Expiration and use of Pedi Irradiated RBC's

[mwlister]

I would like to inquire what is a suitable time to expire Pedi Quad RBC's afer irradiation. In addition, how many institutions typically irradiate all RBC's and other products for premature infants?

Your comments are appreciated.

Thanks, MWLister

[donellda]

I prefer to use irradiated units for neonates when they are fairly fresh. We get ours from Red Cross with the usual 28 day outdate. If they are still on our shelf after 21 days, I tend to put them out as expiring units for adults because the potassium in the unit tends to increase as the unit ages and some neonates cannpt handle the higher potassium concentration.

[mwlister]

Hi Donna:

I am reading material that suggest that you should not use RBC's after 24 hours of irradition. This is from Transfusion Therapy. It does however allow use if the RBC's are washed to remove potassium. Can you suggest a reference?

Thanks, MWL

[donellda]

The only source I have here at home right now is my AABB Technical Manual. It does discuss the problem of potassium leak in stored, irradiated CPDA-1 RBCs, stored for greater than 24 hours and suggests washing them. I think they are referring to older units or aliquots that have been irradiated more than a day before transfusion. This would work if your facility has an irradiator and the capability of washing cells. I remember at the hospital that I was previously employed, we would aliquot the the blood and then irradiate the aliquot just prior to transfusion. Where I work now, we have neither an irradiator or a cell washer. We deal with neonates but we are part of a health system that can transfer the very sick babies to another hospital in the system so we basically get O positive and O negative, CPDA-1, CMV and hemoglobin S negative, irradiated units from Red Cross and aliquot from the units as we need them. Most babies get one or two aliquots from the unit when they are still fresh and the remainder is given to an adult if the unit has more than 200 mls left.

[Eagle Eye]

We use to issue aliquot from the irrdiated AS-3 units up to 14 days. I believe 14 days limit was for freshness. We do not have irradiatior inhouse. We recently change our SOP and we use ped units up to 48 hrs from the time of irradiation. I do not recall numbers but I did run potassium level on fresh and old units and there was significant rise in the potassium level.

[Cliff]

We irradiate all of our NICU products, and will use irradiated aliquots up to 3 days post irradiation.

[mwlister]

We irradiate all of our NICU products, and will use irradiated aliquots up to 3 days post irradiation.

We have a new Neonatology group. Currently, RBC utilization has doubled. Historically we have not provided irradiated blood for premature neonates. I do have a policy for family donors where they have to be irradiated and the unit expires 24 hours post irradiation.

My concern here is that they limit the neonate to a single donor. The Blood Supplier irradiates the entire unit. If I were to switch to 100% irradiated products my wastage would be enormous. What are the hassles and expense of purchasing an irradiator for a 400 bed hospital?

Thanks, MWL

[Cliff]

What are the hassles and expense of purchasing an irradiator for a 400 bed hospital?

Thanks, MWL

Hmm, not sure.

You need a license for the radioactive material, that should not be too tough.

You need training for the staff, and equipment validation. Again, something you should be able to easily handle.

I guess you'd want to change you policies in several places, still pretty simple.

Mostly what you'd need is a lot of money. We have two, and our new one was between 150,000 and 175,000, not sure of the cost.

[adiescast]

We have an irradiator, so we can perform the irradiation on the split right before we issue it. We used to irradiate only blood for babies < 1500 gms birthweight. This was at the request of our neonatology group.

We recently started irradiating all baby splits because of the new labeling requirements - having two types of blood required twice the label stock. Not much in the way of patient care issues with that!

[sgoertzen]

I am the transfusion service supervisor of a children's hospital and our policy for irradiation is:

Irradiated packed cell units are no longer returnable to the donor center so it is important to utilize these units on appropriate patients prior to their 28 day expiration

• RBC products and aliquots should be irradiated as close to the time of issue for transfusion as possible to avoid red cell storage lesion.

• Do not issue RBC products more than 7 days post-irradiation to any patient in the NICUs or PICU due to possible problems with high potassium values.

• If a DD unit or antigen specific unit must be used for a NICU/PICU transfusion after 7 days post-irradiation, consult a pathologist to either obtain a Deviation from SOP to use the unit “as is”, or to wash the unit to remove the anticipated higher levels of potassium in the plasma.

• Attempt to use older irradiated PRBC products on larger pediatric patients without hyperkalemia concerns.

• If PRBCs need to be washed and irradiated, perform the irradiation after the washing whenever possible to prevent excess potassium leakage which can occur in pre-irradiated cells that are subsequently washed.

[mwlister]

Thanks to all for your comments.

