD.
Stable neonates do not require RBC transfusion, regardless of their blood hemoglobin level, unless they exhibit clinical problems attributable to anemia. symptomatic anemia causes tachypnea, dyspnea, tachycardia, apnea and bradycardia, feeding difficulties, and lethargy. However, anemia is only 1 of several possible causes of these problems, and RBC transfusions should only be given when clinical problems are attributable to the anemia.
Measures to reduce multiple blood transfusions in preterminfantsIn preterm and sick neonates, needing multiple transfusion , aliquots from a single donor can be given as sequential transfusions.This is done practically by reserving a bag of fresh PRBC for up to 7 days for a newborn and withdrawing small amounts required repeatedly from that bag under laminar flow using a sterile connecting device, into a fresh blood bag.The PRBC bag is immediately resealed under the laminar flow, and can be reused for withdrawing similar small quantities of blood for up to 7 days.
Choosing the blood group for neonatal transfusions.a.. Mother’s sample should be tested for blood group and for any atypical red cell antibodies.b. ABO compatibility. 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.
Choosing the blood group for neonatal transfusions.c. 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.d. In exchange transfusions for hemolytic disease of newborn-, blood transfused should be compatible with mother’s serum. If the mother’s and the baby’s blood groups are the same, use Rh negative blood of baby’s ABO group. In case mother’s and baby’s blood group is not compatible, use group O and Rh negative blood for
Volume and rate of transfusion: Volume of packed RBC = Blood volume (mL/kg) x (desired - actual hematocrit)/ hematocrit of transfused RBC If more volume is to be transfused, it should be done in smaller aliquots. The dose is 5 to 20 mL/kg transfused at a rate of approximately 5 mL/kg/hour. In chronic anemia and cardiovascular compromise dose is 5ml/kg at the rate of 1-3ml/kg/hr.
It has been seen that transfusion with PRBC at a dose of 20 mL/kg is well tolerated and results in an overall decrease in number of transfusions compared to transfusions done at 10 mL/kg in preterm and VLBW infants. There is also a higher rise in hemoglobin with a higher dose of PRBCs. in infants and newborn, one unit of RCC( 10 ml/kg) increases Hb by 3g/dl.
Properties of RBC products used in neonatal transfusion: RBCs should be freshly prepared and should not be more than 7 days old. concerns with old RBCs are high 2, 3-DPG concentration and higher tissue extraction of oxygen, hyperkalemia, and a reduced RBC life span.
Guidelines for packed red blood cellstransfusion thresholds for preterm neonates ( nnf protocol) Less than 28 days of age and 1. Assisted ventilation with FiO2 more than 0.3: Hb 12.0 gm/dL or PCV less than 40% 2. Assisted ventilation with FiO2 less than 0.3: Hb 11.0 g/dL or PCV less than 35% 3. CPAP: Hb less than 10 gm/dL or PCV less than 30% More than 28 days of age and 1. Assisted ventilation: Hb less than 10 gm/dL or PCV less than 30% 2. CPAP: Hb less than 8 gm/dL or PCV less than 25%
Guidelines for packed red blood cellstransfusion thresholds for preterm neonates ( nnf protocol)Any age, breathing spontaneously and 1. On FiO2 more than 0.21: Hb less than 8 gm/dL or PCV less than 25% 2. On Room Air: Hb less than 7 gm/dL or PCV less than 20%
INFANTS WITHIN THE FIRST 4 MOOF LIFE Hemoglobin of <13.0 g/dL and severe pulmonary disease Hemoglobin of <10.0 g/dL and moderate pulmonary disease Hemoglobin of <13.0 g/dL and severe cardiac disease Hemoglobin of <10.0 g/dL and major surgery Hemoglobin of <8.0 g/dL and symptomatic anemia nelson
CHILDREN AND ADOLESCENTS Acute loss of >25% at circulating blood volume Hemoglobin of <8.0 g/dL in the perioperative period Hemoglobin of <13.0 g/dL and severe cardiopulmonary disease Hemoglobin of <8.0 g/dL and symptomatic chronic anemia Hemoglobin of <8.0 g/dL and marrow failure(nelson)
Chronic Anaemia In anemias that are likely to be permanent, it is also important to balance the detrimental effects of anemia on growth and development vs the potential toxicity associated with repeated transfusions. With chronic anemia, the decision to transfuse RBCs should not be based solely on blood hemoglobin levels because children compensate well and may be asymptomatic despite low hemoglobin levels. Patients with iron-deficiency anemia are often treated successfully with oral iron alone, even at hemoglobin levels of <5 g/dL.
