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4.2 Blood Transfusion Science > Pre/Neonatal and Infant Transfusion > Flashcards

Pre/Neonatal and Infant Transfusion Flashcards

1
Q

In general why do we need to be more careful with neonatal transfusion?

A

Neonates are a lot more unstable then adults

It is much easier to metabolically unbalance babies

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2
Q

How is a neonate defined

A

Infants up to 28 days post birth

However requirements for blood remain the same until over 1 year of life

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3
Q

What is the most common type of transfusion in neonates

A

Top-up transfusions most common especially in premature babies

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4
Q

Why is transfusion so common in neonates, especially premies?

A

Premies are born with less HbA then full term babies

HbF is converted to HbA at birth -> noticable drop in Hb before coming back up again as HbA is formed

Babies will often need a transfusion during this low Hb period

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5
Q

What is the significance when transfusion neonates?

A

They are our longest living survivors of a BT

Thus they are at risk of long-term consequences of transfusion i.e. symptoms of complication not until later in life

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6
Q

When transfusing neonates what considerations should always be made?

A

Every effort should be made to reduce transfusions

Reduce donor exposure as well hence split paedi packs from one donor

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7
Q

What donors are required for neonatal blood?

A

Donors must have previously donated blood in the past two years

Blood must be negative for all mandatory microbiology markers etc

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8
Q

What two main markers must neonatal blood be negative for?

A

Leucocyte depleted -> all components except granulocytes have to be LD

Cytomegalovirus -> CMV serology negative -> LD if in emergence and CMV - not available

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9
Q

Why can LD blood be used as a replacement for CMV- blood in an emergency?

A

CMV resides in leukocytes
therefore CMV- blood = LD blood
Therefore LD blood is considered CMV safe
As it is very unlikely to cause infection in immunocompetent or even in a baby

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10
Q

How do we crossmatch blood for babies, why is this?

A

Neonates up to 4 months old will have any blood crossmatched against the mothers plasma as it takes up until this point for babys immune system to kick in

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11
Q

What would be the four reasons why an IUT would be needed?

A

HDN
Parvovirus
Twin to Twin
FMH (severe)

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12
Q

What are some reasons why a neonatal top-up transfusion would be needed?

A

Anaemia of prematurity
Iatrogenic
ECMO: if baby requires cardiothoracic surgery etc -> causes haemolysis requiring top-up

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13
Q

Talk about parvovirus infection?

A

Infection from animals
It can cause aplastic anaemia in utero or in immunocompromised
Hence need for IUT

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14
Q

What is meant by Iatrogenic

A

This means caused by a doctor i.e. a clinician taking to many blood samples from a baby with a tiny blood volume

1ml + 1ml + 1ml etc all add up and can make baby anaemia and thus requiring a transfusion

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15
Q

What Hb do we try to maintain in neonates

A

Try to keep Hb above 12 or 10
-> try to maintain high Hb thats seen at birth

Hb will drop to 8.5 after a few weeks

Changing physiology of newborns - hence need for strict criteria for transfusion

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16
Q

What pre-transfusion testing is done

A

Group and screen on maternal plasma

ABO and Rh forward group on infant sample

DAT on infant red cells

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17
Q

What should you do if no maternal serum is available to do reverse grouping?

A

Screen infants serum for atypical antibodies used an indirect antiglobulin technique

NB: you probably wont have enough though as you only get 1ml of whole blood

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18
Q

What kind of crossmatching is done if no atypical antibodies are present and the DAT of infant is negative?

A

No cross-matching is necessary for first 4 months of life

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19
Q

Why do we see many DAT positives in labs today?

A

Due to RADP
Probably not HDFN but have to be investigated anyways

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20
Q

what are the four main considerations that have to be applied to blood components for neonates?

A

Smaller blood volume
Reduced metabolic capacity
Higher haematocrit due to HbF
Immature immunological system

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21
Q

What is the estimated blood volume of a newborn?

A

80-85ml/kg of body weight

Normally a baby is 3-4 kilos
Premie is 2 kilos

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22
Q

What two things can be toxic to a baby?

A

Mannitol and potassium

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23
Q

What might cause hypocalcaemia in babies?

A

Citrate in preservatives

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24
Q

Baby’s have an immature immune system, why is this an important consideration?

