NICU questions

[Mabel Adams]

I have just changed jobs and moved to Oregon.

They are ramping back up to a level III NICU here and we are to meet with the new neonatologist. I have some questions for you with NICU experience.

Do you worry about giving Rh neg plts to female neonates that are Rh neg or do you consider their immune systems too immature to make anti-D that could affect them in their child-bearing years?

What do you do for emergency transfusion of plts to neonates when your usual stock of AB plts in unavailable at the moment you need to transfuse plts to a baby with unknown or non-O type? We do not have the ability to volume reduce. Obviously we would use type compatible if available, but what if the only products available are plasma incompatible? Do you leave it up to the doc whether to wait for some to come in (6 hours) or give plasma incompatible?

Can you direct me to a good source of filters and syringes to use to aliquot red cell and plt units in the BB? How would you validate these?

What is different about saline that is labeled "safe for neonatal use" compared to Normal Saline?

How long do you use an irradiated unit for a baby after it was irradiated (my reference says due to K+ increase, they should be given ASAP)?

Recommendations for sterile docking devices also appreciated.

Thanks

[bbbirder]

I have some similar questions as Mabel. Not as complex, we transfuse PLTs to babies about once every 5 years. (Always on evenings or nights of course, when there is a big storm and the helicopters can't fly)

We might need to split a Leukoreduced Apheresis (what filters do you use then and how do you dispense it?) or give out a single non-leukoreduced random concentrate PLT (we have some Pall Purecell PL filters for one PLT concentrate, but this goes into a bag and the nurses would rather have a syringe.) Are your nurses transfusing PLTs to babies using a pump of some kind?

Linda Frederick

[Liz]

I have just changed jobs and moved to Oregon.

They are ramping back up to a level III NICU here and we are to meet with the new neonatologist. I have some questions for you with NICU experience.

Do you worry about giving Rh neg plts to female neonates that are Rh neg or do you consider their immune systems too immature to make anti-D that could affect them in their child-bearing years?

What do you do for emergency transfusion of plts to neonates when your usual stock of AB plts in unavailable at the moment you need to transfuse plts to a baby with unknown or non-O type? We do not have the ability to volume reduce. Obviously we would use type compatible if available, but what if the only products available are plasma incompatible? Do you leave it up to the doc whether to wait for some to come in (6 hours) or give plasma incompatible?

Can you direct me to a good source of filters and syringes to use to aliquot red cell and plt units in the BB? How would you validate these?

What is different about saline that is labeled "safe for neonatal use" compared to Normal Saline?

How long do you use an irradiated unit for a baby after it was irradiated (my reference says due to K+ increase, they should be given ASAP)?

Recommendations for sterile docking devices also appreciated.

Thanks

I can answer a few of the questions:

We colect leukoreduced Apheresis platelets on the TRima, Hemonetics and spectra, thus no need to worry about the D status. But if you have RBC contamination, you should give negative to negative.

Never give plasma incompatible plts to neonates, you will cause hemolysis. If you cannot reduce the plasma, check what the plt count and function is. Definitely let this be a bedside decision.

I am pleased with the Pall filters. We filter a unit and check the post count for WBCs, they should be < 1 million. Also we check for integrity. And we culture for validation.

We make sure that it stops by itself to avoid air embolus.

The ones with syringes I have not tried. The nurses do that on the floor, and use a syringe pump.

Irradiated blood must be used ASAP, so we irradiate the aliquote at the last minute. It just takes 9.5 minutes.

Hope this has helped.

We have a different set up with our own apheresis and donor facilities. So we call in donors.

Good luck.

Liz

[Liz]

I have some similar questions as Mabel. Not as complex, we transfuse PLTs to babies about once every 5 years. (Always on evenings or nights of course, when there is a big storm and the helicopters can't fly)

We might need to split a Leukoreduced Apheresis (what filters do you use then and how do you dispense it?) or give out a single non-leukoreduced random concentrate PLT (we have some Pall Purecell PL filters for one PLT concentrate, but this goes into a bag and the nurses would rather have a syringe.) Are your nurses transfusing PLTs to babies using a pump of some kind?

