Neonatal transfusion guideline

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Objectives

Guidance on the appropriate use of blood and blood components for neonates

Audience

This guideline is applicable to all medical, nursing and midwifery staff working with neonates in the West of Scotland.   Staff should also be familiar with the appropriate pharmacy monographs.  It is a requirement for all staff involved in the ordering or administration of blood components to complete, as a minimum, Module 1 of the online training package “Safe Transfusion Practice for Paediatrics” available at https://nhs.learnprouk.com/

General principles

Whilst frequently life saving, the administration of blood and blood components is not without risks. There is a small but real risk of transmission of blood borne infections, there is a risk of significant morbidity if the wrong blood product is administered and, in addition, the large volumes administered have the potential to cause fluid overload and heart failure. There are a number of general principles which should always be followed when using blood or blood components.

  • Only use blood components when they are clearly indicated.
  • Take steps to minimise donor exposure.
  • Take great care when checking blood components before administration.
  • Closely monitor the patient during administration of blood components.
Blood samples required for group and crossmatch

Before first transfusion

  • Maternal blood sample (if available)
    • Maternal ABO and RhD group
    • Screen for the presence of atypical red cell antibodies
  • Neonatal blood sample 
    • Neonatal ABO and RhD group
    • Direct Antiglobulin test (DAT) on the neonate’s red cells
    • If no maternal sample available, screen infant’s serum  for atypical antibodies by an Indirect Antiglobulin Technique (IAT)

Before subsequent transfusions

Additional "cross-match" specimens are not routinely required for subsequent transfusions. However, they are required for:

  1. Exchange transfusion
  2. All further transfusions after any large volume transfusion (50ml/kg or greater)
  3. Transfusions of infants > 16 weeks
Irradiation of blood and platelets

Please note that irradiation of blood or platelets is rarely necessary and significantly reduces the shelf life of blood once performed.  However, there are a small number of specific indications when irradiation of blood and platelets should be requested to eliminate the risk of Graft Versus Host Disease (GVHD). If you are in any doubt, seek the opinion of a senior neonatologist before requesting an irradiated product

Red cell and Platelet components should be irradiated in the following circumstances:-

  • Intrauterine transfusion,
  • Exchange transfusion after Intrauterine transfusion
  • Top-up transfusion after Intrauterine transfusion of platelets or red cells
  • Exchange transfusion in VLBW infants (<1500g), and preferable for all exchange transfusions
  • Transfusion of blood components from a 1st or 2nd degree relative.
  • Proven or suspected congenital, T- cell related, immunodeficiency
    • Severe Combined Immune Deficiency SCID – may present with persistent (every FBC) lymphopaenia <2 x 109/L
    • Wiskott Aldrich Syndrome – may present with thrombocytopaenia and eczema
    • 22q.11 deletions (Di George) – may present with heart defects, absent thymus, or hypocalcaemia

N.B. Irradiation of blood components will be performed at the Scottish National Blood transfusion Service SNBTS. A complete pack will be irradiated and this pack will subsequently be divided into four aliquots (paedipacks) if required for small-volume transfusions.

Irradiated blood "leaks" potassium during storage, and should therefore be used within 14 days for "top-up" transfusions and within 24 hours for exchange transfusions. In cases of established hyperkalaemia a fresh unit of blood should be requested if the existing pack has previously been irradiated.

In view of the significantly reduced shelf life it is important to avoid unnecessary irradiation of blood components as this will waste blood and increase donor exposure.

Emergency blood transfusion

If blood is required in an emergency, e.g. blood loss at delivery, O RhD -ve blood should be used. A blood grouping sample should be taken from the baby prior to emergency transfusion

1 unit (In some hospitals this may be divided into 4 Paedipacks) of O RhD -ve, leucodepleted, CMV and Hepatitis E -ve blood is available for emergency paediatric use in the satellite blood fridge, the locations are site specific:

Local Arrangements

PRM – In the corridor outside the obstetric theatres 

RHC – In the blood gas room in labour ward

RAH – In Labour ward

Where Bloodtrack is used the blood will need to be collected by a staff member trained in the Bloodtrack system. A member of labour ward staff may be asked to collect the blood for you if required in these circumstances. The emergency button is pressed, the fridge will open & the unit can be removed & scanned.

