Fresh RBCs low K+ vs same unit to decrease donor exposure

[Liz]

Is it better to use aliquotes from the same RBC unit for neonates and peds to decrease donor exposure, or use new fresh units to assure a low K+ ?

Moreover, what is your definition of fresh unit?

Thank you.

Liz

Edited July 16, 2008 by Liz

[adiescast]

I can't say which is "better." We have chosen to use the same unit to reduce donor exposure as much as possible. We have not had any reported problems with this policy, but the new research about older red cells may change that.:disbelief

[zz243]

We put donor exposure on top of the list by using the same unit. Premies would often "share" a unit.

We used 5 days old or fresher whenever possible. 7 days old was the maximum if my memory is correct. Our Medical Director preferred CPDA-1 as opposed to Adsol's diruetic properties.

[SMW]

You may find the recent article "How I transfuse red blood cells....to infants...with the anemia...of prematurity" by Ron Strauss [Transfusion, Volume 48, February 2008] and the associated references helpful. Some excerpts below, but bottom line is to use one unit up to expiration date of unit.........

“Most RBC transfusions are given to preterm infants as small-volume transfusions (10-20 mL/kg body weight) of RBCs suspended in extended storage medium (additive solution AS-1, AS-3, AS-5) at a Hct level of approximately 55 to 60 percent. Although some neonatologists prefer citrate-phosphate-dextrose-adenine (CPDA) solution with RBCs at a Hct level of approximately 70 percent, the superiority of this last solution over extended storage media has not been shown by comparative trials. Some centers prefer to centrifuge RBC aliquots before transfusion to prepare a uniformly packed RBC concentrate (Hct > 80%). Because of the small quantity of extracellular fluid (RBC storage media) infused very slowly (usually over 2-4 hr), the type of anticoagulant and preservative solution in which the RBCs are suspended poses no risk for most premature infants receiving small-volume transfusions. Accordingly, the traditional use of relatively fresh RBCs (<7 days of storage) has been largely replaced by the practice of transfusing aliquots of RBCs from a dedicated unit (or part of a unit) of RBCs stored up to 42 days, as a means to diminish the high donor exposure rates among infants who undergo numerous transfusions.â€

“Because the risks of multiple donor exposure can be nearly eliminated by transfusing in infants with RBCs taken from dedicated, stored units and increased risks of transfusing stored RBCs versus fresh have not been demonstrated, it seems prudent to continue transfusing stored RBCs for small volume transfusions.â€

[Liz]

Thank you for the replies and article.

I had a mishap a few years ago: one unit, 5 days old and irradiated the previous day was send to the OR. The infant had a central line and the doctor needed to give the blood by IV push at one point. The child arrested. He was resussitated , did well, and went home. By EKG it was due to hyperkalemia. When we examined the unit we found K+ was 50 meq/L, all the units were then tested and had normal K+ for their age.

Most neonates take irradated blood, true it is given peripherally and slowly. But can I take the risk? I seem to be marked for life due to this case.

This case was published.

Since then I give < 24 hour old units to new borns and small peds.

Help please, doctors are asking that we keep the same unit for the patient to decrease, as we all know, donor exposure. But what about K+ ?

Thanks

Liz

[John C. Staley]

We provide all of our Neonates with irradiated CPDA-1 RBCs, we do not irradiate and must purchase it from the blood supplier who is 2 - 4 hours away depending on day of the week and time of day. We set up a baby on a unit that is generally 5 - 7 days old and keep that baby on it for the life of the unit or the duration of stay. One baby/one unit.

We've been doing this for approximately 10 years with no known problems. (Knock on wood if you can find any in this plastic world!)

[Liz]

Don't you worry about the K+ as the unit ages? Have you everr tested it.

What wold be the max K+ you would give a neonate? 50mEq/L in the bag?

Liz

[krichards]

We follow the practice of using one CPDA unit until expiration also, sometimes with two babies sharing a unit. We have had a couple of instances in the past where the neonatologist suspected that the units were elevating a baby's K+. Each time, we simply assigned the baby a fresh unit. The fresh units did not help in any instance that I have heard of, so the elevated K+ was probably not caused by the unit.

Also, our NICU keeps track of the expiration dates of each baby's unit, and the docs will frequently order an aliquot the day of expiration (if the unit has not been completely used yet) in order to keep donor exposure to a minimum. None of these transfusions just prior to unit expiration have met with any adverse effects.

Karen

[Liz]

Thank you for the replies.

One more question, we are talking about the NICU. What about the OR for newborns and infants. Do you have a policy that the unit must be fresh, as there will be a central line in place?

