Molly

the sticker is an actual part of the unit tag - so when the tag prints, the sticker is on it and gets printed as well

We use a paper tag with a pre-attached sticky label. The tag has all kinds of info printed on it for the nurses edification, such as transfusion rxn info, only use saline, etc. The computer prints all the patient/donor info on the tag and also on the sticky label which we place on the unit at issue. The tag is primarily used at the bedside for the required checks but the unit itself is scanned into the computer and completed in the computer.  If the computer is down or goes down, the nurse will revert back to the paper tag to complete the transfusion. The label stays on the unit throughout the transfusion. That has been beaten into their heads over the years.
The tags are a specialty type print and are expensive but it is what it is. It took months of committee meetings to approve the tag we have now and every nurse had an opinion about what should be on the tag. 

We use Softbank and print a bag label with patient/donor/product information that adheres directly to the bag.

We print ours on a 4x4 adhesive label and place the label on the back of the unit at issue.

The back cardboard copy of the computer generated bag tag with the patient and unit information is attached to the unit at the time of issue. 

we use both.....
our tags have a sticker on them.  when they print - all the pertinent info from the tag is on the sticker.  we place the sticker on the back of the unit at the time of tagging.
we got dinged during an inspection because the nurses took the tag off the unit while it was hanging....... the sticker solves that.....if they take the tag off - the required info is still on the unit.
we do this with all our blood products.
we currently use SCC-Soft Bank

Ours print on a 4" x 4" label from a Zebra type printer. We stick them on a slightly larger tag made from card stock with an eyelet at the top for a rubber band. The back of the card stock tag is printed with a list of transfusion reaction symptoms and a brief description of response expected. Below that are blood handling instructions/education. All nursing documentation is in Epic.

PAPER TAGS PRINTED ON A DMP PRINTER
 

I'm the supervisor at a children's hospital in Central California and here are our indications for the transfusion of RBCs:
Neonates: Term and near term neonates and infants < 4 months of age*
Hgb/Hct < 7g/dl / 21%
         Stable anemia with no clinical manifestations
Hgb/Hct < 10 g/dl / 30%
         Moderate cardiopulmonary disease
         Major surgery
         Increased oxygen (FiO2) requirement <35%, on CPAP lower setting
         Significant apnea or bradycardia, tachycardia or tachypnea
         Low weight gain
Hgb/Hct <12 g/dl / 35%
         Fi02 requirement greater than 35%, on CPAP higher setting
         Recovering from major surgery
         Severe traumatic brain injury
         Significant deterioration of cardiorespiratory status
Hgb/Hct < 15 g/dl / 45%
         FiO2 requirement > 35%
         Severe cardiopulmonary disease or congenital heart disease
         On extracorporeal membrane oxygenation (ECMO)
*No clear transfusion RBC threshold guideline for low birth weight neonates (BW <1500gm) is available. Randomized clinical trial (Transfusion of Prematures) was started in 2013 and is ongoing.
 
Pediatric patients >4 months old through adult
Not bleeding
Reasonable in almost all patients if Hgb/Hct < 7 g/dl / 21%
Almost never indicated if Hgb/Hct >10 g/dl / 30% unless patient is on ECLS
For Hgb between 7-10 g/dl (Hct between 21-30 %):
         Based on organ dysfunction and ability to handle inadequate oxygenation
         Respiratory or cardiac failure
         Chronic disorders of red cell production, severe platelet dysfunction
         Oncology patients
Intra/perioperative conditions or significant bleeding
         Rapid blood loss exceeding >15% blood volume
         Intraoperative period as clinically determined by anesthesiology and/or surgeon
         Immediate postoperative period to restore hemodynamic stability
 
We have built an alert in Epic with our "Prepare RBC" orders (both in mL and in Units) that warns the provider whenever they are placing an RBC order on a patient with a most recent Hgb value > 7 g/dl (or there is no recent Hgb value in the computer on that patient).  This alert must be overridden with a reason from this drop down menu (below) in order for the provider to continue placing the order.  We can run a report on all transfusions that triggered an Override when the order was placed (that also lists out the trigger value, the override reason, and the patient's problem list) and then the medical director performs an appropriateness review on only those outliers.
BPA Overrides: RBC Orders (in mL) and (in Units):
Warning if: No Hgb result or Most recent Hgb > 7 g/dl
Appropriate criteria:
Neonate w/Cardiopulmonary Disease
Respiratory or Cardiac Failure
ECLS Patient
Sickle Cell Patient
Thalassemia Patient
Active Chemotherapy/Immunosuppressed Patient
Hematopoietic Disorder
Rapid Blood Loss
HOLD for Pre-Op/Procedure
Post-Op Hemodynamic Instability
Other – specify as Comment

Hi! We are planning to do KB testing for traumas as well. Do you report it as fetal cells positive or negative?