Where Bloodtrack is not used staff should use local procedures for the retrieval of emergency blood packs

Take care to avoid taking units for emergency adult use or specific patients

The paediatric packs will be labelled:

FOR PAEDIATRIC USE ONLY
UNMATCHED BLOOD - FOR EMERGENCY USE ONLY
DO NOT INFUSE PRIOR TO OBTAINING A BLOOD SAMPLE FROM THE BABY
FILL IN THE PATIENT NAME, DATE OF BIRTH AND HOSPITAL NUMBER ON THE BLUE TRACEABILITY LABEL AS SOON AS POSSIBLE
INFORM BLOOD BANK

After use
The pack label should be placed in the infant’s case-notes.

The blue traceability label should be filled in.
Blood bank should be informed to allow prompt replacement.

NB - In units where the emergency blood is divided into Paedipacks, the unused packs may be retained by blood bank should the infant require further transfusions.

If the volume infused is large a further cross match sample may be required.

Packed Red Cells – “top-up” transfusions

Anaemia in the neonatal patient is frequently due to a combination of blood loss to phlebotomy and inefficient erythropoiesis, although a smaller number of patients will have anaemia due to other causes of blood loss. The need for “top-up” transfusions increases inversely with the size and gestation of the patient due to the smaller circulating blood volume.  Despite efforts to minimise the need for transfusion, most babies under 28 weeks will have a degree of anaemia and many will require transfusion.

Reducing the need for blood transfusions.

  • Delayed cord clamping: Delayed cord clamping reduces the requirement for subsequent blood transfusion along with other benefits. Staff should refer to the WoS Guideline “Delayed Cord Clamping” for further information.
  • Avoid unnecessary phlebotomy losses: Please take note of the routine investigation guidelines and the blood sampling guidelines in your local unit to ensure that only essential investigations are performed and the minimum volume of blood required for the tests is withdrawn from each patient. Consider whether an investigation is required or whether trends can be monitored on the blood gases (eg Na/Hct)
  • Conservative transfusion practice: Conservative transfusion practices have been shown to be well tolerated and to reduce transfusion events and donor exposures. The following transfusion triggers/thresholds are designed to encourage conservative transfusion practices and are guidelines only! Some very sick/septic infants will require transfusion at higher Hb concentrations; such infants require discussion with a consultant.
  • There is no indication for transfusion to replace phlebotomy losses alone.

Transfusion Triggers for preterm neonates <32 weeks (From BCSH Guideline)

Note – these thresholds are for guidance only, and are intended to encourage conservative transfusion practices.  Transfusion decisions should be taken on an individual clinical basis.

Postnatal Age

Suggested Transfusion threshold Hb (g/l)

Ventilated

On Oxygen, CPAP or High Flow

Off Oxygen and respiratory support

Day 1 (1st 24h)

<120

<120

<100

Day 2-7 (1st Week)

<120

<100

<100

Day 8-14 (2nd Week)

<100

<95

<75

Day15 Onwards

<100

<85

<75


Unit characteristics:

  • Packed cells are supplied in additive solution (SAG-M red cells) with a haematocrit of 0.5–0.7.
  • Where possible, Paedipacks (70ml aliquots) should be used allowing up to 4 transfusions from a single donation. Paedipacks from the same unit may be given for the shelf life of 35 days however this is reduced to 14 days if irradiated.
  • All units selected for neonatal use are CMV and Hepatitis E negative
  • All red cell products for babies are leucodepleted

Volume for transfusion: For neonatal patients this must be calculated in mls/kg and prescribed as the number of mls to be infused.

  • Stable Infant - 20ml/kg to be administered within 4 hours of removal from refrigerator. (Realistically, transfuse over 3.5hours).
  • Additional risk factors – Larger volumes or repeated transfusions may be required in the following infants. Due to high risks of morbidity in such infants, including the risks of fluid volume overload from large volume transfusions, such patient require discussion with the neonatal consultant
    • Ongoing blood loss
    • DIC

Irradiation  - NB this is infrequently required

Please see advice on irradiation – if in doubt consult a senior neonatologist before requesting irradiated packed cells as this will reduce the shelf life of the remaining paedipacks and increase the risk of additional donor exposure

Administration:

