Neonatal Transfusions

[ffriesen]

We are a midsize facility without a NICU but within 20 minutes of several that do. We are also at least an hour from our blood supplier. Within the past 6 years there have been 3 requests to transfuse an infant. We are currently in the process of developing a policy to address those emergent situations where a transfusion is needed before the helicopter can get here to pick up the infant. Does anyone have any policies they would be willing to share that addresses a situation such as this? Or at least some advice on how to approach it? We don't feel we can justify keeping a pedi quad on hand at all times for the rare occasion (every 2 years) the request to transfuse an infant occurs.

[tbostock]

At my previous hospital (Trauma Center), we had to have a similar policy, in case we had a neonate come in (for example in a car accident) until they transferred the baby out. We also did not have pedi-packs, and did not have the equipment to make or label aliquots. So our policy was to issue the freshest O Neg, irradiated, preferrably CMV neg that we had inhouse. If we had time, we would also do a Type and Screen on the mom and give the baby antigen negative O Neg units for any antibody the mom had. The pediatrician would be responsible for calculating the amount to transfuse and they would have to take what they needed in a syringe from the unit and discard the rest of the unit.

[babsglab]

We are a 22 bed hospital who would normally transfer pedi pts, but in the event of an emergency, my procedure says to transfuse O neg red cells, AB FFP. and the blood would have to be removed from the unit by syringe.

[AMcCord]

We also hand out a full unit (freshest, CMV neg if available tho all our stock is leukoreduced, type specific if possible).

[Townsend]

Just a few things to keep in mind, hope they help,

- If the transfusionist is pulling blood into a syringe themselves prior to administering, make sure that the blood is filtered first. You may want to consider supplying a syringe with an inline standard blood filter (charter medical makes some). We have had cases where a whole unit or bag aliquot was pulled into a syringe by anesthesia and (we think) not filtered first.

- Make sure that you are giving O red blood cells to neonates with possible maternal ABO antibodies, unless you are performing testing for the presence of anti-A and/or anti-B at the AHG phase, which most places would not routinely do. (see AABB Standard 5.16.2)

You are doing the right thing by coming up with a procedure and solution now for those rare cases when a neonatal transfusion may be required. Scrambling during this urgency is the last thing you'll want to have to do when the time comes!

[Malcolm Needs ☆]

Just a few things to keep in mind, hope they help,

- If the transfusionist is pulling blood into a syringe themselves prior to administering, make sure that the blood is filtered first. You may want to consider supplying a syringe with an inline standard blood filter (charter medical makes some). We have had cases where a whole unit or bag aliquot was pulled into a syringe by anesthesia and (we think) not filtered first.

- Make sure that you are giving O red blood cells to neonates with possible maternal ABO antibodies, unless you are performing testing for the presence of anti-A and/or anti-B at the AHG phase, which most places would not routinely do. (see AABB Standard 5.16.2)

You are doing the right thing by coming up with a procedure and solution now for those rare cases when a neonatal transfusion may be required. Scrambling during this urgency is the last thing you'll want to have to do when the time comes!

That's an excellent point about giving group O blood in case of maternal IgG anti-A and/or anti-B, but at the same time you should also make sure that the unit is negative for high titre anti-A and/or anti-B.

[Townsend]

That would be great if we knew that. Malcom, do you normally get this information from your blood supplier?

[Malcolm Needs ☆]

Well, we are the blood supplier, but yes, we do test most (if not all) units for high titre ABO antibodies and put the information on the blood bag labels.

[bbbirder]

I am glad to see that I am not the only one struggling with this. I am currently updating aliquoting (for RBC and PLT) procedures as well as exchange procedures.

We have a greater distance both to our supplier and to the children's hospitals that will get the transfer.

We would only exchange in a dire emergency (once in 20 years? maybe), but we need to be prepared.

I found the quote below on the CBBS web. Any thoughts? Especially on the idea that giving AS RBCs as they are would work? What about this in AS-3, vs AS-1, vs, AS-5? At our facility we don't have the ability to pack RBCs to express excess plasma or remove the additive solutions. Adding back FFP would result in an lower than ideal HCT.

Our supplier never checks for high titer anti-A,B on any product.

Again, think about this in a dire emergency only (helicopters grounded or delayed, etc.). Baby will get to a children's hospital eventually.

Linda Frederick

"A colleague from Spain reports that in his opinion, he agrees that the best place to prepare the component is the blood bank laboratory, and that one should take into account the following (his opinion paraphrased is shown below):

• The desired hematocrit is a critical issue, since the neonate hematocrit is physiologically higher that the adult. If you use an adult hematocrit (about 35-40%) for a baby with 55%, you can cause hemodilution. In the actual clinical case, the neonate could have low or high hematocrits, and the reconstituted blood should help the baby reach a desired level.
  

If you want to minimize donor exposure, maybe it is not necessary to use whole blood. The hematocrit of red blood cells in additive solution (i.e. Adsol, SAG-mannitol) is usually within the clinically desired range. In this way, you should only use plasma if the baby shows additional coagulopathy (this is standard practice in the British Health Service). The case for washing red cells could arise from mannitol-containing solutions if the baby is not stable. Sometimes the pediatrician feels safer without manitol."