When to transfuse in chronic anaemiaTransfusion should be considered in a asymptomatic child with a Hb level of less than 4 g/dL.• Transfusion should be considered in a child with a Hb level of less than 5 g/dL with clinical signs of cardiac or respiratory distress .Increases in heart rate or respiratory rate alone may be normal compensatory mechanisms and are not necessarily indications for transfusion.
.• Blood is not generally recommended for children with a Hb level between 4 and 5 g/dL who are clinically stable. These children should be admitted for evaluation and treatment of the cause of their anaemia and should be monitored closely for changes in Hb level and signs of decompensation. Treat the cause as infection , nutritional and mild blood loss anaemia with specific therapeutic agents as indicated (iron, folic acid, B12).
Respiratory distress is unlikely to be due to chronic anaemia if the Hb level is 5 g/dL or greater. Children with a Hb level of 5 g/dL or greater should not be transfused indiscriminately, but the cause of their anaemia should be investigated.• Children should be transfused with 10 to 15 ml/kg of PRBCs or 20 ml/kg of whole blood. Transfusions must be given slowly (over a 4 hour period. At the rate of 2-3 ml/kg/hr. monitored closely to avoid volume overload. Diuretics should be used if the patient is in congestive cardiac failure.
Congenital AnaemiasChildren with congenital anaemias such as sickle cell diseases Hb S/S, Hb S/C, Hb S/ -thalassaemia, like all other children, should only be transfused when they develop cardio-respiratory symptoms from severe anaemia.The transfusion threshold in thalassaemia is generally 9–9.5 g/dL of Hb, in order to guarantee a balance between inhibition of bone marrow erythropoiesis and iron overload from transfusion therapyIn sickel cell anaemia Hb should be maintained at 10-12 gm/dl with <30% Hb S. Transfusion therapy is not normally indicated in patients with Hb values > 7 g/dL consider hydroxyurea, erythrocytapheresis, stem cell therapy.
In children, the transfusion of RCC 5 mL/kg increases the Hb concentration by about 1 g/dL. In the case of a lower than expected transfusion yield, conditions causing the loss, sequestration or destruction of RBCs should be looked for. Such conditions include: - Occult bleeding; - Repeated blood sampling (particularly in children); - Hypersplenism; - Primary and secondary immunological causes; - Mechanical or other type of haemolysis.
Modifications of cellular blood componentAbout 70% of the blood products are filtered to remove leukocytes (white blood cell) that fight foreign material such as bacteria, viruses and abnormal cells that may cause disease.When leukocytes are present in donated blood, they may not be tolerated by the pt receiving the blood and cause some types of transfusion complications.
specifically treated RCCs RBC concentrates deprived of the buffy coat and resuspended in additive solutions. Washed RBC. Leucodepleted RBC. Frozen RBC. Apheretic RBC. Irradiated RBC
1. Leucodepleted/ Leucoreduced RCCsMost plasma & 70-80% WBC(buffy coat) removed &100 ml of Additive Solution added.indications Prevention of febrile non-haemolytic transfusion reactions (FNHTRs) caused by the presence of antibodies to white blood cells: - patients with recurrent FNHTR; - patients who need prolonged transfusion support. Reduction of the incidence of CMV infections Reduction of the risk of rejection in candidates for haematopoietic stem cell transplantation. Prevention of refractoriness to platelet transfusion. Intrauterine transfusions and transfusions to premature babies, neonates, and infants up to 1 year. Candidates for renal transplantation.