  • The blood must be administered within 4 hours of removal from the fridge. It is therefore important to ensure the patient has a working cannula available for the transfusion before requesting blood to avoid unnecessary delays.
  • There is no need for routine furosemide cover for small volume transfusions unless there are existing signs of heart failure.
  • The practitioner must prescribe the total volume in millilitres and the duration of blood transfusion on a Blood Component Prescription Chart (see appendix)
  • Patient and blood component details must be checked at the cot side, crosschecking the patient details with the baby’s name band. (patient name, hospital number, blood component unit number, blood group and expiry date)
  • The sticker from the blood component must be placed on the Blood Component Prescription Chart, the volume administered recorded & signed & the chart should be filed in the infant’s casenotes.
  • Observations (temp, HR and RR) must be recorded during the infusion.
  • The remainder of the component must be kept until the infusion is complete in case of a transfusion reaction.
  • The blue traceability label should be completed with patient details & returned to blood bank. This is audited monthly.
  • Note – some departments advocate the cessation of feeds for the duration of the transfusion in the belief that this may reduce the incidence of transfusion related NEC. However this practice is unproven and does not form part of this guidance. Please refer to local policy.

Transfusion and necrotising enterocolitis (NEC): Infants with NEC may occasionally be systemically infected with neuraminidase-producing organisms, such as the Clostridium species. Neuraminidase can strip residues from red cells exposing the T-antigen and increasing the risk of haemolysis. This is known as "T-antigen activation". There is currently no evidence to support routine testing on infants suspected of NEC. National guidelines based on the best evidence suggest screening only for T activation in an infant who develops haemolysis following a blood component transfusion, and as part of a haemolysis screen (i.e. Coombs test, blood film, reticulocyte count, serum bilirubin, as well as G6PD and pyruvate kinase concentrations-liaise with haematology and see separate guideline).

Exchange Transfusion (ET)

Transfusion Triggers:

Exchange transfusion is required in infants with severe Haemolytic Disease due to blood group incompatibilities or G6PD deficiency.  It is used in these infants to manage severe anaemia at birth Hb <100 g/l, or to treat severe hyperbilirubinaemia which is not controlled by phototherapy and, where appropriate, immunoglobulin therapy. 

The decision to exchange will be made by a consultant but usually is required if the bilirubin exceeds, or is anticipated to exceed, the exchange transfusion cut-off on a gestation appropriate phototherapy chart – see separate guideline

Unit Characteristics:

Plasma-reduced ("partially packed") red cells with a haematocrit of 0.5-0.6 are suitable for ET for both hyper-bilirubinaemia and severe anaemia, this should be the only product used for ET. These units should be less than 5 days old. Irradiation is required for VLBW babies and advised for larger babies.

Sourcing and cross-matching appropriate units may take some time and requirements must be discussed with blood bank as soon as ET is anticipated. In the case of known, severe haemolysis in-utero, blood will need to be ordered before delivery. This requires liaison with obstetric staff  - see separate guidance for the management of the mother with irregular antibodies.

Volume to be exchanged: Twice the circulating blood volume (80 x 2 = 160ml/kg).  Using a double-volume exchange is more effective at removing maternal antibody from the baby’s circulation although even this volume does not remove all the antibody.

Technique: ET may be performed either via a single umbilical venous line or by using a UAC and a UVC combined (blood is withdrawn using the arterial line and replaced via the venous line). Umbilical lines should be placed and position confirmed by x-ray as per WoS policy.

  • ET is a sterile procedure.
  • Pre ET check FBC, Coagulation, U+E, Ca, Glucose, SBR and blood gas.
  • A blood warmer should be used.
  • Each aliquot should be approximately 8ml/kg, indeed initial aliquots may be of smaller volume until it is clear the procedure is well tolerated.
  • Each aliquot should be removed and replaced over a 5 minute cycle. Always commence an ET by removing an aliquot of blood. Each aliquot removed and replaced should be timed by the neonatal nurse assisting with ET and recorded on a standard ET recording chart (see appendix).
  • The ET should take ~2 hours (longer if poorly tolerated and smaller aliquots are required).
  • Blood glucose monitoring is required after every 4 cycles.

Post Transfusion management :

  • Repeat the bloods taken prior to the exchange - FBC, Coagulation, U+E, Ca, Glc, SBR & gas.
  • Continue phototherapy
  • Continue to monitor serum bilirubin concentrations 4 hourly as a rebound hyperbilirubinaemia often occurs.
  • While these babies have evidence of haemolysis they should receive folic acid supplementation

Immunoglobulin therapy for Alloimmune Haemolysis 

A Cochrane review by Alcock et al. in 2009, indicated that significantly fewer infants treated with intravenous immunoglobulin (IVIG) required Exchange Transfusion (ET), relative risk 0.28 (CI 0.17-0.47). The number needed to treat in order to prevent one ET was 2.7 (CI 2.0-3.8). This result was based on a relatively small number of patients but goes some way to support the use of IVIG in infants with Alloimmune Haemolytic Disease of the Newborn (HDN) in whom the Serum Bilirubin (SBR) continues to rise despite appropriately administered phototherapy – see separate guidelines for the management of jaundice.

