BLOOD COMPONENT THERAPY FOR THE NEONATE

Dehdashtian M.Neonatologist, Associated professor of pediatrics

Ahvaz Jundi Shapur University of Medical Science

BLOOD COMPONENT THERAPY FOR THE NEONATE

• RBC transfusion• Platelet transfusion• FFP transfusion• Cryoprecipitate transfusion• IVIG• Granulocyte transfusion

Red Blood Cell Transfusion

Anemia in newborn is indicated by:Central venous hemoglobin<13gr/dl or capillary hemoglobin<14.5gr/dl Anemia occurs when the red blood cell mass does not adequately meet the oxygen demands of the tissue

Risk of Transfusion Therapy• Metabolic Complications• Immunologic Complications• Transfusion-Related Necrotizing

Enterocolitis• Transfusion-Related

Intraventricular Hemorrhage• Infectious Complications

Metabolic Complications

• Hypoglycemia• Hyperkalemia• Hypocalcemia

Immunologic Complication

• Hemolytic Transfusion Reactions• Febrile Nonhemolytic Transfusion

Reactions• Allergic Transfusion Reactions• Transfusion Associated Graft Versus

Host Disease• Transfusion Related Acute Lung Injury• T-Antigen Activation

Transfusion-Related Necrotizing Enterocolitis

• A temporal association may be exist between RBC transfusion and NEC

• The risk of transfusion associated NEC increases with decreasing gestational age of the infant

Transfusion-Related Intraventricular HemorrhageEarly RBC Transfusion may be play a role in IVH development or extension

Infectious Complications• CMV Infection• Hepatitis A Virus• Hepatitis B Virus• Hepatitis C Virus• HIV-1, HIV-2• West Nile Virus• Bebesiosis• Malaria• Trypanosoma Cruzi

CMV InfectionNeonates who at increased risk for post transfusion CMV related mortality and morbidity should be transfused with:• Seronegative Component• Leukoreduced blood products

These potential complications underscore the need to carefully evaluate a neonate's ability to deliver oxygen to tissues prior to ordering a nonemergent transfusion, and to document benefit following the transfusion

RBC TRANSFUSION INDICATIONS

It is often difficult to distinguish the neonate who is anemic and requires RBC transfusion from one who has adapted to a low hematocrit (Hct), and is best treated conservatively to avoid the associated risks of transfusion

Anemia occurs when the red blood cell (RBC) mass does not adequately meet the oxygen demands of the tissue

Oxygen supply to the tissue is defined as the product of cardiac output and arterial oxygen content (1.34×Hgb×Sao2)+(0.003×Pao2)

Suggested Guideline for Red Blood Cell Replacement in high risk neonates

• Acute Blood loss The need for transfusion in an infant with acute blood loss is generally dependent upon persistent clinical signs of inadequate oxygen delivery following intravascular volume restoration

• Chronic Blood Loss The need for RBC transfusion is, likewise, based upon clinical signs of inadequate oxygen delivery (increased resting heart rate, acidosis, poor growth, and apnea) and the degree of respiratory support needed by the infant

Acute blood loss Neonates with significant acute blood loss

require immediate fluid resuscitationTerm infants may tolerate perinatal blood

loss up to one-third of their total blood volume

Infants with a hemoglobin level ≥10 gm/dL following volume expansion usually have adequate oxygen delivery and generally only require iron supplementation to replace iron losses due to the hemorrhage.

