Paediatric

Haematology:
Part 2
Practical issues with blood
transfusions
Learning Objectives
1. Discuss the blood components available for
transfusion in Ghana
2. Outline procedure for setting up and monitoring
transfusions
3. Employ a systematic approach in evaluating acute
transfusion reactions
Outline
• Blood components
• How to transfuse
• Set up and monitoring of transfusions
• Adverse transfusion reactions
 Blood donation in Ghana Courtesy: SZBC

• Ideally, safe, sustainable blood supply achieved through

voluntary blood donors

•Very low blood donation rate (~6 units/1000 population)

oOver two-thirds obtained through family replacement donor
system

•Only 39% of voluntary donors registered at the Southern

Zonal Blood Centre (SZBC) donate blood at least twice in
a year.
Blood components

Platelets
Platelet-rich Cryoprecipitate
plasma
Whole Frozen
blood plasma Albumin
Packed RBC Clotting factors
Immunoglobulins
 Whole blood & PRBC
Component Approx. Compatibility Storage Expiry Infusion
vol. (ml) time
Whole blood 450 ABO & Rh +2°C to +6°C 6 weeks 2 - 4 hrs

Packed red cells 200 - 250 ABO & Rh +2°C to +6°C 6 weeks 2 - 4 hrs

•Used primarily to increase oxygen-carrying capacity of blood

•Correction of acute or chronic anaemia (when non-transfusion
alternatives have been assessed & excluded)

•Dilute Hb S in severe complications of SCD e.g. stroke, acute chest

syndrome
Whole blood & PRBC
Use whole blood only if:
• significant blood loss
•No need to warm
blood unless
• exchange transfusion massive transfusion

• thrombocytopenia, and platelet

concentrate unavailable: fresh
whole blood from a “walking blood
bank”
 Should you transfuse?
•Haemoglobin level •Underlying cause
Ø<4g/dl •Age of patient
Ø4-6g/dl (if signs of severity)
•Pre-operative
•Clinical status:
ØSigns of cardiac failure or
hypovolemic shock
ØPoor feeding/growth
ØOxygen requirements Whole blood: 20 – 30ml/kg
ØChange in mental status PRBC: 10 – 15ml/kg
ØActive haemolysis
 Frozen plasma & cryoprecipitate
Component Approx. Compatibility Storage Expiry Infusion
vol. (ml) time
Frozen plasma 200 ABO ≤ -25°C 1 year 0.5 - 1hr

Cryoprecipitate 15 (ABO) ≤ -25°C 1 year 0.5 - 1hr

 Frozen Plasma
Contains all clotting factors
o10 – 15ml/kg increases factor levels by 15 – 30%

Main use:
◦Multiple factor deficiency + bleeding
◦Life threatening bleed + no specific diagnosis
◦No specific factor concentrate available (e.g.
Haemophilia B)
 Cryoprecipitate
Contains: FVIII, VWF, FXIII, Fibrinogen

• Used mainly for Haemophilia A or von Willebrand

disease when factor concentrate unavailable

Dose: 1 unit/5 – 10kg or 5 – 10ml/kg

 Platelets
Component Approx. Compatibility Storage Expiry Infusion
vol. (ml) time
Platelets 30 - 50 ABO (& Rh) 20°C to 4–5 0.5 - 1hr
24°C days
Used for quantitative & qualitative
platelet defects: prevention of
spontaneous bleeding, treatment of
bleeding, peri-procedural

Dose: 4 units/m2 or 5 – 10 ml/kg

Transfused platelets only last for about 2 – 3 days

How to transfuse
HOW TO TRANSFUSE
A. SIMPLE
ØEasily administered
ØPut in donor blood
ØPeripheral IV access
ØEasily monitored
ØFewer blood units
ØMinimal equipment
 HOW TO TRANSFUSE
B. EXCHANGE
ØGive donor blood
Ø+
ØRemove patient’s
blood
TYPES OF EXCHANGE
TRANSFUSION

1.Partial exchange transfusion

2.Single volume exchange transfusion

3.Double volume exchange transfusion

 Manual
exchange
Automated exchange
EBT VS. SIMPLE TRANSFUSION
ADVANTAGES DISADVANTAGES
ØLarge blood volumes ØRequires more expertise
without volume overload ØTime & energy
ØLess risk of consuming for staff
hyperviscosity ØMay require central
ØReduced iron venous access
accumulation in the long ØMore blood units
term (logistics & complications)
 Common indications for
exchange transfusions
1. Double-volume exchange transfusion for severe
neonatal jaundice
2. SCD: stroke; acute chest syndrome
3. Polycythemia
◦Haematocrit > 65% + symptomatic
◦Haematocrit >70% + asymptomatic
4. Hyperleukocytosis (+ severe anaemia)
SPECIAL CONSIDERATIONS
1. If multiple transfusions anticipated for
neonate/infant: use dedicated donor unit