A

This can put baby at risk of graft versus host disease whereby donor cells can take over bone marrow especially in pre-mature babies etc

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25
Why dont we irradiate all blood?
This shortens the shelf life due to potassium leakage
26
How do we avoid potassium leakage in blood for babies?
We use fresh blood which is less than 5 days old
27
give an example of where a baby will have to go for ecmo?
If baby is born with heart valve issues
28
What is a babys blood volume per kg?
10-20mls per kg
29
How old is the blood used for paedi packs?
First unit transfused must be less than 5 days old Sequential units can be 7, 10, 35 days old etc
30
What temperature blood is used for neonatal transfusion, why is this?
All blood must be prewarmed Babies cannot control their body temperature Cold blood would result in hypothermia and therefore acidosis
31
What additive is found in paedi packs and why?
CPD is used and not SAGM This is because Mannitol in SAGM is toxic -> nephrotoxic -> adults can deal with this in small quantities but small baby kidneys cannot Adults can also produce allergic reactions to this
32
What neonatal units must be irradiated?
Exchange or intrauterine transfusions If baby requires an IUT and a following top up transfusion then both units will be irradiated If only a top up required then blood does not need to be irradiated
33
What is one method of increasing haemoglobin in a newborn which is done by the clinicians at birth
Delayed cord clamping The umbilical cord is raised so as to let any cord blood flow back into the newborn Hb will increase
34
What are the ten risks when transfusing a neonate?
Graft vs Host disease Cytomegalovirus transmission Bacterial infection Volume overload Citrate toxicity Rebound hypoglycaemia Hypothermia Thrombocytopenia after exchange transfusion Manitol toxicity Hyperkalaemia
35
Talk about the tragic case study whereby platelets were not irradiated for a baby
Mother experiencing NAIT Mother had anti-HPA1a antibodies Platelets were taken from mother and irradiated and given to baby However irradiation was not done correctly HLA was only half matched - most severe Baby died 3 weeks later
36
When would is be dangerous to give a neonate plasma?
If the neonate or young child has necrotising enterocolitis T and Tn antigens will be exposed and antibodies will be present in plasma
37
Talk about overload in neonates
TACO Babies are actually more tolerant to this than elderly and we see less reports in this cohort But it is likely to happen due to small volume
38
What metobolic affects can cause cardiac arrythmia in neonates
Hypocalcaemia Magnesium
39
Talk about hypoglycaemia in neonates
Sugar present in CPD preservative This sugar will cause an insulin release Baby will then become hypoglycaemia after the transfusion
40
Talk about hyperkalaemia in neonates
High potassium Seen if old blood is used Reports of fatalities due to this
41
How are paedi packs made and why is this done
Made using multiple satellite bag systems Whereby a single red cell unit is divided into multiple splits This minimises exposure e.g. 5 splits from one donor Mimimises risk of infection
42
When is hypothermia most seen in neonatal transfusion?
Exchange transfusion especially large exchanges
43
Talk about hypothermia in neonates, why does it occur
Carried out if baby experiencing hyperbilirubinaemia Blood must be pre-warmed to prevent hypothermia If cold or even room temp blood is used babies experience increased metabolic rate, hypoglycaemia, acidosis, apnoeic episodes and eventually cardiac arrest
44
What temperature decrease would you see if rt blood transfused into a neonate?
0.7 to 2.5 degree drop
45
Effects of hypothermia on a neonate
Increased metabolic rate Hypoglycaemia Acidosis Apnoeic episodes Cardiac arrest
46
Talk about mannitol toxicity in neonates
If SAGM units used in high volume toxicity occurs -> wont occur if only for top up Nephrotoxic
47
How does mannitol work as an additive
It prevents rbc haemolysis
48
Talk about hyperkalaemia in neonates
Potassium load of a unit above acceptable limits Cardiac affects etc
49
What is the new method ebing looked at at preventing K+ leakage in paedipacks
In America theyre looking at using XRAY irradiation to reduce K+ leakage as seen from gamma irradiation Gamma irradiation has to be done in IBTS -> time then for leakage to occur before transfusion But with XRAY it can be done on the day of the procedure thus minimal leakage is seen
50
What is the acceptable amount of K+ for neonates
Less than 10 mmol But normally we use 3-5mmol/L (normal for baby) This K+ increases linearly in packs
51
What does hyperkalaemia induce?
Cardiac arrest
52
What are the three red cell products available for neonates
Rbcs in SAGM, LD, split into 5 units Partially packed rbcs or whole blood, LD in CPD -> for neonatal exchange Red cells high in Hct LD in CPDA for use in IUT and exchange
53
How many mls per split?
50mls
54
How are packed rbcs for exchange made?
Squeeze of the plasma
55
What are the requirements for a rbc unit for IUT
O-, Kell neg, lacking implicated rbc antigen IAT crossmatch compatible with mother HCT up to 0.7 or 0.85 CPD Less than 5 days old CMV negative Irradiated less than 24 hours ago HbS negative Pre-warmed