MWLister

[John C. Staley]

We have an active 36 bed NICU. We do not have an irradiator and are located between 2 and 4 hours (depends on traffic) from the blood center. We keep 1 O neg, 1 O pos, 1 A neg & 1 A pos irradiated units available for NICU at all times. After about 1 week on the shelf they are moved into the general population. Once a baby is assigned to a unit during that first week we will give the baby aliquots from that unit until the unit is depleted, outdated or the baby leaves the hospital. We seldom are tranfusing from a unit that is approaching it's outdate. Most of the time the baby has stopped receiving blood long before that but we will use it up to the outdate and have not been informed of any problems from the physicians. Our neonatologists are very conservative with their transfusions and with the use of erythropoeitin(sp) our transfusions of have dropped dramatically.

Cliff, where's the spell checker?

[mwlister]

Hi John:

I have to ask why so many institutions are using different dates to release neonatal RBC's after irradiation? I have polled at least five hospitals. Some use the unit 10 days to expiration of the unit and some to the day of expiration. I have heard some from 48 hours to seven days.

I don't have the AABB technical manual with me, however I believe it said you should not exceed 24 hours after irradiation. Cosequences includes infant death secondary to cardiac arrest.

I need to make a decision on expiration and find a way not to destroy a unit after single use. I am impressed with the erythorpoeitin approach. Could you provide me with information on expiration and references?

Thanks, MWLister

[John C. Staley]

My experience with neonates is that there are very few standards. Most practice appears to be driven by the experience of the neonatologists at the facility and most of that is anecdotal. Also a lot depends on where their fears are the greatest. Here we will put twins on the same unit becasue the docs want to expose the family to the fewest donors possible. Other facilities I have talked with are absolutely appalled that anyone would take the chance of exposing both twins to the same donor. Yet there is no standard to follow. I haven't read the technical manual for a while but I don't recall anything so specific as to it saying "you should not exceed 24 hours after irradiation. Consequences includes infant death secondary to cardiac arrest." Our neonatologists are fairly conservative yet progressive in a lot of ways. I'm certain that if they were concerned, our use of irradiated units until expiration would not be allowed. Our limitation is that we do not have an irradiator and never will have one. In the perfect world we would be able to irradiate each aliquot immediately prior to issue but I'm afraid that is not the world I live in at the moment.

[mwlister]

Hi John:

I am at work now and have found the reference. It is in the AABB Technical Manual, Fifteent Edition, page 561.

THanks, MWLISTER

[mwlister]

My Pathologist (Transfusion Director) would like to know what everyone thinks about using one aliquot from an irradiated unit and then puting the remainder of the unit in the general blood supply? Could we justify transfusing a unit to a patient that had as much as 50 mL removed? Would it be fair to bill for an entire unit? No HCPCS code for a partial unit.

Your comments are greatly appreciated.

Thanks, MWLISTER

[sgoertzen]

At this pediatric hospital, we routinely give partial units to patients. In fact, that is how they order blood here ... either in mLs or units. We have our aliquot system set up to bill per aliquot - not per mL. We do aliquot studies every 6 months for the previous 6 months and adjust our billing accordingly. Currently, we are routinely making 2.8 aliquots from each split leukoreduced PRBC unit ($202), so each aliquot is currently being billed at $72.50 - regardless of whether the aliquot is 15 mL or 150 mL. In the example you gave above, at my hospital, each patient would be billed the $72.50 for a partial unit (plus the split fees). We rarely waste much of any blood or platelets, even from the units that have had small aliquots removed from them. I understand how it gets more complicated at an adult facility where you have an NICU population and an adult population and nothing in between. When I used to work at a facility such as this, we would try to make those rarely ordered aliquots for babies from the heavier PRBC units, leaving them with about the same volume as many of the smaller full units. Since PRBC and PLTPH units often vary quite a bit in volume and Hct or Plt count, we felt justified billing the patient for a full unit even though a small part of it had been split off and given to another patient.

Since we are a pediatric hospital, we do have an on-site irradiator and we always try to irradiate each aliquot as close to the time of issue as possible. When freshly irradiated units get issued and come back to us from surgery, we try to use them for > 4 mo. non-cardiac, non-NICU/PICU, patients where potassium is not a concern.

[lef5501]

Hi John:

I am at work now and have found the reference. It is in the AABB Technical Manual, Fifteent Edition, page 561.

THanks, MWLISTER

I have also looked at this quote from the AABB Technical Manual and it is talking about transfusing "large volumes of red cells in such circumstances as surgery, exchange transfusion or ECMO." In the same paragraph before this comment it says that " the transfusion of 10ml/kg of red cells obtained from a unit stored for 42 days would deliver 2 ml of plasma containing only 0.01 mmol/L of potassium." Much less than the daily requirement of 2-3 mmol/L for a 1-kg patient.

I believe it is always preferable to perform irradiation as close to transfusion, however, I don't think babies need to be exposed to too many donors either.