Indications for a RBC transfusion in a term or preterm neonate following an acute blood loss include:

>20 percent blood loss10 to 20 percent blood with evidence of

inadequate oxygen delivery, such as persistent acidosis

Ongoing hemorrhage

Consider the rate of blood loss before transfusion

Chronic Anemia

Anemia of PrematurityNICU care and phlebotomy

Restrictive (low) versus liberal (high) target hematocrit (Hct) thresholds The restrictive (low) transfusion thresholds compared with a liberal (high) threshold resulted in modest reductions in exposure to transfusions, and there were no differences in mortality, major morbidities, and serious neurodevelopmental impairment at 18 to 20 month corrected age

Chronic Blood LossRestrictive (low) transfusion thresholds

Week 1

With respiratory support – 11.5

No respiratory support – 10

Week 2

With respiratory support – 10

No respiratory support – 8.5

Week 3

With respiratory support – 8.5

No respiratory support – 7.5

Chronic Blood LossRestrictive (low) transfusion thresholds

For severe cardiopulmonary disease(Fio2>40%, MAP>8cm H20)

Hematocrit <30% (Hgb 10) For moderate cardiopulmonary disease(Fio2<40%, MAP≤8cm

H20)

Hematocrit <25% (Hgb<8) For infants with anemia (Need to oxygen without pressure

support)

Hematocrit <25% (Hgb<8) with one or more of the following : HR>180/min, RR>60/min, pH<7.2, lactic acid>2.5meq/lit, weight gain<10gr/kg/day, major surgery within 72 hr • For asymptomatic infants

Hematocrit<18%(Hgb≤6) ) with an absolute reticulocyte <100,000/microL (<2 percent).

Suggested Guideline for Red Blood Cell Replacement in high risk neonates

For severe cardiopulmonary disease(Fio2>40%, MAP>8cm H20)

Maintain hematocrit 40%- 45%For moderate cardiopulmonary

disease(Fio2<40%, MAP≤8cm H20) Maintain hematocrit 30%- 40%For major surgery Maintain hematocrit 30%- 35%For infants with stable anemia Maintain hematocrit >20%-25%

Leukoreduced and irradiated red cells Leukoreduction filters remove approximately 99.9 percent

of white blood cells from PRBCs leukoreduction does not eliminate all lymphocytes and

cannot prevent transfusion-associated-graft-versus-host disease (TA-GVHD)

• Irradiation prevents TA-GVHD in susceptible recipients• The dose of radiation is not sufficient to kill viruses and

irradiation does not provide a CMV-safe product• Leukoreduced PRBCs should be used in all neonates• CMV-seronegative PRBCs should be used Infants awaiting or undergoing transplantation Immunocompromised infants Preterm infants of CMV-seronegative mothers

Pretransfusion Testing, Dose and Administration

Blood group and type• Wt (kg) X blood volume per kg X (Desired

Hct - Observed Hct)/Hct PRBCs,10 to 20 mL/kg

• Over two to four hours

Platelet TransfusionIndication <30000 for stable term and preterm infants <50000 for VLBW neonates within the first week of

life, clinically unstable neonates and neonate with alloimmune thrombocytopenia

in neonates prior to major surgery if the platelet count is <100,000/microL

Pretransfusion testing ABO Compatible

Dose 1EU/5-10kg Administration of 10 to 15 mL/kg of platelet

suspension will increase the platelet count from 50,000 to 100,000/microL.

Fresh Frozen PlasmaFFP is used primarily to treat

acquired coagulation factor deficiencies

ABO compatible10- 15 ml/kg

Cryoprecipitate TransfusionIt is a useful product in infant who

required higher concentration of factors 8, 13, vWF, or fibrinogen

It is the treatment of choice for factor 13 deficiency, congenital afibrinogenemia, dysfibrinogenemia, and severe hypofibrinogenemia(<150mg/dl) associated with bleeding

1u/5kg

Intravenous Immunoglobulin

Useful in fetuses and neonates with Rh and ABO immune hemolytic disease

500- 1000 mg/kg/2- 4hrIVIG should be considered in

neonates with DAT- positive immune hyperbilirubinemia who are not responding to intensive phototherapy and whose TB concentration is approaching exchange transfusion

Granulocyte TransfusionGranulocyte transfusion may be

considered in neonates with qualitative neutrophil defects with severe bacterial or fungal infection

ABO and Rh compatible, cross match

Complications