Washed RCCRBC washed with 1-2 L Normal SalinePrevent febrile non hemolytic reactions.Washing eliminates antibodies & other plasma constituentsindication Patients with IgA deficiency . Prevention of allergic reactions not sensitive to antihistamine drugs Post-transfusion febrile reactions, present even when leucodepleted RBCs are used Paroxysmal nocturnul hemoglobinuria Patients with T activated cells by infections who require transfusion
Irradiated RCCs Irradiation, at the dose of 25–50 Gy, is currently the only method available for preventing transfusion-related GvHD.Frozen RCCs -Patients with complex immuno haematological profiles in the absence of compatible donors
PLATELET TRANSFUSIONThrombocytopenia is defined as platelet count less than 1.5 lakh/cubic mm.Presence of thrombocytopenia leads to an increase in risk of bleeding.Dysfunctional platelets in the presence of normal platelet counts may also cause bleeding tendency.Thrombocytopenia has been observed in 1–5% of newborns at birth.Severe thrombocytopenia defined as platelet count of less than 50,000/cubic mm may occur in 0.1– 0.5% of newborns.
In NICU, there is a higher incidence; with thrombocytopenia being observed in up to 22– 35% of all babies admitted to NICUs and in up to 50% of those admitted to NICUs who require intensive care. Significant proportions (20%) of these episodes of thrombocytopenia are severe. Thus a large number of neonates are at risk for bleeding disorders in NICU.
Platelets are stored at 20°C to 24°C using continuous gentle horizontal agitation in storage bags specifically designed to permit O2 and CO2 exchange to optimize platelet quality. Types – SDP and RDP The storage time from collection to transfusion of platelets (RDPs) is 5 days. SDPs can be stored for up to 7 days. thrombocytopenic patients transfusion therapy with RCC is indicated to maintain the Htc around 30% and to reduce the risk of haemorrhage.
Recommandation for platelets use Platelets should never be filtered through a micropore blood filter before transfusion. S’d be transfused as rapidly as pt can tolerate 1 unit/20 min. S’d be ABO compatible. The usual recommended dose of platelets for neonates is 1 unit of platelets per 10 kg body weight, which amounts to 5 mL/kg. The predicted rise in platelet count from a 5- mL/kg dose would be 20 to 60,000/cubic mm. 15 Doses of up to 10-20 ml/kg may be used in case of severe thrombocytopenia.
Neonatal thrombocytopenia Immune thrombocytopenia: a) Neonatal alloimmune thrombocytopenia (NAIT) b) Neonatal autoimmune thrombocytopenia Nonimmunologically mediated thrombocytopenia
Neonatal alloimmune thrombocytopenia (NAIT) The best choice of platelet transfusion is human platelet antigen (HPA) compatible platelets, which are generally maternal platelets, meticulously washed and irradiated. The aim is to maintain the platelet count above 30,000/ cubic mm. HPA compatible platelets are not easily available. In the absence of immunologically compatible platelets, random donor platelet transfusions may be an acceptable alternative, and has been shown to increase platelet counts above 40,000/cubic mm in most of the transfused patients. An alternative approach is the use of intravenous immunoglobulin (IVIG) (1 g/kg/day on two consecutive days or 0.5 g/kg/day for four days), alone or in combination with random donor platelet transfusion.
b. Neonatal autoimmune thrombocytopenia The goal is to keep the count above 30,000/cubic mm. IVIG is given if counts are less than the acceptable minimum at a dose of 1 g/kg/day on two consecutive days.
Nonimmunologically mediatedthrombocytopeniaLow platelet count occurring at less than 72 hours of age is caused most commonly by placental insufficiency, maternal PIH, early onset sepsis (EOS), and perinatal asphyxia.EOS and asphyxia may, in particular, lead to severe thrombocytopenia.