Linda Frederick

I would advise that you filter the whole concentrate and then take aliquotes into the syringe. Using the SCD for the filter, to keep the shelf life of 7 days for the plts. We use the Terumo SCD.

Why would you filter a leukoreduced apheresis unit?

You just need to use a 170micron administration set.

Yes the nurses use syringe pumps for all blood components.

Hope this helps.

Liz

[bbbirder]

Liz,

Thanks for your suggestions.

When I say 'filter' for the L/R PLT apheresis, I mean the administration set (which does have a filter in it, Yes?).

What kind of Administration set are they using? How much extra volume do you allow for these sets?

If you are giving apheresis PLTs to a baby, are you aliquoting them in the BB? putting into a bag or a syringe?

Thanks...

Linda

[GilTphoto]

At my hospital they usually only give 10 mL of PLT's to newborns at a time. I can't see wasting a PLT pheresis for a baby. A single donor platelet unit of 50 mL should be easier to find that is ABO compatible. I wouldn't worry about the Rh, as their immune system is unlikely to respond to the D antigen.

[Liz]

Liz,

Thanks for your suggestions.

When I say 'filter' for the L/R PLT apheresis, I mean the administration set (which does have a filter in it, Yes?).

What kind of Administration set are they using? How much extra volume do you allow for these sets?

If you are giving apheresis PLTs to a baby, are you aliquoting them in the BB? putting into a bag or a syringe?

Thanks...

Linda

Dear Linda,

We use the Terumo 170 u administration set. We used to use Baxter, its also good, but purchasing went for a bid and you know the rest. Lets say they request 15mL for a neonate, initially we filter the unit, then we send them an aliquote of 15mL with an extra 10mL for the administration set.

They then put it into a syringe on the unit.

For platelets, we like to keep one concentrate from a single donor apheresis, to decrease donor exposure. So we send aliquotes in a transfer bag connected with the SCD from one concentrate and it is dedicated to that baby who is only charged once. The nurses transfer the amount to a syringe in the unit and use the syringe pump.

Hope that helps

Liz

[Liz]

At my hospital they usually only give 10 mL of PLT's to newborns at a time. I can't see wasting a PLT pheresis for a baby. A single donor platelet unit of 50 mL should be easier to find that is ABO compatible. I wouldn't worry about the Rh, as their immune system is unlikely to respond to the D antigen.

We can take the 10 mL from an adult concentrate when we are in a rush, or else we do as I wrote above. We often take more than 6 units from a donor, depending on his plt count. We always take into account the neonates.

[krichards]

We do not worry about transfusing our female neonates with Rh positive platelets as their immune systems are not sufficiently developed to produce any anti-D. We try to give all our babies either AB or type specific. If these are not available, we leave it to the neonatologist to decide what he wants to do...and if he wants to give anything else, he must sign an emergency release form.

We use the Chartermed syringes with filters attached for our RBC and PLT aliquots. We've been using them forever, so I am not sure what validation method was employed when we put them into use. It was WAY before my time. We keep the 30cc and 60cc in stock, but there may be more options available. We use Pall filters for the FFP aliquots. Although, when unavailable, we have used the Chartermed syringes for these as well.

I have never heard of saline for neonate use. Our nurses deal with all of that at bedside, since we no longer wash cells.

We do not irradiate a unit until it is needed to give. Once irradiated, we assign it to one (or sometimes two if they are not very sick) babies within the first 2 days. After that, we will use the unit to expiration (28 days) for those babies. Our neonatologists are willing to risk the increased K+ levels in order to reduce total donor exposures. To date, we have not had a single baby with K+ problems that were traced back to a donor unit.

