Emergency Neonatal Transfusion in Small Hospitals

[mollymotos]

Hi everyone! I'm the transfusion service supervisor in a small remote hospital. Recently, we had a situation where an emergency neonatal transfusion was needed. The flight team was on its way and our Pediatric team was consulting with a neonatologist. Can you share emergency neonatal transfusion procedures that a small rural hospital could use? We are not planning to do this routinely but we want to be prepared if it happens again.

[jayinsat]

There are several layers to this question. First, you will need a fresh O negative, CMV-, irradiated prbc available rather quickly. We are not small but we only transfuse neonates about 3-4 times/year yet we receive a fresh unit every Monday to use for emergency transfusions. If it is non emergent (say for iatrogenic anemia), then we order from our supplier a fresh unit with satellite bags sterile docked so we can continue to use that unit for future transfusions on that baby. The goal here is to limit donor exposure. You may not need to worry about that if you do not have a high level NICU.

Are you aliquoting the unit into syringes? You will need a procedure and supplies for that. You need to meet with your Neonatologist and work out your logistics.

Those are just a few things to think about. I assume you already have policies and procedures in place for this.

[Neil Blumberg]

If the unit if leukoreduced, as all red cell transfusions should be, there is no need for CMV negative in my view.  

[David Saikin]

We do not routinely transfuse neonates (have not done one here in 30 or so years).  We would give the freshest O= we have; irradiated if we have one.  We are 3 hrs from our blood supplier.  Chances are the infant will be transfused before we could receive appropriate products. 

[BankerGirl]

I agree with David and his comments above.  We transfuse neonates very rarely as well.  Considering you are a small rural health center and will not be doing this routinely, you just have to do the best you can in an emergent situation.  We do keep neonatal syringe sets and most of them outdate.

[AMcCord]

On 9/13/2022 at 10:02 AM, BankerGirl said:

I agree with David and his comments above.  We transfuse neonates very rarely as well.  Considering you are a small rural health center and will not be doing this routinely, you just have to do the best you can in an emergent situation.  We do keep neonatal syringe sets and most of them outdate.

I agree. You do the best you can with what you have. Unless your blood supplier or a large neighbor who can transfer product is close by, you are not going to be able to ship in product in time. It is cost prohibitive for us to stock product routinely for an event that occurs very infrequently (and your blood supplier may not be very enthused about the constant rotation of product). 

We are 150+ beds, have a NICU, and are one of the 'large' hospitals in our rural area, but still transfer our critical neonates/kids to Children's 150 miles away. We only transfuse babies and small children 1 to 3 times over an average year. Our facility sees quite a few Onc patients, so I do stock a small inventory of irradiated products including 2 O neg Irrad on top of our normal O neg stock (if we can get O neg - fun times!). If we have time to crossmatch, we provide the freshest type specific unit (if we know mom's type) on the shelf, irradiated if requested and we have it in stock. If not, we provide the freshest O neg unit on the shelf, irradiated if requested and available. Children's gives LR as CMV neg equivalent, so that's the policy we follow. I don't stock syringes because we would outdate almost all of them and our software is not set up to split/label units. (It would be very rare for us to even have the possibility of pulling blood off that unit a second time, so not worth setting up.) We hand over the entire unit and the pediatrician/nurses pull what they need for transfusion in the 4 hours after issue.

Edited September 15, 2022 by AMcCord

[NancyC]

We do the same as David, issue the freshest O NEG unit we have, irradiated if fresh. We issue the whole unit of pack cells and nursing staff remove desired quantity to infuse and airlift is generally on their way to take the baby to Children's hospital. We transfuse about once every 10 years or so.

[Bet'naSBB]

Have an O neg, CPDA-1 or AS-3 irradiated unit (no mannitol) on hand and give it.  The fresher the better. - Could maybe set up some sort of standing order with your supplier for 1 fresh O neg AS-3 every 10 days so that you can rotate the older O neg into regular inventory and keep 1 fresh set aside for the off chance you'll need one?????

[Neil Blumberg]

 

There is reason NOT to use the freshest possible units. They may be more toxic than intermediate stored units. This is something that made sense but was almost certainly wrong.  See below for the reasoning and published data.  We use <21 days as fresh for this reason and avoid <7 days storage for everyone based upon the randomized trial data.