Thanks

Liz

[John C. Staley]

I can't give you my 2 cents worth on this question, we don't do any surgeries on newborns or infants that would require transfusion support. Those patients get sent to the local childrens hospital about 1 hour away.

[OPUS104]

The only time our area Childrens Hospital requests age specific units from us is for exchange transfusions. (less than 5 days O neg. CMV=) When I worked at the only level one trauma center in this area, we had a "Pedi-unit" that we had pedi bags docked onto and used until expiration. We had a couple of doctors worry with this, usually after some chapter was read in a book, (like increases in ordered Sed rates when the interns get to the S section of their books) but never had a documented problem. K+ would be measured if a doc. thought something was fishy.

[skoopus]

We take a fresh, irradiated, O neg unit (<14 days), and split it via SCD. We wash one half at a time, effectively volume depleting it and reducing the K+ levels, when blood is requested by the NICU. We then draw off syringes for the amount needed. The washed unit has a 24 hour outdate, and is shared.

If we have a neonate cardiac patient, we wash the first unit, to prime the pump, for the OR. When the baby is on the PICU, we will then volume deplete and aliquot a red cell. We will keep that unit for that neonate to reduce donor exposure.

[Liz]

Thank you Skoopus, that helped a lot.

Liz

[GilTphoto]

While our policy is that blood must be < 7 days old, our neonatal doctor insists on blood < 5 days old. If it's day 6 or day 7, he won't accept it. Should we change our policy to accommodate him? Is there any reference for < 5? Only references I can find indicate < 7 because of potassium.

[rcurrie]

We did a study on K+ as units aged, and found that 5 days was the maximum storage time we could risk on our preemies. We use CPD blood for our preemies- no adinine, which can be toxic to the kidneys when they are multiply transfused. How to keep using the same unit without worrying about K+? Simple- wash the aliquot.

BC

[Liz]

There is an article in Transfusion about a filter to reduce K+. I have no experience with it.

Efficacy in reducing potassium load in irradiated red cell bags

with a potassium adsorption filter

Received for publication January 11, 2008; revision

received March 3, 2008, and accepted March 4, 2008.

doi: 10.1111/j.1537-2995.2008.01776.x

TRANSFUSION **;**:**-**.

Have a look at it.

For us, Fresh means < 24 hours for open heart infants. Thats due to the fact that the central line is practically sitting on the AV node and you certainly do not want to flush it with K+; especially when the surgeon decides that there is a bleeder and that the patient needs to be given Blood by IV push.

Adults do ok because the RBCs have time to act as drains for K+ since they are depleted of K+. You may get hyokalemia!

Again Fresh is < 5 days, I definitely agree with rcurrie, BC. If in doudt do a stat K+ level on your blood unit. Chemistry section will be happy to do it for you if you charge it to the BB budget.

Liz

Edited August 11, 2008 by Liz
Typo

[Liz]

PS: We have our own donor room. So fresh blood <24 hours comes in all the time, and with the random access screening platform with the stat option, we have an advantage.

Liz

[davenoso]

Like everyone, I think each situation/conditions/Dx mandate what action to take (this is difficult in these times of cross-trained staff and need for "one size fits all" policies. The important issues to consider are the 1) volume of the transfusion, 2) the rate in which products are transfused, 3) when (or if) the RBC products were irriadiated, 4) facilities ability to wash products, and 5) Dx/procedure (OHS, ECMO, hyperkalemia, heart issues?). Also keep in mind the accumulative effect of several small volume (60ml) transfusions.

Donor exposure has become much less of an issue with improved ID testing (and relatively stable O neg donor popultation) according to our blood suppliers, so we try to keep things in perspective. We use fresh (<5d, if fresh not available wash an older unit), LR, irradiated upon issue, HbS neg units for large volume transfusions (>60ml). Our pediatric cardiac team is much less interested in donor exposure than K+. Our PICU and NICU are more interested in limiting donor exposure. We are lucky that we can irradiate and wash units in-house and we are one block from our blood supplier, but it's still a complex process and requires a moderate level of decision-making not possible with all staff - all the more complicated by our litigeous society and healthcare industry run out of (cost) control. Good luck everyone! Diane

[Liz]

Well said, Diane

[Debbie McCaskill]

We have been using Adsol units that we invert upon receipt in blood holders for our neonates. They have 7 aliquot bags attached to them and the units are irradiated. For aliquots, we split off some of the blood into the bag and then put it in a syringe with a filter. The unit is allocated to two babies each ( although sometimes we will put three on a unit). The unit is used until outdate. Since most of the plasma and preservative is in the top part of the bag, the unit has a higher hematocrit and not much preservative is in the unit ( low K+). We have had no reports of a problem for many years thank goodness.

[Liz]

Very practical info Debbie, Thank you.