Thrombocytopenia occurring beyond the initial 72 hours is most commonly caused by sepsis and necrotising enterocolitis.Other infrequent causes include intrauterine infections, metabolic errors and congenital defects in platelet production.Indications for platelet transfusion in nonimmune thrombocytopenia depend on the level of sickness of newborn
Indications for platelet transfusion in nonimmunethrombocytopenia in newborn 1. Platelet count less than 30,000/cubic mm: transfuse all neonates, even if asymptomatic 2. Platelet count 30,000 to 50,000/cubic mm: consider transfusion in a. Sick or bleeding newborns b. ELBW or less than 1 week of age c. Previous major bleeding tendency d. Newborns with concurrent coagulopathy e. Requiring surgery or exchange transfusion 3. Platelet count more than 50,000 to 99,000/cubic mm: transfuse only if actively bleeding
INFANTS WITHIN THE FIRST 4 MO OF LIFE PLTs < 100 × 109/L and bleeding PLTs < 50 × 109/L and an invasive procedure PLTs < 20 × 109/L and clinically stable PLTs < 100 × 109/L and clinically unstable PLTs at any count, but with PLT dysfunction plus bleeding or an invasive procedure
CHILDREN AND ADOLESCENTS PLTs < 50 × 109/L and bleeding PLTs < 50 × 109/L and an invasive procedure PLTs < 20 × 109/L and marrow failure with hemorrhagic risk factors PLTs < 10 × 109/L and marrow failure without hemorrhagic risk factors PLTs at any count, but with PLT dysfunction plus bleeding or an invasive procedure
Plasma-Derived Blood ComponentsFFPPlasma separated from a unit of whole blood and frozen within 8 h of collection is designated fresh frozen plasma (FFP) . The usual volume of FFP is about 225 ml. FFP supplies all of the constituents of fresh plasma, including the labile coagulation factors, albumin and globulin.Plasma contains about 1 unit/mL of each of the coagulation factors
Labile coagulation factors, like factors V and VIII, are not stable in plasma stored for prolonged periods at 1–6° C; therefore plasma is usually stored frozen at –18° C or lower. It contains about 87% of factor VIII present at the time of collection but decay later. FFP must be ABO-compatible with the recipient’s red blood cells.
Recommendations for use of Fresh frozen plasma Fresh frozen plasma is indicated for correction of coagulation abnormalities and for correction of microvascular bleeding when prothrombin time and partial thromboplastin time are greater than 1.5 times the mid-range normal reference value. FFP should not be used when a coagulopathy can be corrected with vitamin K. Volume of FFP to be transfused is usually 10–20 mL/kg 10-15ml/kg dose increses factor activity by 20-30%.
FFP should not be used when a coagulopathy can be corrected with vitamin K. Volume of FFP to be transfused is usually 10–20 mL/kg 10-15ml/kg dose increses factor activity by 20-30%.
Indications Severe clotting deficiency (including DIC) with bleeding Severe clotting deficiency in a neonate undergoing an invasive procedure Vitamin K deficiency with bleeding Dilutional coagulopathy with bleeding Severe anticoagulant protein deficiency Reconstitution of packed RBC for exchange transfusion
FFPFFP has newborn been used for a variety of use in traditionally reasons, including volume replacement, treatment of DIC, treatment of a bleeding neonate for prevention of intraventricular hemorrhage, and in sepsis. It has not been shown to have any survival benefits in most of these conditions and currently the only valid indications for transfusing FFP in a newborn include 1. Disseminated intravascular coagulopathy 2. Vitamin K deficiency bleeding 3. Inherited deficiencies of coagulation factors
Cryoprecipitate:It is prepared from FFP by thawing at 2 – 4C.Undissolved cryoprecipitate is collected by centrifugation and supernatant plasma is aseptically expressed into a satellite bag.contains approximately 100 u of factor VIII and von Willebrand factor,75 u of factor XIII, and250mg of fibrinogen in a volume of 20 ml.It is stored at a temperature of -20o C or below.
Dose of cryoprecipitate in treating hypofibrinogenemia is an initial infusion of 10 bags, followed by 10 to 20 bags q8h or as necessary to keep the fibrinogen level above 100 mg/dl. 1-2 unit /kg cryo increases fibrinogen by 1g /dl. Volume of cryoprecipitate to be transfused is usually 5 mL/kg. The half-life of fibrinogen is about 4d.
Recommendations for Factor VIII/ cryoprecipitate: Congenital factor deficiencies are rare in the neonatal period. While treating bleeding neonates, cryoprecipitate is often considered an alternative to FFP because of its small volume. cryoprecipitate contains only factors VIII, XIII and fibrinogen and is not effective in treating the more extensive clotting factor deficiencies.