56
What is the required Hct of a rbc unit for an IUT
0.7->0.85
57
What needs to be remebered when treating a neonate who has had a previous IUT
Any blood or platelets now needed will need to be irradiated At 8 weeks the neonate will often have a hyporegenerative anaemia and will often require a top up (irradiated)
58
What are the requirements of a rbc unit for a small volume top up transfusion
Must be ABO compatible with mother and infant IAT compatible with mother or if available the neonates (4 months +) SAGM 35 days or CPDA less than 28 days 1 unit must be less than 5 days old Hct 0.5-0.7 Transfuse 10-20ml/kg over 2-4 hours Dedicate one paedipack to a patient (5 splits) Irradiate if appropriate i.e. if IUT
59
Compare the shelf life of SAGM vs CPD
SAGM 35 days or CPDA less than 28 days
60
What methods are in place now to limit the need for a neonatal rbc transfusion?
Clinicians limit the number of blood samples they take Delayed cord clamping Guidelines implemented Maximimse nutritional status iron folate Training of staff in phlebotomy - prevents need for re-draw etc Regular audits Erythropoietin - limited use though as it takes too long for effects
61
Talk about the requirements of a partially packed neonatal exchange rbc unit
O-, lacking implicated rbc antigen crossmatch with maternal plasma Hct: 0.5-0.55 (UK) or o.4 to 0.5 (AABB) CPDA or reconstitute <5 days CMV negative Irradiated and transfused within 24 hours HbS negative Pre-warmed
62
What are the leading causes of death in neonatal transfusions
Single haplotype match and non-irradiated platelets
63
How does LD affect risk of TA-GVHD
Universal LD has greatly reduced TA-GVHD Removes 3-4 logs total wbcs Removes 3.5 logs CD3+ cells LD will not prevent GVHD in the immunodeficient individuals e.g. bone marrow patients but it has been sufficient in doing so in all other cohorta
64
What are the four different platelet products available for neonates
Apheresis platelets NAIT In utero transfusion Hyperconcentrate of platelets
65
Talk about apheresis platelets for neonates
A single apheresis donation is split into either two or three donations One one donor exposed
66
Talk about platelet transfusions for NAIT, what anitbodies are most commonly causative
Usually HPA-1a (80-90% of cases) antibodies involved HPA-5b negative platelets also a common need for IUT
67
When might in utero transfusion of platelets be needed
Can be used for NAIT Often uses hyperconcentrate of platelets Weekly transfusions of selected platelets given in utero to minimise risk of bleeding associated with foetal blood sampling
68
What is the conc of platelets in hyperconcentrate
120 x 10^9 platelets in 60mls plasma
69
What are the requirements of all neonatal platelets
CMV - Irradiated
70
When can ABO incompatible platelets be used for neonates?
If not high titre antibodies Can also remove plasma supernatant and resuspend in saline or PAS -> IBTS looking to do this for apheresis platelets as at the moment only are pooled platelets are suspended in PAS and these arent suitable for neonates
71
What are the three plasma products available to neonates?
AB Octaplas LG in Ireland Group AB FFP or same ABO group as infant -> UK Group AB FFP with low titre anti-T => only in UK NB: both UK products can be from either whole blood donors or apheresis donors
72
How is plasma treated in the UK
Methylene blue to pathogen inactive the plasma
73
What is Octaplas
A blend of A, B and AB plasmas with low titre antibodies intended for use as a universal plasma but used by the IBTS primarily for issue to AB patients
74
What percentage of neonates will receive Octaplas
Less than 0.3%
75
Why might a neonate need octaplas
To increase clotting times in preterm infants in DIC where PT/APTT ratio >1.5 and neonate is at significant risk of bleeding If undergoing an invasive procedure Inherited coag factor deficiencies without available concentrates e.g. FV deficiency
76
When should a neonate not be given octaplas, what is not an indicator for use>
A volume replacment If coag factor recombinant product is available
77
Talk about cryoprecipitate for neonates
Group AB cryoprecipitate used to be used Used to make single units of approximately 20 mls Fibrinogen concentrate is used instead today UK still uses cryo
78
What are the requirements of a neonatal donor
Must have donated and tested negative for all mandatory virology markers in the past 2 yeats Donors should not have had a transfusion Donors should not have an antibody DCT negative C- and E- if RhD- K- CMV antibody negative HbS negative
79
What labelling requirements are there for neonatal units
>5days old Filtered within 24 hours of donation Negative haemolysin if group O CMV Ab negative K negative Leucodepleted HbS negative
80
When is Irradiation a requirement
IUT Exchange transfusion Top up after IUT First or second degree relative or HLA matched donor Proven or suspected immunodeficiency Platelet IUT Post platelet or rbc IUT Allogeneic stem cell transplant Hodkgins disease/NHL/leaukaemia
81
How does irradiation affect potassium
Doubles potassium Decreases shelf life to 14 days
82

4.2 Blood Transfusion Science (21 decks)

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