pediatric blood component theraphy

1. SUBJECT SEMINAR
 BLOOD COMPONENT THERAPHY
 BIRTH DEFECTS & ITS CLASSIFICATION
 ANTICIPATORY GUIDELINES IN DOWNS SYNDROME
• CHAIRPERSON – DR VENKATAMURTHY
• MODERATOR - DR MADHAV KAMATH
• PRESENTOR-DR HARSHAVARDHAN

2. BLOOD COMPONENT
THERAPHY

3. Introduction
• Blood is a precious commodity. The demand for this life sustaining
product invariably exceeds the amount collected.
• In spite of this, majority of the country’s annual collection is wasted
as single unit whole blood transfusions
• Advances in transfusion therapy have improved blood preservation
technique and enabled separation of whole blood into its component.
• It has thus become possible to transfuse specific components
selectively, depending on the actual need of an individual patient.

6. Blood Component and Separation Techniques
• Whole blood is made up of cellular elements (RBCs, leukocytes,
platelets) and plasma. Whole blood can be separated into its
components by centrifugation techniques.
• Apheresis is a specialized procedure wherein whole blood is removed
from the donor and is then separated into its component parts by
centrifugation in a cell separator.
• The desired components (e.g. platelets) are harvested, and the
remainder returned to the donor. The procedure allows selective
collection of platelets or granulocytes in sufficient amounts from a
single matched, ABO compatible donor.

7. Apheresis –an illustration

10. Whole Blood
• There are very few indications for the use of whole blood.
• The major indication would be in some cases of cardiac surgery or
massive hemorrhage. It may be the only choice for life-threatening
hemorrhage when red blood cell component therapy is not available.
• For ET in neonates, whole blood or reconstituted whole blood may be
used.

12. Fresh Whole Blood
• It is a myth that whole blood collected within 24 hours is the best. It is
often requisitioned in bleeding disorders in the erroneous belief that
it provides platelets and clotting factors.
• Almost 90% of platelets and 40% of activity of factor VIII are lost
within 24 hours of storage at 4°C.
• In addition, time is required for mandatory screening for infections.
This age old practice, therefore, has no role in modern times. Specific
blood component therapy should be requested depending on the
etiology of bleeding.

13. • For neonatal ET, blood up to 7–10 days old is good enough to prevent
hyperkalemia.
Packed Red Blood Cells
• The usual dose for packed RBCs is 10–15 mL/kg, but varies greatly on
the clinical indication.
• In severe (Hb < 5 g/dL) chronic anemia, child should receive 2–3
aliquots of 3–5 ml/kg over 2–3 hours, separated by a few hours
• A partial ET may be considered in those presenting with overt
features of CHF. This corrects the anemia rapidly and isovolumetrically.

17. Platelet Transfusion
• platelet rich plasma and platelet concentrate. The alternative
approach involves the collection of single donor platelets by apheresis
using a cell separator.
• A single unit obtained from apheresis equals 5–6 random donor
platelets. The yield is higher with single donor platelets and the donor
exposure is reduced.
• Platelets are stored at 20–24°C, under constant agitation to avoid
aggregation. Storage is recommended only for 3–5 days because of
risk of bacterial contamination.

18. • The dose of random donor platelets is 1 unit per 10 kg of body
weight or 5–10 ml/kg for newborns.
Indications include
• DIC with bleed (50 × 109/L), major surgery (50–100 ×
• 109/L), leukemia, AA (10 × 109/L; the units may have own policy,
lower threshold if concomitant fever or sepsis) and
• platelet function defects with severe bleeding.

20. Fresh Frozen Plasma
Indications
• Coagulopathy with bleeding (e.g. hemorrhagic disease of newborn,
liver disease)
• Hemophilia A/B (if factors cannot be afforded)
• Deficiency of antithrombin III, Protein C/S
• Massive transfusion.
• The use of FFP is not justified for hypovolemia (use crystalloids),
prolonged INR in absence of bleeding and for hypoalbuminemia (use
albumin).
• The dose is 10–20 ml/kg for infants/children and 5–10 ml/kg for
newborns.

