neonatal transfusion

[Antrita]

We are working towards a neonatal unit in the next year. From what I read the age and anticoagulant used in the unit is not important since such a small amount is given at one time. This would allow one unit to be saved for one baby reducing the amount of donor exposure. Also, should all units be irradiated? If all of our units are leukoreduced at donation, do we need the units to be CMV negative?

Thanks

Antrita

[Malcolm Needs ☆]

We are working towards a neonatal unit in the next year. From what I read the age and anticoagulant used in the unit is not important since such a small amount is given at one time. This would allow one unit to be saved for one baby reducing the amount of donor exposure. Also, should all units be irradiated? If all of our units are leukoreduced at donation, do we need the units to be CMV negative?

Thanks

Antrita

As long as the unit is being given as a "top-up" transfusion, and the neonate was not given an IUT, and is not very small for age or very premature, then, yes, you can use blood up to its normal expiry, with no particular problems with, for example, potassium ion concentration in the suspending medium.

It is also important that one complete unit is reserved for one neonate. There are two reasons for this. Firstly, and most commonly quoted, is the desire to minimize the exposure of the neonate to "foreign" antigens (although I've often wondered about this, as the neonates immune system is so immature that he/she is unlikely to be immunized, but may become "used" to the foreign antigens, and would not necessarily make antibodies to these antigens when challenged in later life). The second (more gruesome) reason is that, if the donation is infected by a bacterium, if it is transfused to one neonate, rather than several, only one neonate will die, rather than several.

There are good arguments that all cellular blood components transfused to a neonate should be irradiated, on the grounds that, just by chance, there may be a shared HLA haplotype, and also by chance, some viable T cell lymphocytes present, that may result in transfusion associated graft versus host disease. This is particularly true with premature neonates, when their own immune system is compromised by age. One has to remember that not every single unit of cellular components will have been tested to ensure that the leucodepletion has "worked", and that one may slip through that has a near normal leucocyte count (and, of course, they will, almost by definition, be "fresh" blood components).

All that having been said, the literature to support this theory is pretty scant!

As for CMV negativity, unless you have tested the mum to ensure that she is CMV negative, and has not, therefore, passed on the CMV virus to her baby, and taking into account that, unless the CMV testing is performed by nucleic acid testing, there is approximately a 2% false negativity for serological testing for CMV, and looking at the data coming out of Scandinavia (admittedly by Pall, who make the filters) then leucodepletion is as good as, if not better than, CMV testing.

PLEASE NOTE THAT, AS ALWAYS, THIS IS A PERSONAL POINT OF VIEW.

:):)

[John C. Staley]

One thing Malcolm forgot to mention is that in order to maintain the original outdate you must access the blood by using a sterile connection devise (SCD). Otherwise your original unit will then require a 24 hour outdate.

This usually is understood but it never hurts to mention those thing that we all know.

[RR1]

In the UK paed units are pre-aliquoted into 8 x 30ml packs. Would this be how you would process your main unit or would you 'tap-off' from the main unit the required volumes as and when needed ?

Another point to consider is if 8 smaller units are made up, as Malcolm said- only use for one patient or, since only really severe infants would use be transfused this amount in 35 days, if you share the unit between two patients you must ensure twins/ triplets etc always receive from different donors.

[SMW]

Antrita--

I would suggest you take a look at “How I transfuse red blood cells and platelets to infants with the anemia and thrombocytopenia of prematurity†written by Ronald Strauss. [Transfusion 2008; 48:209-217.] All of the items you mentioned are discussed by this well known and respected expert on neonatal transfusion and the article includes a number of references that may be useful in your decision process.

[Malcolm Needs ☆]

One thing Malcolm forgot to mention is that in order to maintain the original outdate you must access the blood by using a sterile connection devise (SCD). Otherwise your original unit will then require a 24 hour outdate.

This usually is understood but it never hurts to mention those thing that we all know.

Absolutely correct John, and I should have mentioned it.

[L106]

Rashmi -

I'm probably missing something very obvious, but I'll ask anyway: Why is it important that twins/triplets receive from different donors?

[Malcolm Needs ☆]

It's because, if the unit is infected, the parents won't lose both twins or all three triplets.

[John C. Staley]

That is a very contentious(sp?) subject. It depends on the neonatologists and their feeling on the subject and on where their paranoia lies.

The counter point to Malcolm's argument is that by giving the twins etc, the same unit you are exposing the family to fewer donors and there by less likely to infect any of them.

I've seen the argument go both ways. At my previous employment the neonatologists wanted the multiple birth babies on the same unit if serologically possible. That was their philosophy on the subject and their decision to make.

[SMW]

........and back to the original post.......be prepared that the neonatologists that come on-board with the progam will likely "request" whatever they are using at the facility where they are currently treating patients and/or what was used at the facility where they did their training and it will be very "difficult" to convince them of any other alternatives. A particular challenging scenario is when the new docs are coming directly from a speciality children's hospital where the hospital and blood bank have very different resources available than say a community hospital, many miles from the primary blood supplier, where "booster" transfusions (let alone exchange transfusions) may only be performed sporadically. Arm yourself with peer-reviewed references and since with most new programs there is a one-time opportunity to acquire new equipment, try to get a sterile connection device as part of this new process if you do not already have one (and which you will find useful for applications in addition to neonates).

[Malcolm Needs ☆]

That's terribly cynical SMW, and I agree entirely with everything you say!!!!!!!!!

[L106]

Oh, so true, SMW!!!!!

[AMcCord]

Working in one of those community hospitals, far from the blood center, I can also tell you that's exactly how it will work. And they will ask for O neg on every baby, 'cause that's what I was taught' so there must be a really good (mandatory) reason for that. (Usually the really good reason is because that was what their teacher was taught and his/her teacher before them, with no reference to references.) Heaven help you if you have a baby who needs c negative red cells! Good reference material is a must when you have to win these kinds of arguments.

[younglau]

This is what we do....

One unit per neonate (must be less than 10 days old at time of first transfusion) aliquoted as needed using sterile docking technique, irradiated but CMV not an issue no matter what the size/gestation of the neonate.

The only time we use the same unit for neonates is when there are twins/triplets etc ABO compatible with a Directed Donation from a parent.