Dose: 500mg/kg Intravenous Immunoglobulin given by infusion over 4h.  The dose may be repeated once after 48h if required.  

Supply: Immunoglobulin is ordered via pharmacy using an Immunoglobulin request form – see appendix of the pharmacy monograph for Immunoglobulin.

Emergency Supplies: A small number of units are kept locally within the neonatal units and in the emergency drug cupboards.  See local details below

Local Arrangements

PRM   

  • 2x vials in the neonatal unit
  • Further vials available in A&E and in the emergency drug cupboard in GRI. The latter may be accessed by paging the hospital coordinator via switchboard.

RHC

  • Vials are kept in the neonatal unit
  • Further supplies are available via pharmacy

RAH  

  • Vials are kept in the neonatal unit
  • Further supplies are available via pharmacy

 

 

 


Fresh Frozen Plasma (FFP)

Disorders of coagulation are a common problem in the neonatal intensive care. 

Very immature infants have low levels of most clotting factors and may have prolonged clotting times. However, correction of these prolonged clotting times using FFP, in the absence of clinically significant bleeding, has not been shown to reduce the risk of IVH.  Therefore, routine estimation of coagulation in otherwise well preterm infants is not recommended.

Other infants have acquired coagulopathies secondary to sepsis, NEC or asphyxia. 

NB See separate advice for inherited disorders of coagulation.

Who should have a coagulation screen performed:

Coagulation screens should be performed in the following situations.

  • Hypoxic Ischaemic Encephalopathy (HIE) – See Cooling Guideline
  • Pre exchange transfusion – see Exchange Transfusion Section above
  • Clinical indications e.g.
    • Bruising/bleeding tendencies
    • Thrombocytopenia
    • Sepsis / NEC

NB – Coagulation results will be unreliable if samples are taken from a heparinised line even if a large volume of dead space has been aspirated.  Samples should be taken by Venepuncture or from a line which has not been flushed with heparin

Transfusion triggers

  • All neonates in the above groups – APTT > 75 s 

Unit Characteristics

  • A single unit of FFP will contain around 230 ml
  • FFP is subjected to virus inactivation using photo-inactivation with white light in the presence of methylene blue (MB FFP).
  • CMV negative units are usually selected for use in neonates. However as FFP is leucodepleted, CMV positive units may be used if there are no available CMV –ve units.
  • Hepatitis E negative units are selected

Volume required: 15 – 20 ml/kg FFP over 30 minutes
N.B. Platelet packs have a large coagulation factor component. If platelets and FFP are both required, BTS recommend giving platelets first, at a slightly increased dose (20ml/kg), then reassessing coagulation before using FFP. This may minimise volume overload (by negating the need for FFP)

Repeat coagulation screen following administration of FFP to assess further need for blood components

Cryoprecipitate

Transfusion triggers:

Cryoprecipitate is prepared from a unit of FFP and has a higher concentration of FVIII, VWF, FXIII, fibronectin and fibrinogen than FFP.  It is not a straightforward, more concentrated, alternative to FFP.  It is therefore used for infants with a severe coagulopathy with low Fibrinogen levels (<1g/l) despite administration of platelets and/or FFP.

Approval is required from on-call haematologist.

Unit Characteristics:

  • A pack contains about 20-40ml

Volume for transfusion:

  • Stable patient – 5 – 10 ml/kg over 30 mins.
    FFP and cryoprecipitate can be given in the same line if required.
  • Acute haemorrhage – where haemorrhage is not controlled using standard doses, additional aliquots of FFP and Cryoprecipitate may be given under the direction of a consultant neonatologist
Platelets

Thrombocytopenia is common issue in the neonatal unit affecting as many as 22% of NICU admissions in one study.  Causes of thrombocytopenia can be classified into disorders of increased destruction, increased consumption, or decreased production. However, despite its frequency, there is currently very little evidence from which to gauge optimal management in neonatal patients.