Indications for use of cryoprecipitate: Afibrinogenemia, Von Willebrand factor deficiency, congenital antithrombin III deficiency, hemophilia. Protein C deficiency and protein S deficiency when specific factor replacement is not available. It is also used for reconstitution of blood for exchange transfusion.
Granulocyte TransfusionsGranulocyte concentrates are collected from single donors by use of a blood cell separator. 10Each concentrate contains approximately 10 granulocytes which are about one tenth of the normal adult,s daily production and that is far fewer than that of an infected patient.Granulocytes are fragile and may be stored no longer than 24 h. The usual concentrate contains about 250 ml of plasma and has a Hct of 15 to 20 percent.ABO compatibility is necessary.
GTX is recommended only when infections are clearly unresponsive to antimicrobial drugs, infected children with sustained bone marrow failure (malignant neoplasms resistant to treatment, aplastic anemia, and hematopoietic progenitor cell transplant recipients) may benefit when GTX is added to antibiotics. The use of GTX for bacterial sepsis unresponsive to antibiotics in patients with severe neutropenia (<0.5 × 109/L) is supported by many controlled studies .
Guidelines for Pediatric GranulocyteTransfusionsCHILDREN AND ADOLESCENTS Neutrophils of <0.5 × 109/L and bacterial infection unresponsive to appropriate antimicrobial therapy Qualitative neutrophil defect and infection (bacterial or fungal) unresponsive to appropriate antimicrobial therapyINFANTS WITHIN THE FIRST 4 MO OF LIFENeutrophils of <3.0 × 109/L (1st wk of life) or <1.0 × 109/L (thereafter) and fulminant bacterial infection
Human serum albuminHSA is comprised of 96 percent albumin and 4 percent α-and β –globulin.Dose is 0.5- 2 gm/kgindications – Hypovolemic shock, Hypotension associated with hypovolemia in liver failure or protein-losing conditions, Inadequate diuresis in fluid overloaded hypoproteinemic patients.
INTRAVENOUS IMMUNOGLOBULIN IVIG is a concentrated purified solution of immunoglobulins with stabilizers such as sucrose. contain >90% immunoglobulin G (IgG) with small amounts of immunoglobulin M (IgM) and immunoglobulin A (IgA)Indications. Alloimmune disorders Congental immunodeficiency syndromes. Hyperimmune immunoglobulins- several infectious agents including Varicella-zoster virus and respiratory syncytial virus, rabies. Severe sepsisDosing ==of 500 to 900 mg/kg.
TRANSFUSION ASSOCIATED RISKSBlood transfusion reactions may be broadly classified as 1. Infectious 2. Non-infectious a. Acute i. Immunologic ii. Non-immunologic b. Delayed
Infectious complicationsViral infections: (HIV), hepatitis B and C viruses (HBV & HCV), and cytomegalovirus (CMV).contaminate platelet products more commonly than RBC products Risk of post transfusion hepatitis B/C in India is about 10% in adults despite routine testing because of low viraemia and mutant strain undetectable by routine ELISA.
Bacterial infections: Platelets are at a higher risk The highest fatality is seen with gram-negative bacteria. febrile nonhemolytic reaction post transfusion, bacterial contamination always remains a possibility. higher rise in temperature than other febrile transfusion reactions.Parasites: Plasmodium, trypanosomeand may occur in spite of blood bag testing, as the screening tests for malaria are insensitive
Prions : Variant Cruetzfold Jacob Disease ( v CJD) is an established complication of blood transfusion and has been reported since 2004. incubation period of approximately 6.5 years. no easy test as yet to detect the presence of prions. not very clear whether leukoreduction prevents transmission of CJD. Restricted transfusions and avoidance of transfusions unless essential, are the only ways currently to prevent transmission
Noninfectious complications:immune mediated and nonimmune mediated reactions, and as acute and delayed complications.Acute immune mediated reactions1. Immune mediated hemolysis 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.