BMJ 2019;366:l4968 doi: 10.1136/bmj.l4968 (Published 5 August 2019) Page 1 of 1

Letters

Trivella and colleagues present some caveats around the subject of duration of red cell storage and clinical outcomes.1 Studies have been widely interpreted as showing that transfusion is not associated with adverse clinical outcomes. I think this is a serious misinterpretation of the data.

In addition to the concerns raised by the authors, another valid hypothesis, which has received little attention, is that very short storage red cells might be more dangerous than medium storage periods (say 7-21 days) and equally dangerous as longer storage red cells (say 28-42 days). An inverted U shaped curve. The evidence for this comes from a meta-analysis finding that “ultra short” storage of red cells was associated with a post-transfusion increase in nosocomial infection.2 Shorter storage red cells have a greater imbalance of oxidation-reduction potential than longer storage red cells in preliminary studies in vitro.3 Red cell storage duration is also a poor predictor of post-transfusion free haemoglobin and heme, putative mediators of toxicity from transfusions.4 5

We need better metrics for predicting red cell transfusion efficacy and toxicity. The simple expedient of fresher red cells is clearly not that metric and might be leading us to transfuse more toxic red cells (very fresh) in the most fragile patients,

such as premature newborns. A new approach is clearly called for by the current data. At our centre we define fresh as <21 days of storage, and we generally never transfuse a red cell that has been stored for much less than 7-10 days, for the above reasons as well as logistics of supply.

Competing interests: None declared.

1 Trivella M, Stanworth SJ, Brunskill S, Dutton P, Altman DG. Can we be certain that storage duration of transfused red blood cells does not affect patient outcomes?BMJ 2019;365:l2320. 10.1136/bmj.l2320 31186250

2 Alexander PE, Barty R, Fei Y, etal . Transfusion of fresher vs older red blood cells in hospitalized patients: a systematic review and meta-analysis. Blood 2016;127:400-10. 10.1182/blood-2015-09-670950 26626995

3 Schmidt A, Gore E, Cholette JM, etal . Oxidation reduction potential (ORP) is predictive of complications following cardiac surgery in pediatric patients[abstract]. Transfusion 2016;56(Supplement S4):20A-1A.

4 Cholette JM, Pietropaoli AP, Henrichs KF, etal . Elevated free hemoglobin and decreased haptoglobin levels are associated with adverse clinical outcomes, unfavorable physiologic measures, and altered inflammatory markers in pediatric cardiac surgery patients. Transfusion 2018;58:1631-9. 10.1111/trf.14601 29603246

5 Pietropaoli AP, Henrichs KF, Cholette JM, etal . Total plasma heme concentration increases after red blood cell transfusion and predicts mortality in critically ill medical patients. Transfusion 2019;59:2007-15. 10.1111/trf.15218 30811035

Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/ permissions

LETTERS

[SbbPerson]

I think we give the freshest blood because it is at its most effective for oxygen carrying capacity, since pH level may drop due to possible cell lysis during storage. We basically do the same thing as mentioned above by several people, except we also do HbS testing on the RBC unit. We want to give the freshest and best oxygen-carrying red cells to our neonatal patients in need.  

[Neil Blumberg]

Those are theoretical constructs. The data suggest fresh isn't best if there are more infections as there have been in randomized trials of fresh vs. average storage period.  More study needed, but the data are more important than the dogma.  Infection is the most common cause of morbidity and mortality in all hospital patients, including newborns.

Edited September 21, 2022 by Neil Blumberg

[Auntie-D]

Irradiation is not required unless the neonate has been transfused in utero 

[applejw]

Is there any concern that the RBC is irradiated more than 24 hours prior to the transfusion?  Irradiated units will have higher K+ levels which could be an issue, couldn't it?

[Auntie-D]

19 minutes ago, applejw said:

Is there any concern that the RBC is irradiated more than 24 hours prior to the transfusion?  Irradiated units will have higher K+ levels which could be an issue, couldn't it?

We also wouldn't as we keep 6 packs for our NICU babies to reduce donor exposure (and also the amount of work needed for us when there are maternal antibodies) - Irradiation would mean we would need to recrossmatch every week

[Malcolm Needs ★]

The paedipacks supplied by NHSBT, or, rather, the donors are also tested for unusually high levels of potassium ions, as a result of findings a few years back where babies had been affected by fresh, rather than stored blood from such donors (natural hyperkalaemia).