We still do K-Bs for trauma and such to determine if baby is bleeding into mom. No counts, just are there fetal cells or not.
We don't do them to determine RhIG dosage. For that we send positive screens to the local reference lab for flow.

I think we give the freshest blood because it is at its most effective for oxygen carrying capacity, since pH level may drop due to possible cell lysis during storage. We basically do the same thing as mentioned above by several people, except we also do HbS testing on the RBC unit. We want to give the freshest and best oxygen-carrying red cells to our neonatal patients in need.  

There is reason NOT to use the freshest possible units. They may be more toxic than intermediate stored units. This is something that made sense but was almost certainly wrong.  See below for the reasoning and published data.  We use <21 days as fresh for this reason and avoid <7 days storage for everyone based upon the randomized trial data.
BMJ 2019;366:l4968 doi: 10.1136/bmj.l4968 (Published 5 August 2019) Page 1 of 1
Letters
Trivella and colleagues present some caveats around the subject of duration of red cell storage and clinical outcomes.1 Studies have been widely interpreted as showing that transfusion is not associated with adverse clinical outcomes. I think this is a serious misinterpretation of the data.
In addition to the concerns raised by the authors, another valid hypothesis, which has received little attention, is that very short storage red cells might be more dangerous than medium storage periods (say 7-21 days) and equally dangerous as longer storage red cells (say 28-42 days). An inverted U shaped curve. The evidence for this comes from a meta-analysis finding that “ultra short” storage of red cells was associated with a post-transfusion increase in nosocomial infection.2 Shorter storage red cells have a greater imbalance of oxidation-reduction potential than longer storage red cells in preliminary studies in vitro.3 Red cell storage duration is also a poor predictor of post-transfusion free haemoglobin and heme, putative mediators of toxicity from transfusions.4 5
We need better metrics for predicting red cell transfusion efficacy and toxicity. The simple expedient of fresher red cells is clearly not that metric and might be leading us to transfuse more toxic red cells (very fresh) in the most fragile patients,
such as premature newborns. A new approach is clearly called for by the current data. At our centre we define fresh as <21 days of storage, and we generally never transfuse a red cell that has been stored for much less than 7-10 days, for the above reasons as well as logistics of supply.
Competing interests: None declared.
1 Trivella M, Stanworth SJ, Brunskill S, Dutton P, Altman DG. Can we be certain that storage duration of transfused red blood cells does not affect patient outcomes?BMJ 2019;365:l2320. 10.1136/bmj.l2320 31186250
2 Alexander PE, Barty R, Fei Y, etal . Transfusion of fresher vs older red blood cells in hospitalized patients: a systematic review and meta-analysis. Blood 2016;127:400-10. 10.1182/blood-2015-09-670950 26626995
3 Schmidt A, Gore E, Cholette JM, etal . Oxidation reduction potential (ORP) is predictive of complications following cardiac surgery in pediatric patients[abstract]. Transfusion 2016;56(Supplement S4):20A-1A.
4 Cholette JM, Pietropaoli AP, Henrichs KF, etal . Elevated free hemoglobin and decreased haptoglobin levels are associated with adverse clinical outcomes, unfavorable physiologic measures, and altered inflammatory markers in pediatric cardiac surgery patients. Transfusion 2018;58:1631-9. 10.1111/trf.14601 29603246
5 Pietropaoli AP, Henrichs KF, Cholette JM, etal . Total plasma heme concentration increases after red blood cell transfusion and predicts mortality in critically ill medical patients. Transfusion 2019;59:2007-15. 10.1111/trf.15218 30811035
Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/ permissions
LETTERS

Have an O neg, CPDA-1 or AS-3 irradiated unit (no mannitol) on hand and give it.  The fresher the better. - Could maybe set up some sort of standing order with your supplier for 1 fresh O neg AS-3 every 10 days so that you can rotate the older O neg into regular inventory and keep 1 fresh set aside for the off chance you'll need one?????

We do the same as David, issue the freshest O NEG unit we have, irradiated if fresh. We issue the whole unit of pack cells and nursing staff remove desired quantity to infuse and airlift is generally on their way to take the baby to Children's hospital. We transfuse about once every 10 years or so.