Infants are at a higher risk of passive immune hemolysis direct antiglobulin (Coombs) test may confirm the presence of an antibody on the RBC surface. Smaller quantities of ABO-incompatible plasma (less than 5 mL/kg) are generally well tolerated. Newborns do not manifest the usual symptoms of hemolysis. An acute hemolytic event in newborns may be present as increased pallor, presence of plasma free hemoglobin, hemoglobinuria, increased serum potassium levels, and acidosis.Treatment is mainly supportive and involves maintenance of blood pressure and perfusion with intravenous saline bolus of 10 to 20 mL/kg along with forced diuresis with furosemide
Symptoms and Signs of Acute Haemolytic Transfusion ReactionsGeneral: - Fever, chills, flushing - Nausea, vomiting - Headache - Pain at infusion site - Back or loin painCardiac/respiratory: - Chest pain - Dyspnoea - Hypotension - TachycardiaRenal: - Haemoglobinuria - Oliguria - AnuriaHaematological: - Anaemia Disseminated Intravascular Coagulation Thrombocytopenia
2. TRALI (Transfusion related acute lung injury): It refers to noncardiogenic pulmonary edema complicating transfusion therapy It has been associated with all plasma-containing blood products. anti-HLA and/or anti-granulocyte antibodies. The most common symptoms associated with TRALI are dyspnea, cough, and fever, associated with hypo- or hypertension. initial 6 hours after transfusion. Treatment is mainly supportive in this self-limiting condition.
3Febrile nonhemolytic transfusion reactions (FNHTR)4. Allergic reactions rare occurrence in newborns presence of preformed immunoglobulin E mild, and respond to antihistaminics. Severe anaphylactic reactions are rare ..
Acute non immune reactions1. Fluid overload: Neonates are at increased risk of fluid overload from transfusion because the volume of the blood component issued may exceed the volume that may be transfused safely into neonates. There is no role for routine use of furosemide while transfusing newborns.
2. Metabolic complications: These complications occur with large volume of transfusions like exchange transfusions.a) Hyperkalemia: large volume transfusions,old RCC,b) Hypoglycemia: Blood stored in CPD blood has a high content of glucose leading to a rebound rise in insulin release 1-2 hours after transfusion. This may lead to hypoglycaemia and routine monitoring is necessary, particularly after exchange transfusion, after 2 and 6 hours
c) Hypocalcemia and hypomagnesemia are caused by binding of these ions by citrate present in CPD blood.d) Acid- base derangements: Metabolism of citrate in CPD leads to late metabolic alkalosis. Metabolic acidosis in sick babies who cannot metabolize citrate.
Delayed complications1. Alloimmunization: Alloimmunization is an uncommon occurrence before the age of 4 months, and is caused by transfusion of blood products with are mismatched for highly immunogenic antigens like Rh.2. Transfusion associated graft versus host disease (TA- GVHD): Newborns are at risk for TA-GVHD if they have received intrauterine transfusions, exchange transfusions, or are very small, or immunocompromised. Unchecked donor T cell proliferation is the cause of TA-GVHD it can be effectively prevented by leukoreduction of the transfused blood products in at risk patients3 .Iron ovrload4. ROP and CLD in preterms
Summary Blood should be used only to relieve clinical signs of cardiac and respiratory distress in severely anaemic patients, in order to achieve haemodynamic stability. Blood should NOT be used to correct anaemia. Most patients with chronic anaemia have nutritional and/or mild blood loss anaemia responds rapidly and effectively to specific therapies. These patients have normal blood volumes and the transfusion of whole blood may cause circulatory overload, with harmful effects. Thetransfusion of PRBCs should be carried out slowly, with careful monitoring of the patient.
Transfusion in the newborn requires selection of appropriate donor, measures to minimize donor exposure and prevent graft versus host disease and transmission of Cytomegalovirus.• Component therapy rather than whole blood transfusion, is appropriate in most situations.• A clear cut policy of cut-offs for transfusions in different situations helps reduce unnecessary exposure to blood products.• Transfusion triggers should be based on underlying disease, age and general condition of the neonate.
RBC Tx remains an essential part of management of high risk preterms Focus on prevention of anaemia, donor restriction and restriction of no of TX Avoid unnecessary Tx. RESTRICT no of transfusions, Avoid unnecessary sampling, Micro-techniques, noninvasive monitoring, rhEPO Blood transfusion is not a cure for anaemia. Blood transfusion is used to relieve the clinical signs of cardiac or respiratory distress, but the underlying cause of the anaemia still needs to be investigated and treated.