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Neonatal RBC "top-up" transfusions - to irradiate or not?


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In my hospital we irradiate all blood for neonatal top-up transfusions, and because we reserve units for the neonate to reduce donor exposure, some blood is even irradiated up to the unit being 35 days old. All irradiated blood is transfused within a few hours.

I have just belatedly read the 2020 British Committee for Standards in Haematology (BCSH) guidelines for the Use of Irradiated Blood Components.  These guidelines are now saying that blood for neonatal top-up transfusions does not need to be irradiated (with a couple of exceptions of course, such as after an IUT). They also state that blood should only be irradiated up to the unit being 14 days old, and then the unit can be used for up to 14 days afterwards, even for neonates.

So my questions are: What are other facilities doing for neonatal top-up transfusions? Is the blood irradiated or not? If it is irradiated do you transfuse as soon as possible, or the unit can be used for a neonate up to 14 days post irradiation? Do you irradiate units that are more than 14 days old? Do you reserve a blood unit for a neonate for the shelf-life of the unit, or do all your neonates get as fresh blood as possible?

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Our neonatal intensive care transfusions are all irradiated because many severe immunodeficiency states are not evident until weeks to months after birth.  These are rare, and leukoreduced transfusions probably mitigate the risk of GVHD somewhat, but we are erring on the side of caution.  We irradiate just before transfusion so the storage based problems with irradiated red cells are less of a concern. We define fresh as <21 days of storage, because the data suggest very fresh blood is actually more dangerous to patients than blood stored 7-21 days or so.  Seat of the pants, to be sure, but somewhat data driven. No one knows for sure, but very fresh blood (<7 days storage) is totally unnecessary in terms of proven benefit and may actually be more dangerous, for reasons that are largely unknown.

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1 hour ago, Neil Blumberg said:

No one knows for sure, but very fresh blood (<7 days storage) is totally unnecessary in terms of proven benefit and may actually be more dangerous, for reasons that are largely unknown.

Is there a reference for the non use of very fresh blood?

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I've summarized the data in this letter:

https://www.bmj.com/content/366/bmj.l4968

In randomized trials, the fresher blood arm is associated with a higher incidence of nosocomial infection (immunomodulation, presumably). There has never been any data examining clinical outcomes that actually favors using very fresh blood.  Mostly just "expert opinion" and "it seemed like a good idea."  That's not good enough now, in my view.

Two key references (one only published in abstract form) are:

    1. Alexander PE, 
    2. Barty R, 
    3. Fei Y, 
    4. et al
    . Transfusion of fresher vs older red blood cells in hospitalized patients: a systematic review and meta-analysis. Blood2016;127:400-10. doi:10.1182/blood-2015-09-670950 pmid:26626995
    1. Schmidt A, 
    2. Gore E, 
    3. Cholette JM, 
    4. et al
    . Oxidation reduction potential (ORP) is predictive of complications following cardiac surgery in pediatric patients[abstract]. Transfusion2016;56(Supplement S4):20A-1A.
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Sorry, I cannot not have a question about this practice.  Are you serious?  A "neonate" is a general term.  A neonate that is requiring transfusion is not a normal occurrence and "top-off" transfusions should not be considered normal practice.  Transfusions should be considered carefully especially for neonates and the chance of TA-GVHD. Irradiated leukodepleted blood products should always be used.  The risks of transfusion of irradiated red blood cells based on age of the unit prior to or afterwards of irradiation is another discussion and a medical decision based upon the patient issues and the data the medical staff wants to follow.  But no one wants to speak with the family about TA-GVHD that could have been prevented.

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Mrmic, are you saying that a prestigious an institution as the British Committee for Standards in Haematology is wrong in this recommendation? - Quote " Routine irradiation of red cells for transfusion to preterm or term infants (other than for EBT) is not required unless there has been a previous IUT". Even though they reviewed relevant publications over an eleven year period?  Note it is only a recommendation.

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As a "recommendation" I believe that leaves room for having another opinion.  Even though I have seen only 1 case of TA-GVHD in 30 years of a pre-term neonate, that is one too many.   And use of non-irradiated products would not be my recommendation.

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On 1/22/2021 at 10:18 PM, YorkshireExile said:

Mrmic, are you saying that a prestigious an institution as the British Committee for Standards in Haematology is wrong in this recommendation? - Quote " Routine irradiation of red cells for transfusion to preterm or term infants (other than for EBT) is not required unless there has been a previous IUT". Even though they reviewed relevant publications over an eleven year period?  Note it is only a recommendation.

What does EBT mean? Thanks a lot.

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