Guidelines for Red Cell Transfusion

 

Reviewed by Clinical Practice Group

March 2018

Clinical Guidelines

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Causes of Anaemia

Indications for Transfusion

Consent

Ordering Multipacks

Transfusion Volume

Other Related Documents

References

Blood components available for red cell transfusion of neonates

New Zealand Blood Service currently provides two types of red cell components for neonatal use.

A detailed datasheet on these components can be accessed on the New Zealand Blood Service website (www.nzblood.co.nz). See also Transfusion handbook 2016

All blood components provided by NZBS are leucodepleted at source and CMV negative (see special considerations). Statistical process control is used to ensure that greater than 99% of components will have a level of <5 x 106 WBC per unit (95% confidence).
 

Common Causes of Neonatal Anaemia

Although these factors combine to result in the ‘normal’ fall in haemoglobin concentration in the first 6-9 weeks after birth, this is accompanied by improved oxygen unloading capacity as 2,3-DPG levels rise, so that tissue oxygen delivery may improve despite reduced oxygen carrying capacity. Thus the possible benefits of transfusion need to be balanced against the known (and unknown) risks for each individual baby.

Indications for Transfusion

  1. Shock due to blood loss. If severe see the Massive transfusion protocol. (Term baby estimated total blood volume is 80ml/kg and extremely preterm baby is 100ml/kg).
  2. Exchange transfusion for severe haemolytic anaemia – See neonatal jaundice protocol.
  3. Anaemia of Prematurity - Transfusion Thresholds

Table 1: Haemoglobin concentration, g/L (haematocrit, %)

 

Respiratory Support

No Respiratory Support

<7 days

115 (35)

100 (30)

8-14 days

100 (30)

85 (25)

>15 days

85 (25)

75 (23)

 

These thresholds are for guidance only and should be individualised considering the following factors:

  1. Stable growing babies > 6 weeks old

Reducing the need for RBC transfusion

Delayed cord clamping

Waiting for 30 to 120 seconds before clamping the cord allows about 15 to 20 mls/kg of blood to move from the placenta to the baby. There is good evidence from trials to date that delayed cord clamping reduces the need for later blood transfusion and reduces the total number of transfusions needed.4 In the most recent meta-analysis (which includes the 2017 Australian Placental Transfusion Study, APTS) delayed cord clamping in preterm infants reduced the proportion of infants needing a blood transfusion by 10%.5

Erythropoetin

The use of exogenous erythropoetin (EPO) to reduce the need for transfusion in preterm infants has been the subject of many clinical trials. Systematic review of these trials shows that early (before 8 days of age) or late EPO reduces the need for one or more transfusions and the number of transfusions per baby however, the small reductions are likely to be of limited clinical importance.6,7 There is a non-significant trend to a higher rate of ROP with early EPO. There is little support for the routine use of EPO but it should be considered in cases where there is a need to minimise the risk of requiring a blood transfusion, e.g babies of Jehovah’s Witnesses (see section below).

Special considerations when transfusing neonates

Cytomegalovirus Infection,

Irradiation of Blood Components

Irradiated components are required for:

Routine irradiation of cellular blood components for neonates outside of the above is not required by current international guidelines.

Hyperkalemia

Potassium leaches out of red cells during liquid storage. The potassium level in donated blood therefore increases with age. Clinically this is not normally a problem since the potassium rapidly re-enters the red cells following transfusion. The rate of potassium leakage increases significantly in red cell components that have been irradiated.

In certain clinical settings however the increased potassium level may be important. In such settings fresh blood (less than 5 days old) should be used. This applies to:

Prescribing of blood and blood products

The Doctor/NS-ANP:

The Nurse must be notified that the blood or blood product has been ordered.

Transfusion volume

Volume to Transfuse:

Ordering

Paediatric packs of blood are requested one at a time from the Blood Bank as required. Individual aliquots from one adult can be reserved for sequential transfusions to the same baby over the 35-day shelf life of the red cells. This reduces multiple donor exposure. Blood must not be used if out of chilling facility for more than 15 minutes during transport, or prior to infusion.

If blood is not required, the Blood Bank must be informed and blood returned to the Blood Bank immediately.

Fill in the NZ Blood Request for Blood Bank Tests and Blood Components or Products form. You will also need to complete a Blood Bank Issue Sheet form CC7029.

Blood and blood products are sent to the unit by the chute.

Pre-Administration Checklist

Administration

Set-up for administering blood via Central Venous Catheter:

Monitoring and documentation

Potential complications

Irradiated Blood

Graft Versus Host (GVH)

Hyperviscosity

Haemolysis

Haemolysis is the disintegration of red blood cells. It can be caused by:

Transfusion reactions

Type of Reaction

Symptoms and Signs

Febrile

  • Pyrexia, rigors.

