Current NICU practices?

[caj1018]

I would like to know what red cell product you use for your NICU babies:

What anticoagulant, irradiation, CMV, as well as dating. Do you use only fresh less than 10 day old blood or do you use one unit/baby until it expires?

I would also like to know what sample you use from the baby - Do you use the cord blood sample only? And do you perform an antibody screen on it or do you ue the mom's results for the antibody screen? Do you get a new sample from baby and do a type&screen?

We are currently restarting a NICU practice at our hospital with new physicians and there is current debate about best practices.

Thank you for your help

[John C. Staley]

Our preferred RBC product for NICU is type specific, CPDA-1, Leukoreduced and Irradiated. We try to set it up for the baby as early as possible and will use it until it is gone or outdates. We can not irradiate (long story) so we have to purchase the blood already irradiated and the blood supplier is too far away to order as needed so we keep a couple of Os and As both pos and neg that meet the above requirements on the shelf at all times. As a general rule if they have been on our shelf for 7 days and not assigned to a baby they are replaced with fresher units. Luckily we have enough call from oncology for irradiated units we don't waste many.

Each baby gets their own unit with the exception of twins, triplets, etc. Our neonatologists like to have all babies from multiple births on the same unit if the types allow. I think this is to minimize donor exposure to the "family" but I'm not real sure. I've heard of places where this is strictly forbidden. A different philosophy of not wanting all of the family exposed to the same donor. I guess this is a matter of how your neonatologists feel on the subject.

We absolutely will not use a cord blood sample for pretransfusion testing. (labeling concerns!!!) We get 3mls drawn from the baby in EDTA. That is usually plenty for a type and screen. If the antibody screen is positive we will use mom's sample for antibody ID.

[adiescast]

We use type O rbc only and match the Rh of the baby. We use leukodepleted rbc in adsol for the entire dating period. We do have a blood irradiator, so we can irradiate the blood right before we use it. As a result, we irradiate each split instead of shortening the life of the original bag. We obtain a sample from the baby for a type and screen. Cord blood samples are not used for this. These results are used for the entire admission (or until the baby is >4 months old). Like John, we use the mother's sample for antibody identification, if it is available. Babies with antibody circulating must have antigen matched rbcs. We repeat the screen once a week to monitor the presence of maternal antibody until it disappears. After that, the weekly screens and antigen matched blood are discontinued.

[Yanxia]

We don't routinely irradiate all the blood components for the infants. We just irradiate it for the immuno-deficiency baby , the baby have been intrauterus transfused and the blood component comes from the family member.

I think do the antibody screening can use the mother's blood only then give the baby antigen negative blood component.

[Karen Olsen]

We give O neg leukoreduced < 7 day old units in Adsol to babies and then keep them on that unit until it expires or is gone. We do not use cord blood specimens for transfusion purposes. We draw a bullet in EDTA. We use Mom's Ab screen status if available. We irradiate as stated above by Shily and then give the unit a 24 hour outdate - so we also irradiate the aliquots instead of the entire unit.

[kate murphy]

We give O neg CPD irradiated leukoreduced to all babies. One unit dedicated to one baby - used till gone or outdated. CPD has a higher hct than Adsol and the babies theoretically need less transfusions. We use the cord for baby ABO/Rh, and mom's spec for ABS - we XM antigen neg units to mom if there is an antibody, till the baby is 4 months old.

Exchange transfusions are different - washed rbc's reconstituted with AB plasma.

[pdavenport]

For small volume transfusions we use irradiated AS-1 leukoreduced. We irradiate the aliquots as we make them and use the unit for that infant until it's used up or outdates. For exchange, heart surgery, or ECMO we use fresh CPD.

[Kathy3171]

We have a unit of fresh O negative, CMV neg, Adsol unit with pedipaks attached delivered from our blood supplier every other week. Our neonatologist does not require irradiated blood. So we use our 'fresh' unit whenever a transfusion for an infant is requested. (not that often). We do not use cord blood but require a heel stick for type and hopefully enough for a screen. If not, we use the mother's specimen and if there is an antibody, then we would honor it by giving antigen negative blood. The baby's that we transfuse do not usually require more than 2 aliquots and if they are that sick, they are transported to a childrens hospital with a higher level of care.

