Old phenotyped blood versus fresh non phenotyped blood

[Amra23]

Emergency case of a cardiac malformation on a new born baby with 0+ ccDEEK-  DAT=neg,  mother 0+ CcDEeK- .
0+ ccDEEK- fresh blood not available.Only 10 days old blood with this phenotype.
Which is the best option for transfusion for this baby (it will be needed for the cardiac extracorporeal circulation),10 days old blood with his phenotype or fresh blood (within 5 days) with a slightly different phenotype?If the second option is the one,which phenotype would be best in this case?
This  kind of patients tend to receive multiple transfusions after surgery.

Edited June 14, 2019 by Amra23

[Malcolm Needs ★]

This is most certainly a decision for a clinician, although I do have some ideas myself.

[Amra23]

Malcom,I would love to hear your ideas,please!
My first option would be ccDEeK- if cross-matching is OK.
Also I should say that the old unit of O ccDEEK- is not leucodepleted. But we do have leucoreduction filters.
And about old units given to  a new born..,is the high potassium levels the only concern?
 

Edited June 15, 2019 by Amra23

[Malcolm Needs ★]

Well, the high potassium is undoubtedly a factor, in particular as it is a cardiac case.

All units in the UK are leukodepleted, but I wouldn't have thought that "unleukodepleted" blood should be of too much concern in this case.

The difference in the Rh type would be of no concern to me whatsoever.  The baby's immune system would be immature, and so it is highly unlikely that the "foreign" Rh antigens would cause immunisation.  Indeed, exposure to these "foreign" Rh antigens may be advantageous in a way, as there is the possibility, as this age, that these may lead to "accomodation", meaning that the baby may never produce antibodies against these antigens, but this has not been proved, as far as I know.

[Amra23]

Thank you so much,Malcom!

[slsmith]

We don't honor phenotypically matched blood on a newborn unless the baby has a positive antibody screen due to the mother's antibody. The product that is set up for the baby is fresh ( less than 5 days old), O =/O+(depending on the babies type),  irradiated (same day), leukoreduced(comes that way from supplier) and hemoglobin S negative.

[carolyn swickard]

How many of you are giving Hgb S neg (tested) blood to your neonates services?  Any problems with not doing it?

I know it is an AABB recommendation for neonates and we have been doing it, but are getting very mixed responses in the region on continuing it.  Also, our regional supplier is noting anecdotal evidence that Hbg S positive units (for trait) will not generally flow though a leukoreduction filter - they fail the filtration step.  Any feelings on this either way?  

We get one pediatric unit every 2-3 weeks and we must be able to use it for either small volume transfusions or the rare exchange transfusion. 

 

On 6/15/2019 at 3:39 AM, Malcolm Needs said:

The difference in the Rh type would be of no concern to me whatsoever.  The baby's immune system would be immature, and so it is highly unlikely that the "foreign" Rh antigens would cause immunisation.  Indeed, exposure to these "foreign" Rh antigens may be advantageous in a way, as there is the possibility, as this age, that these may lead to "accomodation", meaning that the baby may never produce antibodies against these antigens, but this has not been proved, as far as I know.

Malcolm - good post - I always wondered about babies and Rh Pos units.  It is so difficult to get a CMV negative, Rh neg unit in this region (US southwest) that we have often thought about having an O Pos unit for pedi stock - never been brave enough to try it though.

  

[Malcolm Needs ★]

50 minutes ago, cswickard said:

Malcolm - good post - I always wondered about babies and Rh Pos units.  It is so difficult to get a CMV negative, Rh neg unit in this region (US southwest) that we have often thought about having an O Pos unit for pedi stock - never been brave enough to try it though.

Ah cswickard, I was talking more about the C, c, E and e antigens, rather than the D antigen, which is much more immunogenic.  Sorry, I should have made that distinction.

[Mabel Adams]

58 minutes ago, cswickard said:

How many of you are giving Hgb S neg (tested) blood to your neonates services?  Any problems with not doing it? 

I know it is an AABB recommendation for neonates and we have been doing it, but are getting very mixed responses in the region on continuing it.  Also, our regional supplier is noting anecdotal evidence that Hbg S positive units (for trait) will not generally flow though a leukoreduction filter - they fail the filtration step.  Any feelings on this either way?  

 

  

We don't worry about Hgb S in neonates except for exchange transfusions for which we request it.  I've heard the same about the LR filters but don't have true evidence.

[Malcolm Needs ★]

4 minutes ago, Mabel Adams said:

We don't worry about Hgb S in neonates except for exchange transfusions for which we request it.  I've heard the same about the LR filters but don't have true evidence.

From empirical, but unpublished evidence when we started to use them in the early 1990's (before our units were universally leukodepleted, we found this to be true.

[Marilyn Plett]

When we converted to 100% leuko-reduction, my former blood center found that Hgb S units did not leuko-reduce even if they passed through the filter.

 

[Amra23]

Very useful information,thanks to everyone responded here!

Edited June 18, 2019 by Amra23

[Baby Banker]

We generally wash older units of RBCs for ECMO.  They still don't work quite as well (pH issues), but at least that takes care of the extracellular potassium.

 

As has been mentioned, I would not worry overmuch about matching the baby's phenotype.

 

[Neil Blumberg]

Just to confuse things a bit, there is absolutely no evidence that fresher units of red cells, or hemoglobin AA units are superior for neonates (or anyone else).  The potassium can be an issue, but some fresher units have very high potassiums as well.  We define fresh for everyone as 21 days of storage or less.  We wash transfusions for newborns in the ICU, or others with high potassium levels,  which fixes the potassium issue (I realize this isn't feasible at many hospitals).  But I would not worry overly much about storage duration.  If concerned, measure the supernatant potassium in a few units and give the one that is lowest.  All hospitals can readily measure potassium so why not do that if you are concerned?  Storage duration is a poor surrogate for actually measuring potassium.

As for CMV seronegative, it's totally unnecessary if the unit is leukoreduced.  Not a shred of evidence that it helps and it may preselect for donors who are infected but pre-seroconversion.  Save yourself the expense and aggravation and eliminate the use of CMV seronegative units, and convert to 100% leukoreduction if you haven't done that.  There are randomized trial data and many observational studies showing the clinical benefits of leukoreduction, including fewer episodes of nosocomial infection, the major cause of hospital morbidity and mortality.  Sermon over :).

[carolyn swickard]

On 6/18/2019 at 8:49 AM, Neil Blumberg said:

As for CMV seronegative, it's totally unnecessary if the unit is leukoreduced.  Not a shred of evidence that it helps and it may preselect for donors who are infected but pre-seroconversion.  Save yourself the expense and aggravation and eliminate the use of CMV seronegative units, and convert to 100% leukoreduction if you haven't done that.  There are randomized trial data and many observational studies showing the clinical benefits of leukoreduction, including fewer episodes of nosocomial infection, the major cause of hospital morbidity and mortality.  Sermon over :).

Been there - done that - still can't make any headway with the neonatologists!  Not even when we brought our Blood Distributor"s  Medical Director with all the facts and figures.  They still want CMV neg. 

On the plus side - everyone else is OK with leukoreduced cells as CMV safe now..  I think leukoreduction is the best production step that has ever been added to blood - especially the pre-storage leukoreduction we get now.  Now - if we could just get some more donors....