NB – Platelet clumping in a FBC sample can give a false diagnosis of thrombocytopaenia especially when taken from a poorly flowing capillary specimen.  This is often identified by the laboratory but if there remains any doubt a further sample should be taken to confirm the diagnosis before treatment is commenced.

Transfusion triggers:  

  • All Patients - Platelet count < 25 x 109/l
    Stable platelet counts above 25 x 109/l in an otherwise well patient are usually well tolerated and are not associated with spontaneous haemorrhage. These patients require regular monitoring of the platelet count. THIS INCLUES NEONATES WITH NO BLEEDING (ALSO INCLUDES NEONATES WITH NAIT IF NO BLEEDING AND NO FAMILY HISTORY OF INTRACRANIAL HAEMORRHAGE)
    In some patients with persistent thrombocytopaenia, refractory to treatment, platelet counts as low as 10 x 109/l may be tolerated – requires consultant approval

  • Patients with additional risk factors – Platelet count < 50 x 109/l
    • Active bleeding. NB. unless the diagnosis is known, investigation is required to rule out other disorders of coagulation, especially Disseminated Intravascular Coagulation (DIC). Send a sample for coagulation prior to platelet transfusion.  
    • Before invasive procedures e.g. LP, SPA or insertion of central line
    • Infants < 32 weeks gestation who are <7 days old, due to the risk of IVH.
    • Acute thrombocytopenia of any cause
    • INFANTS WITH NAIT IF PREVIOUSLY AFFETED SIBLING WITH INTRANCRANIAL HAEMORRHAGE
  • Patients with major bleeding or requiring major surgery g. neurosurgery – platelet count <100

Units characteristics:

  • Platelets are supplied as CMV and hepatitis E negative packs
  • Platelet packs are leucocyte depleted by filtration
  • Platelets are supplied which are free of clinically significant irregular antibodies
  • Labelled ‘platelets for neonatal use’
  • There are two types of pack available for use
  1. Pooled donor packs
    1. Pooled donor packs are prepared from 4 blood donations
    2. The volume of each pack will be approximately 310ml
  2. Apheresis packs
    1. Apheresis units are prepared from a single donor and are the preferred type of unit, when available, for this reason.
    2. The packs are of larger volume and may be separated into 4 smaller paediatric units if repeated transfusions of the same patient are anticipated.

Volume for transfusion: For neonatal patients this must be calculated in mls/kg and prescribed as the number of mls to be infused.

  • Stable infant – 15 – 20 ml/kg over 30 minutes
  • Additional risk factors – Larger volumes or repeated transfusions may be required in the following infants.  Due to high risks of morbidity in such infants, including the risks of fluid volume overload from large volume transfusions, such patient require discussion with the neonatal consultant
    • Active bleeding
    • DIC
    • Severe Neonatal Alloimmune Thrombocytopaenia

Irradiation:  NB. This is infrequently required
Indications for irradiation of platelets are the same as for red cells – refer to advice above

Administration:

  • If blood and platelets are required, platelets should be given first
  1. platelet transfusion is quicker
  2. This may help control ongoing bleeding
  • Platelets should be administered shortly after receipt to avoid clumping which reduces efficacy
  • Platelets should be drawn up through a blood transfusion giving set to ensure the removal of aggregates.

Post Transfusion Management:

  • It is usually necessary to perform a post-transfusion FBC to asses the increment in the platelet count.
  • If there is evidence of ongoing platelet consumption a further FBC will be necessary to assess the ongoing rate of fall of the platelet count. The timing of this interval will depend on the severity of the thrombocytopaenia.
  • Persistent or refractory thrombocytopaenia requires investigation of the cause if not already known. Causes include sepsis, DIC, and Neonatal Alloimmune Thrombocytopaenia (NAIT)
Neonatal alloimmune thrombocytopenia

Neonatal alloimmune thrombocytopenia (NAIT) occurs when fetal platelets contain an antigen inherited from the father that the mother lacks (akin to rhesus incompatibility). The mother forms IgG class antiplatelet antibodies against the "foreign" antigen; these cross the placenta and destroy fetal platelets, resulting in fetal and neonatal thrombocytopenia. In contrast to Rhesus sensitization, NAIT often develops in the first pregnancy of an at-risk couple but, as with Rhesus disease does increase in severity in subsequent pregnancies. There are a number of antigens however Human Platelet Antigens (HPA) -1a and HPA–5b are responsible for 95% of cases of NAIT in caucasians. NAIT can result in severe thrombocytopenia. The most serious complication is intracranial haemorrhage, which occurs in 10 to 20% of affected newborns. Of these up to 50% occur in-utero.