Circulatory Overload

  •  Increase in blood pressure, heart rate and respirations.
  • Pulmonary oedema, dyspnoea, increase in urinary output

Allergic

  • Urticaria, facial oedema, dyspnoea, hypotension
  • TRALI (transfusion associated lung injury)

Haemolytic

  • Collapse with hypotension.
  • Shock, pyrexia, rigors, haemoglobinuria, haemoglobinaemia, oliguria, later uraemia.

Infected Blood

  • Pyrexia, profound collapse and shock, pallor, dyspnoea, low blood pressure, rapid pulse.

Management of Transfusion Reactions

Follow the steps below to manage the baby's reaction to blood and blood products.

Transfusion associated NEC (TANEC).

It is currently uncertain whether NEC developing within 48 hours of a blood transfusion is an association or causation. In a meta-analysis of observational studies Mohamed et al report a moderate risk of bias, studies do not address the fact there are many cases of NEC that are not associated with transfusion, and many transfusions happen in preterm neonates who are not linked to NEC within 48 hours.9 Another prospective observational study reported severe anaemia, not transfusion, was associated with NEC.10 Some authors have suggested withholding feeds around a transfusion may reduce the risk of TANEC, however the level of evidence is low.11 It is not our routine practice to withhold feeds during a transfusion.

Risk of Infection

Human Immunodeficiency Virus (HIV) In Australia and NZ approximately 1 million units of blood and blood products are transfused annually.  Since 1985 when HIV screening commenced, no known cases of post transfusion HIV infection have been detected.
Hepatitis B Now very rare post transfusion.
Hepatitis C No acute cases of Hepatitis C post transfusion have been detected since HCV screening commenced in 1992.
Creutzfeldt-Jakob Disease (CJD) There are no clearly documented cases of CJD being passed on by blood products.  However it remains a theoretical possibility.  This may be markedly reduced with pre-storage filtering of blood.
Cytomegalovirus (CMV) Occasional cases occur but are relatively rare.  Neonatal transfused red blood cells are leukodepleted and CMV antibody negative

In New Zealand, blood for transfusion is carefully screened prior to being issued by blood bank. However there is always a risk that in the future other infectious diseases may be discovered.


Jehovah's Witnesses

The ADHB provides information for staff about Jehovah's Witnesses including medical management, and hospital liaison committee member contact details - see here for more information.

Jehovah's Witnesses have definite objections to blood transfusions. In the event that a transfusion is indicated for an infant, then the following is recommended:

  1. Make sure Consultant is aware
  2. Discuss need for transfusion with the parents
  3. Review non-blood medical alternatives and if possible treat patient without using allogeneic blood. Erythropoietin use should be considered on an individual basis
  4. Consider contacting Hospital Liaison Committee member - see ADHB intranet for details


If transfusion is urgent:

  1. Ask parents for consent. If consent is withheld, then a decision to go ahead with the transfusion must be made in consultation with senior members of the medical team and clearly documented in the clinical record.
  2. If further transfusions are likely to be needed, ADHB legal counsel should be contacted

For less urgent transfusions, or where the need for transfusion is anticipated:

  1. Ask parents for consent. If consent is withheld then contact ADHB legal counsel for further advice including seeking legal guardianship for the blood transfusion

Anticipated transfusion need can include unwell ELBW infants, babies < 26 weeks, anaemic VLBW infants, significant haemolytic disease, very sick term infants (although many of these would fit the urgent transfusion criteria).

There is law within the Health Act 1956 (Section 126B) that protects medical practitioners from civil or criminal proceedings for administering blood transfusions without consent to any person under the age of 20 years as long as the judge is satisfied that:

Associated documents

For further information call the New Zealand Blood Service - Northern Region and ask to speak to the Medical Officer.
Bloodbank will inform the caller as to who this is and advise of appropriate telephone number.

References

1

Kirpalani H, Whyte RK, Andersen C et al. The premature infants in need of transfusion (PINT) study: A randomised, controlled trial of a restrictive (low) versus liberal (high) transfusion threshold for extremely low birth weight infants. J Pediatr 2006;149:301-

2

Whyte R, Kirpalani H. Low versus high haemoglobin concentration threshold for blood transfusion for preventing morbidity and mortality in very low birth weight infants. Cochrane Database of Systematic Reviews 2011, Issue 11. Art. No.: CD000512. DOI: 10.1002/14651858.CD000512.pub2.