[dcharland]

We use CPDA1 Group O Rh mactched, leukoreduced, irradiated, cmv-, HBS- RBC's for our NICU < 4 month old babies. We make syringes for each aliquot and irradiate the aliquot. The syringe outdates in 4 hours. We keep the baby on that unit until it expires.

We just started ECMO here for our peds patients and the new surgeon doesn't care about the anticoagulant, so we have just started using Adsol for only our open heart babies even if they are the less than 4 months. We hope to eventually switch all the NICU babies to Adsol.

We do not use the cord blood to many mislabelled specimens. We draw a bullet for the ABORH, Dat and Antibody screen. Antigen neg units if the Mom has an antibody.

[rcurrie]

I have about 25 dedicated O neg CMV neg donors who we collect into CPD (AS-5 without the additive). We keep these high HCT units on a neonatal shelf for 5 days and then put them into general inventory if not used for neonates. We irradiate for low birth weight premmies only unless requested by the physician (but the medical director always gives them a hard time if irradiation is not indicated). I usually keep about 100 O negs on the shelf (eat your hearts out, guys!) We are not adverse to giving Rh positive blood to a neonate if that is their type, but we only make CPD units out of O negs, so we rarely have the occasion to transfuse Rh matched units. If we have an irradiation need, we will not irradiate until they come to pick it up. We also dedicate units to a single baby once they need blood. We sterile dock 8-pack bags onto the mother bag and aliquot as needed using an SCD 312 sterile docking device.

BC

[John C. Staley]

Bob,

Now I know where I'm going next time somebody tries to tell me there is a shortage of O negs!!! I knew it was a fairy tale and some troll under the bridge had them all. ;>)

[rcurrie]

Hey John,

You will have move to Texas if you want some of my blood. I gave up our FDA licenses (WB, RBC, PLT, Apheresis PLT, FFP, CRYO) two years ago to cut down on my reporting, so I can't ship across state lines. We probably have more blood per capita than any other institution in the US. We keep about 1,000 units of RBC in inventory. Population: 55,000.

BC

[Debbie McCaskill]

We have a 45 bed NICU department. We purchase irradiated, CMV neg, adsol units that have been sterile docked with 7 bags per unit. We give type specific if there is no circulating anti a or anti b detected at AHG. We allocate 2 or 3 babies to one unit and use it until it expires or is used up. When we get the units from our supplier, we invert them so the hematocrit will be higher once it settles out. This procedure has been utilized here for over 10 years.

[MJDrew]

Debbie, it's good see another "inverter"! We have been using this method here for over a decade as well, one unit/baby, and it produces good aliquots from LR Adsol units all the way to outdate. (I actually started using it withe CPDA units in the early 1990s!) If irradiation is needed, we irradiate the syringe aliquot, good for 4 hours. The syringes are a godsend; we are happy to be able to label the syringe ourselves and know that it's been properly done! We irradiate for LBW & VLBW (generally <1000 gm) infants' aliquots, and of course for exchange transfusions, which we very rarely do any more. When we do, we use O cells from an inverted LR Adsol unit and mix with AB plasma to the desired Hct. Aliquots are O+ or O- depending on baby's Rh type, respecting any antibodies mom may have. Rarely we get an A or B unit as a directed unit (usually from dad) and if this is baby's type and compatible, we will use it for aliquots.

I always refer people to Dr. Strauss' excellent article on neonatal RBC transfusion when questions arise about using Adsol units to outdate, leukoreduction, irradiation, and other issues: Strauss, RG, Data-driven blood banking practices for neonatal RBC transfusions. Transfusion 2000;40:1528-40.

MJ :cool:

[Mabel Adams]

Do you then leave the separated adsol in the primary bag when you use these inverted units, thereby reducing the amount of it the baby is exposed to?

[Debbie McCaskill]

Yes- When the bag gets depleted of most of the red cells, the remaining part is mostly adsol with a small amount of red cells. We then discard the remainder of the unit.