We are using the Terumo SCD. We have had this since the mid-90s, I believe, and have had no problems with it. I highly recommend it.

I hope some of this will help.

[kelliott]

Hi Mabel, welcome to the Pacific Northwest! I might be able to help you. Our blood supplier is 4 hours away and they have worked with us as our NICU was implemented. Our NICU is not the highest level...I think we are level 2 at the moment. We transfuse very few infants at this point but when we do we order what PSBC calls an assigned aliquot...they dedicate one AS-5 unit, leukoreduced unit to the infant then divide into 8 pedi packs. When they ship they irradiate the number of packs we request. Our neonatologist [OHSU based] will use an irradiated AS=5 unit for up to 28 days. They know how to manage the potassium problem clinically so are not concerned...if it is a small volume transfusion..most are.

We would never give out of group plasma for platelets ...if we didn't have plasma compatible platelets we can get from across the river. The only thing you could do is as you have said...medical decision at the bedside unless the problem was known before delivery and you had some time.

We keep AB FFP from same donor and AB cryo.

Chartmed filters are great.

We don't have a sterile docker....for us it isn't practical at this point because we have so few transfusions, the maintenance, QC, training would not be worth it..I wouldn't be able to keep everyone competent on its use. Using the pedi packs precludes the need for that at the moment. When volume increases it will be more practical.

[Mabel Adams]

Thanks Kay. Do you ever give plts to neonates? We might have to do that rarely. We don't have a sterile docker at this time and our supplier is 6 hours away, barring weather issues, and does not make plts from WB donations. If it is rare enough, we will probably just sacrifice an entire pheresis unit.

Does anyone have pro or con on the Genesis Pedi-syringe Filter syringes and filters?

[John C. Staley]

Mabel, make sure what ever syringe you go with is compatible with NICU's syringe pumps. I'm not sure how "universal" they are so it does not hurt to check.

[anti]

We, in the deep south, were told to ONLY use CPDA-1 units for neonates. The majority of our babies needing blood are 22-26 weeks. The super low birth weight can't allow any Adsol (well, I think it is 1 cc per kilogram of birthweight and these babies are maybe 400-500 grams...kinda pointless.)

As for filters...our NICU does the filtering of all products. We send an aliquot of whatever the NICU needs, in a bag with about 10 cc extra for priming tubing. They filter using a Hemonate filter, which gets down to 17 microns. With LBW premies, you have to be super careful about what may get through a 170 micron filter and cause respiratory distress or stroke.

As for products, we keep a docked CPDA-1 LR, CMV negative O neg rbc for its life. We try to manage lowest donor exposure, if possible. For FFP, always AB...aliquot and go on. The remainder is going to expire in 24 hours (we use it for QC.) As for platelets, we try to get type specific. No joy...whatever is available (catch-22) We request docked, LR, CMV negative. Then, we pull into aliquot bags. We don't have a sterile docking device and with money troubles, will never see one.

I know the LR and CMV negative are somewhat redundant, but it is what my medical director and neonatologists have agreed on. Until I can convince them otherwise, I will continue as is.

As for worry about "D"...our understanding is "until baby is 4 months old, baby is unable to develop ANY antibodies." That is why we will transfuse baby based on Mom's antibody screen (if negative.) If Mom is positive, we test baby until baby is negative, then start testing again at 4 months of age.

anti

[Liz]

If you do not use a docking device for the platelets, what do you do with the remaing part: if it is an apheresis unit?

Liz

[Christie Loe]

Hi Everyone,

Christie from Charter Medical here and I am certainly happy to answer your questions regarding our neonatal syringe sets. Our most frequently used product is a 150 micron filter set with either a 30 or 60 cc BD syringe--it can be used with sterile connection devices or spiked into an aliquot bag/whole blood derived platelet, and is FDA cleared for use with platelets (store in syringe for up to 4 hours), plasma and red cells (store in syringe for up to 24 hours in refrig). I have an extensive reference list of customers, of which I myself was before joining the company in 2005. My email is cloe@lydall.com please contact me directly if you have any specific product questions. Thanks to all of you who are current customers!