Clinical features: Incidence of NAIT has been estimated at 1 in 1000 to 5000 births. Affected newborns are otherwise healthy, with signs consistent with thrombocytopenia; widespread petechiae and bruising, with haematoma formation around the site of vitamin K administration. In many cases NAIT may be diagnosed following the incidental finding of a reduced platelet count. There is a significant risk of bleeding (more so than in thrombocytopenia associated with maternal thrombocytopenia)

Investigation:

  • FBC, film and coagulation
  • Screen for CMV
  • Review for possible sepsis, Thrombocytopaenia is a non red flag clinical indicator for sepsis (see Early Onset Sepsis MCN guideline)  
  • Maternal platelet count
  • Maternal platelet antigens & antiplatelet antibody  (ask O&G to do next working day, sent in EDTA bottles)
  • In some cases it may be necessary to determine paternal platelet antigens also
  • Cranial USS

Management:

  1. Platelet transfusion if < 25 x109 OR IF <50 IF PREVIOUS SIBLING HAD ICH ( give 15ml/kg platelets) using, in order of preference:
    • Matched platelets, these may take time to arrange - liaise with BTS as soon as the diagnosis is suspected.
    • Human Platelet antigen (HPA)–1a negative HPA-5b negative platelets.  These are likely to be effective in ~95% of cases where the antibody types are not yet known.
    • Washed platelet concentrate from the mother.  These donations must be irradiated before use
    • Random donor platelets with concurrent immunoglobulin infusion (see below).  Platelet counts are unlikely to increment but this may help control bleeding, if present.
  1. Use Intravenous Immunoglobulin - 1gram/kg per day for two days is effective however the response may be delayed for 24-48h. However, this must be used as an adjunctive therapy to platelet transfusion. If random donor platelets are used, BTS suggest an increased dose of 2g/kg immunoglobulin concurrent with platelets. Order from Pharmacy and prescribe as a 4 hour infusion. Routine blood observations are required during infusion.
  2. Liaise with obstetric staff. - There are implications for future pregnancies (recurrence is more than 75% ) management may include maternal immunoglobulin therapy during pregnancy and the avoidance of assisted delivery. Referral to a fetal medicine unit is often required and antenatal therapy given. A copy of the discharge letter should be sent to the Consultant obstetrician.
G-CSF

Indication: Treatment for severe neutropenia - consultant approval required.

NB –Routine use of G-CSF or GM-CSF for the treatment of neutropaenia in neonates has not been shown to reduce the incidence of sepsis or improve treatment of established sepsis.  

Dose: Preparation (and dose) may vary between units – refer to local pharmacy monographs / data sheets.      

Discontinue treatment if WCC exceeds 20 x 109/litre

20% Albumin

Indication: Consider in symptomatic hypoalbuminaemia - albumin < 20g/l

N.B. This is a pooled blood component with a consequent risk of blood borne infection. Consider benefit carefully as it is unlikely to improve serum albumin numbers! Instead consider the aetiology of the hypoalbuminaemia.

Dose: 1g/kg = 5ml/kg/dose. Infuse over one hour

Supply: Order from Pharmacy

4.5% Albumin

There is now accepted adult and paediatric evidence that there is no benefit obtained from the use of 4.5% albumin as a resuscitation fluid. Indeed much evidence suggests that there is a worse outcome if 4.5% albumin is used compared to crystalloid solutions such as 0.9% sodium chloride.  Therefore in WoS neonatal units 0.9% saline is the fluid of choice for newborn resuscitation

Good Clinical Practice

Serious Hazards of transfusions (SHOT)/ Serious Adverse Blood Reactions & Events (SABRE) continue to occur.  The risks of such events can be minimised by following good clinical practice These include having a guideline, good documentation & communication & also giving consideration to safety aspects e.g. Avoid routine top ups out of hours and ensure the component is prescribed in mls