I agree. You do the best you can with what you have. Unless your blood supplier or a large neighbor who can transfer product is close by, you are not going to be able to ship in product in time. It is cost prohibitive for us to stock product routinely for an event that occurs very infrequently (and your blood supplier may not be very enthused about the constant rotation of product). 
We are 150+ beds, have a NICU, and are one of the 'large' hospitals in our rural area, but still transfer our critical neonates/kids to Children's 150 miles away. We only transfuse babies and small children 1 to 3 times over an average year. Our facility sees quite a few Onc patients, so I do stock a small inventory of irradiated products including 2 O neg Irrad on top of our normal O neg stock (if we can get O neg - fun times!). If we have time to crossmatch, we provide the freshest type specific unit (if we know mom's type) on the shelf, irradiated if requested and we have it in stock. If not, we provide the freshest O neg unit on the shelf, irradiated if requested and available. Children's gives LR as CMV neg equivalent, so that's the policy we follow. I don't stock syringes because we would outdate almost all of them and our software is not set up to split/label units. (It would be very rare for us to even have the possibility of pulling blood off that unit a second time, so not worth setting up.) We hand over the entire unit and the pediatrician/nurses pull what they need for transfusion in the 4 hours after issue.

I agree with David and his comments above.  We transfuse neonates very rarely as well.  Considering you are a small rural health center and will not be doing this routinely, you just have to do the best you can in an emergent situation.  We do keep neonatal syringe sets and most of them outdate.

We use either ABO identical or washed O red cells.  Usually volume reduced so the hematocrit is around 70-80% either by centrifugation or washing with Plasmalyte.  We have data that saline washing is likely associated with more hemolysis and metabolic acidosis.  Leukoreduced and <21 days old.
We prefer not to use the very short storage red cells (<7 days) as there is evidence they are more dangerous from randomized trials, albeit in mostly adult patients. 
We do not CMV test or test for hemoglobin S, except for exchange transfusions.  No evidence that hemoglobin S trait is a problem for transfusion in any situation, but particularly for smaller volume transfusions.
We do irradiate for newborns since immunodeficiencies, while very rare, are often not diagnosed until later in infancy or early childhood.

We are a 400ish bed hospital, but our NICU usually sends the really sick babies to nearby Children's Mercy.  We do not irradiate on site.  We would have to get them irradiated at the blood center and the docs usually don't want to wait.  I'm just trying to get information to adjust my policies since we ALWAYS have to get it out when a request comes through.
Do you aliquot the unit to a syringe or send the entire unit to the NICU?

We are the same. We get a fresh <7 day old unit shipped in weekly from our blood supplier, so there is always an option for a fresh unit. We don't transfuse a ton of neonates, but our policy is to provide freshest possible, CMV safe/leukoreduced and HgbS neg to all babies. Those who have a very low birthweight or other indications for irradiated products will also require irradiated. Since the unit we get weekly is irradiated, pretty much all babies get irradiated because it's the freshest we have.
We aliquot units to a syringe or bag, but in emergencies we will send the whole unit to the NICU if they can't wait. Same for platelet units. 

Hi everyone! I'm the transfusion service supervisor in a small remote hospital. Recently, we had a situation where an emergency neonatal transfusion was needed. The flight team was on its way and our Pediatric team was consulting with a neonatologist. Can you share emergency neonatal transfusion procedures that a small rural hospital could use? We are not planning to do this routinely but we want to be prepared if it happens again.

There are several layers to this question. First, you will need a fresh O negative, CMV-, irradiated prbc available rather quickly. We are not small but we only transfuse neonates about 3-4 times/year yet we receive a fresh unit every Monday to use for emergency transfusions. If it is non emergent (say for iatrogenic anemia), then we order from our supplier a fresh unit with satellite bags sterile docked so we can continue to use that unit for future transfusions on that baby. The goal here is to limit donor exposure. You may not need to worry about that if you do not have a high level NICU.
Are you aliquoting the unit into syringes? You will need a procedure and supplies for that. You need to meet with your Neonatologist and work out your logistics.
Those are just a few things to think about. I assume you already have policies and procedures in place for this.

If the unit if leukoreduced, as all red cell transfusions should be, there is no need for CMV negative in my view.  

We do not routinely transfuse neonates (have not done one here in 30 or so years).  We would give the freshest O= we have; irradiated if we have one.  We are 3 hrs from our blood supplier.  Chances are the infant will be transfused before we could receive appropriate products. 

Welcome