[Mabel Adams]

Does anyone know of an X-ray blood irradiator in which syringes will fit? Who makes Xray blood irradiators anyway? Just the one company (Raycell I think)?

Also, does anyone know of a source of such an instrument as used equipment? I heard of someone that bought one a couple of years ago that was used and the price was much more possible.

I might as well dream, right?

[Mabel Adams]

Also, does anyone have any experience with the Genesis BPS syringe and filter sets? Are they just like Charter Medical's?

[Mabel Adams]

Does anyone know if all the sterile connecting devices out there are compatible with all the syringe sets? I can find SCDs made by Terumo and Haemonetics. Are there any others? What is everyone else using for an SCD and are you happy or unhappy with it?

[Liz]

We had a Hemonetics and were very pleased with it. Then we bought a Terumo as a back up, just because we could not find Hemonetics at that time. Then we had a donor offer us another Terumo. Both brands are excellent. I cannot imagine the Blood Bank without a SCD.

[Debbie McCaskill]

We have a 45 bed NICU department. Our supplier sterile docks pedi bags to the irradiated leukopoor CMV neg units that are type specific for each baby ( unless there is maternal Anti A or Anti B in the baby's plasma then we give type O). Since they are receiving small aliquots we do not worry about the K+. When a request is made for an aliquot, we split it off from the parent unit and then filter it using one of the Chartermed syringes and then issue the syringe. Our supplier only issues apheresis platelets. If it is for a baby we try and give ABO type specific and do not pay much attention to the Rh. Our supplier will sterile dock pedi bags to the apheresis platelet and we issue an aliquot in the bag for the transfusion. I do not know what filter NICU uses for the platelet transfusion. If we have several babies taking platelets, we sometimes will order an AB platelet pheresis to use for them. Thankfully, if we tell our supplier it is for a neonate they give us a better price on the platelet pheresis! We have had no complaints about these policies for as long as I can remember and I've been here for a very long time!

[BBK710]

Dear Linda,

We use the Terumo 170 u administration set. We used to use Baxter, its also good, but purchasing went for a bid and you know the rest. Lets say they request 15mL for a neonate, initially we filter the unit, then we send them an aliquote of 15mL with an extra 10mL for the administration set.

They then put it into a syringe on the unit.

For platelets, we like to keep one concentrate from a single donor apheresis, to decrease donor exposure. So we send aliquotes in a transfer bag connected with the SCD from one concentrate and it is dedicated to that baby who is only charged once. The nurses transfer the amount to a syringe in the unit and use the syringe pump.

Hope that helps

Liz

If they put it into the syringe on the unit how is the syringe labeled?

[Liz]

It is labeled with the printed barcoded labels.

[Christie Loe]

Hi everyone,

As a former AABB Assessor and Children's Hospital transfusion service employee, labeling neonatal aliquots is a topic I am very passionate about. With the advent of FDA's barcode requirement and their very specific guidance that even a syringe set should contain the appropriate unit and recipient information, Charter Medical has focused on increasing awareness of labeling requirements and suggested approaches at meeting the standards. Please do take a few minutes to view the attached photos and for additional information, you are all wecome to visit our website to view presentations from our 2007 AABB Industry Workshop, "Best Practices in Neonatal Transfusion Medicine."

http://www.chartermedical.com/products/transfusion-cell-therapy/syringe-sets.html

CharterMed Syringe Set labeling.pdf

[BBK710]

It is labeled with the printed barcoded labels.

So you are sending a prelabeled empty syringe along with the aliquot of packed cells to the nicu and then they fill the syringe from the aliquot?

[rcurrie]

Mabel,

I have always had great luck with the Terumo sterile docking devices.

BC