3

Fetus and Newborn Committee. Whyte RK, Jefferies AL; Canadian Paediatric Society Red blood cell transfusion in newborn infants. Position Statement. Paediatr Child Health 2014;19(4):213-17

4

Rabe H, Diaz-Rossello JL, Duley L, Dowswell T. Effect of timing of umbilical cord clamping and other strategies to influence placental transfusion at preterm birth on maternal and infant outcomes. Cochrane Database of Systematic Reviews 2012, Issue 8. Art. No.: CD003248. DOI: 10.1002/14651858.CD003248.pub3.
5 Fogarty M, Osborn DA, Askie L et al. Delayed versus early umbilical cord clamping for preterm infants: A systematic review and meta-analysis, Amer J Obst and Gynae. 2017; 218(1)1-18.doi:10.1016/j.ajog.2017.10.231.
6 Ohlsson A, Aher SM. Early erythropoietin for preventing red blood cell transfusion in preterm and/or low birth weight infants. Cochrane Database of Systematic Reviews 2014, Issue 4. Art. No.: CD004863. DOI: 10.1002/14651858.CD004863.pub4.
7 Aher SM, Ohlsson A. Late erythropoietin for preventing red blood cell transfusion in preterm and/or low birth weight infants. Cochrane Database of Systematic Reviews 2014, Issue 4. Art. No.: CD004868. DOI: 10.1002/14651858.CD004868.pub4.
8 Balegar V, Kumar K and Kluckow M. Furosemide for Packed Red Cell Transfusion in Preterm Infants: A Randomized Controlled Trial. J Pediatr 2011;159: 913 -8
9 Mohamed A; Shah PS. Transfusion associated necrotizing enterocolitis: a meta-analysis of observational data. Pediatrics 2012;129:529-40,
10 Patel RM, Knezevic AShenvi N et al. Association of Red Blood Cell Transfusion, Anaemia and Necrotising Enterocolitis in Very Low-Birth-Weight Infants. JAMA 2016;315:889-97.
11 Keir AK; Wilkinson D. Do feeding practices during transfusion influence the risk of developing necrotising enterocolitis in preterm infants? Archives of Disease in Childhood 2013;98(5):386-8.


 

1.Kirpalani H, Whyte RK, Andersen C et al. The premature infants in need of transfusion (PINT) study: A randomised, controlled trial of a restrictive (low) versus liberal (high) transfusion threshold for extremely low birth weight infants. J Pediatr 2006;149:301-7.
2. Whyte R, Kirpalani H. Low versus high haemoglobin concentration threshold for blood transfusion for preventing morbidity and mortality in very low birth weight infants. Cochrane Database of Systematic Reviews 2011, Issue 11. Art. No.: CD000512. DOI: 10.1002/14651858.CD000512.pub2.

3.Fetus and Newborn Committee. Whyte RK, Jefferies AL; Canadian Paediatric Society Red blood cell transfusion in newborn infants. Position Statement. Paediatr Child Health 2014;19(4):213-17
4.Rabe H, Diaz-Rossello JL, Duley L, Dowswell T. Effect of timing of umbilical cord clamping and other strategies to influence placental transfusion at preterm birth on maternal and infant outcomes. Cochrane Database of Systematic Reviews 2012, Issue 8. Art. No.: CD003248. DOI: 10.1002/14651858.CD003248.pub3.

5.Fogarty M, Osborn DA, Askie L et al. Delayed versus early umbilical cord clamping for preterm infants: A systematic review and meta-analysis, Amer J Obst and Gynae. 2017; 218(1)1-18.doi:10.1016/j.ajog.2017.10.231.
6.Ohlsson A, Aher SM. Early erythropoietin for preventing red blood cell transfusion in preterm and/or low birth weight infants. Cochrane Database of Systematic Reviews 2014, Issue 4. Art. No.: CD004863. DOI: 10.1002/14651858.CD004863.pub4.
7.Aher SM, Ohlsson A. Late erythropoietin for preventing red blood cell transfusion in preterm and/or low birth weight infants. Cochrane Database of Systematic Reviews 2014, Issue 4. Art. No.: CD004868. DOI: 10.1002/14651858.CD004868.pub4.

8.Balegar V, Kumar K and Kluckow M. Furosemide for Packed Red Cell Transfusion in Preterm Infants: A Randomized Controlled Trial. J Pediatr 2011;159: 913 -8

9.Mohamed A; Shah PS. Transfusion associated necrotizing enterocolitis: a meta-analysis of observational data. Pediatrics 2012;129:529-40,
10.Patel RM, Knezevic AShenvi N et al. Association of Red Blood Cell Transfusion, Anaemia and Necrotising Enterocolitis in Very Low-Birth-Weight Infants. JAMA 2016;315:889-97.