21. Cryoprecipitate
• The contents include fibrinogen, Von Willebrand factor, factor VIII
and XIII. The corresponding indications are fibrinogen less than 1.0
g/L (e.g. DIC with bleeding), hemophilia A (Note: it does not contain
factor IX), Von Willebrand’s disease and Factor XIII deficiency.
• The average dose is 1 unit for 5–10 kg body weight.

22. Irradiated Blood Products
• Under normal circumstances, T lymphocytes in donor blood are destroyed
by the recipient. They can survive and proliferate if they are not
recognized as foreign (e.g. related donor) or if recipient is
immunocompromised.
• The proliferating T-cells cause GVHD. It is a rare but frequently fatal
complication that occurs 3–30 days following blood transfusion.
• As there is no effective treatment, aim is to recognize high-risk patients
and to use blood products with T cells that have been rendered ineffective
This is done by exposing blood bag to ionizing radiation.
• Facilities for irradiating blood are gradually increasing at various centers in
India

23. Leukoreduction
• It refers to the removal of white cells from a blood product.
Deleterious effects caused by leukocytes include:
• Febrile-nonhemolytic reactions
• HLA alloimmunization
• Platelet refractoriness
• Transmission of CMV
• Possibly organ dysfunction
• Increased mortality.
• White cells can be removed soon after collecting blood (prestorage) or at
bed-side.

24. • Pre-storage leukoreduction is better as inflammatory cytokine
accumulation from WBC during storage is avoided.
• It is likely that leukoreduction will prevent GVHD, but is not certain. In
Indian circumstances, bed-side leukocyte filters should be considered
for patients receiving multiple transfusions, e.g. thalassemia major.

26. Autologous Blood
• It is the collection and reinfusion of the patient’s own blood. It is
possible for some children who have to undergo elective surgery for
which transfusion is anticipated.
• Advantage is reduction in the risk of transfusion-transmitted viral
diseases.
• Blood, proportionate to the size of the child is collected 4–5 weeks
prior to surgery. The Hb should be greater than 11 g/dL before
collection of blood.
• Oral iron is supplemented. All risks are not avoided: the stored unit
could still be contaminated with bacteria or a wrong unit could be
inadvertently transfused.

27. Hazards of Blood Transfusion
• Adverse reactions to blood transfusion can be subdivided according
to whether they are immediate or delayed and whether they are
immunologically mediated.
• Acute hemolytic reaction is the dreaded complication of blood
transfusion, one of the common causes being clerical errors of
mislabeling or misidentification, resulting in the infusion of the wrong
patient’s blood.
Signs and symptoms
• include fever, chills, back/chest pain, flushing, nausea and
hemoglobinuria. These can progress to shock with acute renal failure.

28. Bacterial Contamination of Blood Products
• This is a relatively common, however poorly recognized complication.
The source of contamination could be the donor (skin commensals or
unrecognized bacteremia), environment or improper handling of
product.
• Clinical profile often resembles an acute hemolytic reaction.
• Platelets are most commonly implicated as they are stored at room
temperature. Broad-spectrum antibiotics should be initiated at the
earliest suspicion.

31. Transfusion-Related Acute Lung Injury ( TRALI )
• It is currently the most common cause of transfusion-related death
reported in western literature:
• The incidence is 1/1,200–5,000 plasma containing transfusions (RBCs,
platelets, FFP)
• Typically occurs during or within 6 hours of completion of transfusion
• It is characterized by acute onset hypoxemia in absence of circulatory
overload
• CXR shows bilateral lung infiltration
• It usually resolves in 24–72 hours
• Management is supportive. Mechanical ventilation may be required

32. Blood is never to be stored in the fridge