CG PEDICON 2006, 7-8th Oct 2006, Rajnandgaon, Chattisgarh

Prof. Dr. N. L. Phuljhele,
Department of Pediatrics
Pt. J.N.M. College & Dr. BRAM Hospital, Raipur

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Recent advancement of neonatal survival new technique are adapting in which one of blood transfusion and blood component is useful, sequential description.

Blood from which components are not separate. With the advent of component therapy use of whole fresh blood has reduced.

Indication of use in neonates

• Hemolytic disease of newborn due to materno-fetal ABO incompatibility
  
• Hypercoagulability like Polycythemia
  
• Septicemia fulminant
  
2. Red cell replacement in acute blood loss with hypovolemia
3. In condition of shock
4. In neonate undergoing open heart surgery or over operative procedure

Packed RBC are prepared by centrifugation of 1unit of whole fresh blood with removal of plasma & are suspended in the anticoagulant preservation storage solution.

• Hematocrit value in 60 % (for children & adults)
• In neonate RBC concentrate is 70-90 %

Definite Guidelines for Transfusion of RBC concentrates:

In infants within first 4 months of life

1. Hb <13gm/dl & severe pulmonary distress
2. Hb <13gm/dl & severe cardiac disease like CCF
3. Hb <10gm/dl & moderate pulmonary disease
4. Hb <10gm/dl & major surgery
5. Hb <8 gm/dl symptomatic anemia
6. In preterm infants who are sick
   
• To replace blood sample taken for lab tests
  
• To treat hypotension & hypovolemia
  
• To treat the combined effect of anemia of prematurity and blood loss due to sampling
  
7. In neonates with late anemia to maintain to their Hb level to 13-14 gm/dl to ensure adequate tissue perfusion
8. In neonates with late anemia
   
1. Poor weight gain
   
2. Fatigue with feeding
   
3. Tachypnea & Tachycardia
   
4. Other sighs of decompensation
   

The usual indication of RBC transfusion is to increase O2 carrying capacity of blood in patients of anemia.

This is based on various factors:

1. Presence or absence of symptoms or signs of anemia like tachycardia tachypnea, lethargy
2. Level of hematocrit
3. The presence of cardiorespiratory, vascular or CNS disease
4. Whether anemia is acute or develop slowly

In symptomatic anemia premature RBC transfusion:

• Shows increased weight gain
  
• Decrease risk of apneic spells
  
• Improvement of systemic O2 transport
  

Concentrate of platelets are prepared from 1 unit of donated whole by first removing RBC & then concentrating the platelets. The concentrated platelets are suspended in 50 ml plasma constituting one unit.

Guidelines for Transfusion of Platelets:

1. Platelet at any count but with platelets dysfunction like von Willebrand disease, bleeding or undergoing invasive procedure
2. Platelets <100 x10/ L & bleeding
3. Platelets <50 x10/ L invasive procedure
4. Platelets <20 x10/L & clinically stable
5. Platelets <100 x10/L & clinically unstable
6. Platelets <50 x10/L in premature infants in ventilatory support or risk of IVH

Condition requiring plate late transfusion in neonates:

1. Bleeding due to thrombocytopenia during septicemia
2. DIC
3. In idiopathic thrombocytopenic purpura in life threatening hemorrhage
4. Von Willebrands disease
5. Immune mediate neonatal thrombocytopenia
6. Prolonged antimicrobial therapy
7. Neonatal alloimmune thrombocytopenia which is a cause of cerebral hemorrhage

Storage:

• Up to 72 hr at 20 to 24 C
• Shelf life is 5 days
• Should be used in at 2 hr from collection
• Longer storage increases risk of bacterial proliferation & septicemia in recipient

Dosage:

• 1 unit of Platelet/10 kg body weight

     Transfusion of 10 ml/kg is adequate as it add 10 x10 platelets to 70 ml of blood and increase plates by 100 x10.
    Patient requiring repeated platelet transfusion should given leucocyte reduced blood products, including platelet concentrates to decrease alloimmunisation & platlate transmitted CMV infection.

RBC that are preserved with a cryoprotective agent usually glycerol, may be stored upto 10 yrs. This can be stored for longer time. Draw back - Costly and not easily available.

Uses high frequency filter which can remove over 99% of leucocytes.

Indications:

I. H/O febrile transfusion reaction
II. Preterm infants <1.2 kg susceptible to CMV infection
III. GVHD
IV. Allogenic leucocyte transfusion reaction

Granulocyte concentrates should be used severely neutrophilic patient with life threatening bacterial or fungal infection not responding to antibiotics therapy after 24 to 48 hrs.

Neonates are susceptible to bacterial infection because of decrease in body defense mechanism. These abnormalities are much accentuated in sick premature infants, fulminate septicemia, relative neutropenia, decrease bone marrow storage and congenital neutropenia.

Guideline for neutrophilic transfusion

In infants within 1st 4m of life

• Neutrophil <3 x 10/L (with in 1st wk of life) +fulminant
  
• Neutrophil <1 x 10/ L& fulminant bacterial infection + fulminant
  
  Granulocyte obtained by apheresis of a single CMV negative ABO & Rh compatible donor prepared with corticoids are preferred.
  The dose is 1-2 x 10 granulocyte/kg/day repeated fro at least 4 days until the infection resolved and count exceeds 1 x 10

Fresh frozen Plasma is plasma is separated and rapidly frozen to -18c or less. About 180 to 250 ml plasma is obtained from a single unit of blood & half-life is 1yr.

Guide for transfusion in infants, children and adolescents:

• Severe clotting factor deficiency and bleeding
  
• Severe clotting factor deficiency and invasive procedure
  
• Emergency reversal of warfarin effects
  
• Dilutional coagulopathy and bleeding
  
• Anticoagulant protein (AT-3, protein c, s) replacement
  
• Plasma exchange replacement fluid for TTP
  

Transfusion of FFP is effective for treatment of deficiency of clotting factor II, V, X, XI.

Transfusion of FFP in patient with chronic liver disease & prolonged clotting time is not recommended unless bleeding is present or an invasive procedure like biopsy is planned.

In neonates, FFP in transfusion is required because clotting time are prolonged due to development deficiency of clotting protein & FFP should be transfused only after reference to normal value expected for the birth weight and age of patient.

Indications for FFP transfusion in neonates:

1. Reconstitution of RBC concentrated to whole blood for use in massive transfusion (e.g. Exchange transfusion or Cardiovascular Surgery)
2. Hemorrhage secondary to Vit K deficiency
3. DIC
4. Bleeding in congenital congenital factor deficiency when more specific treatment is

The usual initial doses of FFP for treating coagulopathies is 10-15 ml/kg. Allergic reaction such as urticaria is common with transfusion reaction.

Cryoprecipitate is formed from FFP which thawed and each bag contain about 150 mg of fibrinogen & 80 unit of factor VIII. It also contain factor XIII.
It is more in bleeding infants because if its small infusion volume.

The minor indications for cryoprecipitate is correction of:

• Hypofibrinogenemia
  
• Congenital factor VIII deficiency
  
• DIC
  
• Hemophilia A & Hemophilia B
  
  

CG Pedicon 2006 - Conference Abstracts.Pediatric Oncall [serial online] 2007 [cited 15 March 2007(Supplement 3)];4. Available from:
http://www.pediatriconcall.com/fordoctor/Conference_abstracts/
cgpedicon2006/Blood1.asp