Communication

  • Parents
    • Informed consent should be taken except in the case of an emergency – There is currently no requirement for written consent however the conversation should be recorded in the casenotes.
      • For premature / sick infants admitted to NICU, where the likelihood of needing blood components on one or more occasions is high, a single instance of informed consent is all that is required at the start of treatment.
      • For low risk infants where there was no anticipation of the need for blood components consent should be sought at the time of transfusion, by phone if necessary. However this should not delay the administration of blood, or blood components, in an emergency situation.    
    • Parents should be offered the leaflet
      “Babies receiving blood transfusion. Information for parent and carers” prior to transfusion where possible and given the opportunity to ask questions. For preterm babies in ITU babies where the likelihood of transfusion is higher, the leaflet can form part of the Admission Pack
  • Blood bank – when calling blood bank you should clearly indicate the following:
    • Blood component required
    • Any special requirements eg irradiated (NB irradiation is seldom required)
    • The degree of Urgency
    • The location for delivery of the blood
    • It is important to inform blood bank if units of emergency blood are taken from the satellite fridge in order to facilitate replacement
  • Colleagues
    • Medical handover – Ensure the new team understand the indication for the transfusion and what further investigations are required once the transfusion is complete.
    • Nursing staff – Ensure the new team understand the indication for the transfusion and what observations are required.
    • If consent could not be obtained prior to an emergency transfusion the new team should inform the parents and give them the transfusion leaflet at the next contact with the parents

Documentation

  • Record the details of the discussion with the parents, confirming that they have given their consent. You should also confirm that this has occurred on the Blood Component Prescription Chart (tick box).
  • Record details of the indications for transfusion of the blood components. This will include the current haematology Laboratory results.
    A record of the clinical indications for transfusion is particularly important where a decision has been made to transfuse at levels  other than the “transfusion triggers” in the sections on the individual components earlier in this document.
  • Record details of the component transfused and the volume given
  • Where appropriate (see above), Record the response to transfusion – Change in laboratory values.
Appendix 1: Normal Haemoglobin values in term infants by day of life

Appendix 2: Normal values of Haemoglobin for preterm infants by day of life

Appendix 3: Exchange transfusion record chart
Appendix 4: Local arrangements - Blood Component Prescription Form

Appendix 5: Choice of ABO group for blood components for administration to children

Patient’s ABO group

ABO group of Blood Products to be Transfused

Red cells

Platelets

FFP

Cryoprecipitate

O

 

 

 

 

First Choice

O

O

O*

O*

Second Choice

-

A or B or AB

A or B or AB

A or B or AB

 

 

 

 

 

A

 

 

 

 

First Choice

A

A

A

A

Second Choice

O

AB

AB

AB

Third Choice

-

B†

Fourth Choice

-

O†

-

-

 

 

 

 

 

B

 

 

 

 

First Choice

B

B

B

B

Second Choice

O

AB

AB

AB

Third Choice

-

A†

Fourth Choice

-

O†

-

-

 

 

 

 

 

AB

 

 

 

 

First Choice

AB

AB

AB

AB

Second Choice

A or B

A†

Third Choice

O

B†

Fourth Choice

-

O†

-

-

 

 

 

 

 

Unknown

 

 

 

 

First Choice

 

AB

AB

AB

Second Choice

 

A†

Third Choice

 

B†

Fourth Choice

 

O†

-

-

Platelets - Tested and negative for HT antibodies: here denoted on the component label this indicates that the component has been tested and contains a low titre of anti-A or anti-B in the plasma.

  • Group B or AB platelets may not be available. However, the use of group O platelets for non-O patients should be avoided as much as possible. Platelets should be compatible for D.
  • If a patient requires HLA-matched platelets, HLA match usually takes precedence over ABO group

FFP & cryoprecipitate:

* Group O FFP and cryoprecipitate should only be given to group O patients.

¥ Group compatible plasma should be used wherever possible. MB FFP, SD FFP and MB cryoprecipitate are not tested for HT antibodies. Non-compatible groups should only be used in emergencies when compatible groups are not available.

  • AB plasma, though haemolysin free and suitable for patients of any ABO group, should be conserved for group AB patients or emergency transfusions where the patient’s groups is unknown. Group AB MB cryoprecipitate has limited availability
Editorial Information

Last reviewed: 06 October 2016

Next review: 01 October 2019

Author(s): Dr Oyenike Osifodunrin & Dr K Kasem – Consultant Neonatologist PRM

Co-Author(s): Other professionals consulted: Dr Campbell Tait, Consultant Haematologist; Elaine Harrison, Transfusion Practitioner; Stephen Bowhay, Pharmacist

Approved By: West of Scotland Neonatology Managed Clinical Network