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

Pre/Neonatal and Infant Transfusion Flashcards

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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
Q

Why dont we irradiate all blood?

A

This shortens the shelf life due to potassium leakage

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26
Q

How do we avoid potassium leakage in blood for babies?

A

We use fresh blood which is less than 5 days old

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27
Q

give an example of where a baby will have to go for ecmo?

A

If baby is born with heart valve issues

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28
Q

What is a babys blood volume per kg?

A

10-20mls per kg

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29
Q

How old is the blood used for paedi packs?

A

First unit transfused must be less than 5 days old

Sequential units can be 7, 10, 35 days old etc

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30
Q

What temperature blood is used for neonatal transfusion, why is this?

A

All blood must be prewarmed

Babies cannot control their body temperature

Cold blood would result in hypothermia and therefore acidosis

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31
Q

What additive is found in paedi packs and why?

A

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

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32
Q

What neonatal units must be irradiated?

A

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

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33
Q

What is one method of increasing haemoglobin in a newborn which is done by the clinicians at birth

A

Delayed cord clamping

The umbilical cord is raised so as to let any cord blood flow back into the newborn

Hb will increase

34
Q

What are the ten risks when transfusing a neonate?

A

Graft vs Host disease
Cytomegalovirus transmission
Bacterial infection
Volume overload
Citrate toxicity
Rebound hypoglycaemia
Hypothermia
Thrombocytopenia after exchange transfusion
Manitol toxicity
Hyperkalaemia

35
Q

Talk about the tragic case study whereby platelets were not irradiated for a baby

A

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
Q

When would is be dangerous to give a neonate plasma?

A

If the neonate or young child has necrotising enterocolitis

T and Tn antigens will be exposed and antibodies will be present in plasma

37
Q

Talk about overload in neonates

A

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
Q

What metobolic affects can cause cardiac arrythmia in neonates

A

Hypocalcaemia
Magnesium

39
Q

Talk about hypoglycaemia in neonates

A

Sugar present in CPD preservative

This sugar will cause an insulin release

Baby will then become hypoglycaemia after the transfusion

40
Q

Talk about hyperkalaemia in neonates

A

High potassium

Seen if old blood is used

Reports of fatalities due to this

41
Q

How are paedi packs made and why is this done

A

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
Q

When is hypothermia most seen in neonatal transfusion?

A

Exchange transfusion

especially large exchanges

43
Q

Talk about hypothermia in neonates, why does it occur

A

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
Q

What temperature decrease would you see if rt blood transfused into a neonate?

A

0.7 to 2.5 degree drop

45
Q

Effects of hypothermia on a neonate

A

Increased metabolic rate
Hypoglycaemia
Acidosis
Apnoeic episodes
Cardiac arrest

46
Q

Talk about mannitol toxicity in neonates

A

If SAGM units used in high volume toxicity occurs -> wont occur if only for top up

Nephrotoxic

47
Q

How does mannitol work as an additive

A

It prevents rbc haemolysis

48
Q

Talk about hyperkalaemia in neonates

A

Potassium load of a unit above acceptable limits

Cardiac affects etc

49
Q

What is the new method ebing looked at at preventing K+ leakage in paedipacks

A

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
Q

What is the acceptable amount of K+ for neonates

A

Less than 10 mmol

But normally we use 3-5mmol/L (normal for baby)

This K+ increases linearly in packs

51
Q

What does hyperkalaemia induce?

A

Cardiac arrest

52
Q

What are the three red cell products available for neonates

A

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
Q

How many mls per split?

A

50mls

54
Q

How are packed rbcs for exchange made?

A

Squeeze of the plasma

55
Q

What are the requirements for a rbc unit for IUT

A

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
Q

What is the required Hct of a rbc unit for an IUT

A

0.7->0.85

57
Q

What needs to be remebered when treating a neonate who has had a previous IUT

A

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
Q

What are the requirements of a rbc unit for a small volume top up transfusion

A

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
Q

Compare the shelf life of SAGM vs CPD

A

SAGM 35 days or CPDA less than 28 days

60
Q

What methods are in place now to limit the need for a neonatal rbc transfusion?

A

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
Q

Talk about the requirements of a partially packed neonatal exchange rbc unit

A

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
Q

What are the leading causes of death in neonatal transfusions

A

Single haplotype match and non-irradiated platelets

63
Q

How does LD affect risk of TA-GVHD

A

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
Q

What are the four different platelet products available for neonates

A

Apheresis platelets

NAIT

In utero transfusion

Hyperconcentrate of platelets

65
Q

Talk about apheresis platelets for neonates

A

A single apheresis donation is split into either two or three donations

One one donor exposed

66
Q

Talk about platelet transfusions for NAIT, what anitbodies are most commonly causative

A

Usually HPA-1a (80-90% of cases) antibodies involved

HPA-5b negative platelets also a common need for IUT

67
Q

When might in utero transfusion of platelets be needed

A

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
Q

What is the conc of platelets in hyperconcentrate

A

120 x 10^9 platelets in 60mls plasma

69
Q

What are the requirements of all neonatal platelets

A

CMV -

Irradiated

70
Q

When can ABO incompatible platelets be used for neonates?

A

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
Q

What are the three plasma products available to neonates?

A

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
Q

How is plasma treated in the UK

A

Methylene blue to pathogen inactive the plasma

73
Q

What is Octaplas

A

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
Q

What percentage of neonates will receive Octaplas

A

Less than 0.3%

75
Q

Why might a neonate need octaplas

A

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
Q

When should a neonate not be given octaplas, what is not an indicator for use>

A

A volume replacment

If coag factor recombinant product is available

77
Q

Talk about cryoprecipitate for neonates

A

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
Q

What are the requirements of a neonatal donor

A

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
Q

What labelling requirements are there for neonatal units

A

> 5days old
Filtered within 24 hours of donation
Negative haemolysin if group O
CMV Ab negative
K negative
Leucodepleted
HbS negative

80
Q

When is Irradiation a requirement

A

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
Q

How does irradiation affect potassium

A

Doubles potassium
Decreases shelf life to 14 days

82
Q
A

4.2 Blood Transfusion Science (13 decks)

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