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Pediatric and neonatal transfusion considerations


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Hello all looking for some references/articles for our upcoming SOP changes. 

We are rewriting our pediatrics and neonatal transfusion SOPs; specifically MTP and plasma use. What articles out there state we should not use A plasma for pediatrics and or neonates (or reversed, what articles DO say we can use this). As well as FP5, pediatric populations vs neonates. In searching for some answers, it appears many facilities do not use A plasma for pediatrics <18 years as well as FP5. I would like to be able to cite the articles in our SOP to reflect our decisions. 

 

Thanks!

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Working in a children's hospital we have MTP set up by weight (which is either taken by the trauma bed or guessed by MD).  We only give O NEG RBC, AB FFP and AB NEG platelets to females, males are allowed AB POS platelets without MD notification but anything else needs to be approved by pathologist on call and trauma MD or surgeon:

<20 kg:  1 full RBC prefer fresh <7 days CPDA-1 or AS3 or whatever we have on hand if no other option, 1 <200ml FFP or 1 AB NEG liquid plasma and 60cc of AB NEG apheresis platelets (LVDS, PRT or other apheresis platelet including low volume - with less platelets in the original bag).  

20-49kg:  2 RBC, 2 FFP (200-400mL) or 1 liquid plasma + 1 FFP or 2 liquid plasma, 1/2 unit platelets

>50kg:  4 RBC, 4 FFP (start with 2 liquid plasma then switch to FFP, 1 full apheresis platelet

We have been having a really hard time getting AB NEG liquid plasma so we're working on doing 5 day thawed plasma but it's a huge computer build.  It's currently approved for MTP activation just like our liquid plasma, so we would start with 5 day thawed plasma and switch to FFP once it was thawed and ready that way we're not dealing with decreases in coag factors.  According to the Tech Manual we're supposed to give ABO group specific or compatible platelets but it doesn't say anything about FFP compatibility.  Since we deal a lot more in very small volume patients we choose to only use type AB if unknown type.  I unfortunately don't have any other resources except the AABB 20th edition tech manual and Pediatric Transfusion Therapy (AABB publication from 2002).  Hope this helps a little.

 

 

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I think the evidence (mostly adults) is that AB plasma is no safer than A plasma, probably because it is soluble antigen incompatible with 95% of patients compared with 60% for A plasma.  Obviously ABO identical is safest and probably most effective.  With platelets, giving ABO major incompatible platelets increases bleeding in adults so I would definitely not be preferring AB platelets which are incompatible with 95% of recipients.  At this point, group O may be safest and most effective for initial transfusions until ABO identical can be transfused.  We've worried about hemolysis but have neglected to detect that transfusing incompatible antigen (A and B cellular and soluble antigen) forms immune complexes that contribute to hemolysis even when the incompatible antigen isn't from red cells.  This is a rapidly evolving field with not a lot of clinical outcome data, much less randomized trials.  Nonetheless, it appears we've gotten the ABO system wrong when it comes to what is safest. And it isn't AB plasma, which, in adults, is associated with with increased sepsis, lung injury and mortality in group O patients.  

Arch Surg
. 2010 Sep;145(9):899-906.

 doi: 10.1001/archsurg.2010.175.

 

 Sang
 
  •  
  •  
  •  
. 2009 May;96(4):316-23.

 doi: 10.1111/j.1423-0410.2009.01167.x. Epub 2009 Feb 24.

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I think the evidence (mostly adults) is that AB plasma is no safer than A plasma, probably because it is soluble antigen incompatible with 95% of patients compared with 60% for A plasma.  Obviously ABO identical is safest and probably most effective.  With platelets, giving ABO major incompatible platelets increases bleeding in adults so I would definitely not be preferring AB platelets which are incompatible with 95% of recipients.  At this point, group O may be safest and most effective for initial transfusions until ABO identical can be transfused.  We've worried about hemolysis but have neglected to detect that transfusing incompatible antigen (A and B cellular and soluble antigen) forms immune complexes that contribute to hemolysis even when the incompatible antigen isn't from red cells.  This is a rapidly evolving field with not a lot of clinical outcome data, much less randomized trials.  Nonetheless, it appears we've gotten the ABO system wrong when it comes to what is safest. And it isn't AB plasma, which, in adults, is associated with with increased sepsis, lung injury and mortality in group O patients.  There are no data, but I assume the same would be true for AB platelets given to O recipients.  So our choice would be O red cells (or low titer group O whole blood), A plasma and A or O platelets.  We would never use AB plasma or platelets except for AB patients, given the bad outcomes in adult patients.

Arch Surg
. 2010 Sep;145(9):899-906.

 doi: 10.1001/archsurg.2010.175.

 

 Vox Sang
 
. 2009 May;96(4):316-23.

 doi: 10.1111/j.1423-0410.2009.01167.x. Epub 2009 Feb 24.

Edited by Neil Blumberg
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  • 8 months later...
On 8/5/2021 at 4:49 AM, Neil Blumberg said:

 

Blood
ABO major incompatible platelets increase bleeding in intracranial hemorrhage
. 2021 May 13;137(19):2699-2703.

 doi: 10.1182/blood.2020008381.

Do you know if they assessed the results based only on recipient blood type?  I would think that group O patients would be much more likely to get ABO-incompatible platelets.  Group O patients are known to have different bleeding tendencies for other reasons.  I would like to be sure they accounted for this possible confounder, or understand why it doesn't matter.

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It is true that group O patients are more likely to bleed if injured or on anticoagulants.  Not something easily adjusted for, but many O patients (they are 45% or so of the patients in NYC) received ABO identical platelets and did not bleed or have increased mortality.  When we switched to ABO identical platelets, cryo (and plasma) for all, our mortality rate per red cell transfused in surgical patients went down by about 15% or so.  Transfusing ABO major incompatible red cells is bad for patients. The same apparently holds true for platelets.  What is surprising is that it took us this long to realize that transfusing incompatible cellular antigen is bad for patients, whether those cells are red cells or platelets.  Soluble incompatible antigen (e.g., AB plasma to group O patients) as mentioned above, also seems to be bad for patients as well.  Animal models of immune effects of administering incompatible antigen support these observations.  In vitro models show that immune complexes of ABO antigen and antibody interfere with endothelial cell integrity, clot formation, platelet function and stimulate inflammation, which worsens bleeding and organ function.

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