2. If patient with SCD: use sickle negative blood

3. Directed donations (generally discouraged)

Irradiation vs. Leukoreduction
•Irradiation: removes viable T lymphocytes from
donor blood; prevents transfusion-associated
GVHD

•Leukoreduction: removal of WBC using a

special filter; minimizes febrile non-haemolytic
reactions, alloimmunization and transmission of
leukotropic viruses such as EBV & CMV
 Safe transfusions
• Right reason
• Right patient • Discuss need for
transfusion, including
• Right blood product
benefits & risks
• Right volume
• Right time • Meticulous documentation
• Right response
Pre-transfusion
• Complete all sections of request form
• Do not pre-label sample tubes
• Ensure good venous access (+ ensure that IV is
dedicated to the transfusion)
•Only trained/competent staff should collect blood from
blood bank
When blood product is
received
•Cross check name on bag, type of product,
expiry date; ensure appropriate giving set
available

•Reconfirm patient & indication for transfusion

•Inspect blood bag

Visual inspection of
blood bag
When blood product is
received
•Check pre-transfusion vitals & monitor during
transfusion (15 mins, 30mins, 1 hour, hourly &
end)

•Write transfusion notes

•Must complete transfusion within 4 hours of

removal from controlled storage
Adverse Transfusion
Reactions
Adverse Transfusion Reactions
(ATR)
•Can be grouped by:
•How quickly they occur: Acute vs. Delayed
•Triggering mechanism: Immune vs. Non-
immune

•Severity: ranges from non-severe to death

Immune-mediated ATR
ACUTE DELAYED
•Haemolytic •Delayed haemolytic
•Non-haemolytic •Alloimmunization
•Allergic; Anaphylactic •TA-GVHD
•Febrile
•Transfusion-related
acute lung injury
(TRALI)
Non-Immune mediated ATR
ACUTE DELAYED
•Bacterial contamination •Transfusion transmitted
•Circulatory overload infections
(TACO) •Iron overload
•Metabolic e.g.
hyperkalemia; hypocalcemia,
hpothermia
•Emboli
Risk of events
Mild allergic reaction – 1 in 100
TACO – 1 in 100
FNHTR – 1 in 300
AHTR – 1 in 40,000
Anaphylaxis – 1 in 40,000

Courtesy: Canadian Blood Services

Look out for…
•Change in vital signs: temp, BP, respiratory rate, heart rate
•Increased respiratory effort: dyspnoea, stridor, wheeze
•Rigors
•Any complaints of pain in chest, flank or back
•Jaundice
• Pruritus; urticaria; facial swelling
•Change in urine output and colour
•Abdominal pain; nausea; vomiting
•Abnormal bleeding – e.g. at IV site
•Mental state - anxious, drowsy or has a sense of “impending doom”
4-step approach to dealing
with ATR
1. Stop transfusion & keep vein open with
normal saline
2. Assess patient
3. Call for help & continue monitoring patient
4. Recheck all clerical data: product bag & patient
and return product (and tubing) to blood bank
+ fresh blood sample from patient
Managing acute ATR
• If anaphylaxis – IM epinephrine (1:1000), IV steroids,
antihistamines, airway management
• If mild allergic reaction – antihistamines
• If bacterial contamination suspected – blood culture &
start antibiotics
• If TACO – diuretics
• If TRALI – ventilatory support
•If acute haemolysis – IV hydration
 Child with suspected ATR
↓

STOP transfusion & keep vein open

ASSESS: cardiorespiratory, temperature, skin/appearance
CALL for help
RECHECK data – patient + product
CONTACT blood bank

Adapted from UpToDate; 2021

 ASSESSMENT: cardiorespiratory,
temperature, skin/appearance
↓ ↓ ↓
Fever Normal temp Fever +
+ otherwise + Respiratory
normal Respiratory distress
distress
and/or
Pruritus, Rash,
Angioedema
Adapted from UpToDate; 2021
 CLINICAL ASSESSMENT
↓
Fever + no other symptoms
↓ Paracetamol

• Febrile non-haemolytic Antibiotics

transfusion reaction
Blood culture
• Bacterial contamination
• Fever from underlying Treat
underlying
disease disease
Adapted from UpToDate; 2021
 CLINICAL ASSESSMENT
↓
Normal temp. + Respiratory distress
&/or
Angioedema; Rash
↓
Normal BP + rash
Blood pressure

↓
only: mild allergic
↓ reaction
↓
Increased BP: TACO Low BP: anaphylaxis
Adapted from UpToDate; 2021
 CLINICAL ASSESSMENT

↓
Fever + respiratory distress +/- hypotension
↓ ↓ ↓
TRALI AHTR Sepsis
↓ ↓ ↓
Urine dipstick IV antibiotics
Monitor SPO2 Serial urine checks Blood Culture
Oxygen Aggressive hydration (Patient + product)
CXR
FBC, Coombs, PT/APTT,
Adapted from UpToDate; 2021
Markers of haemolysis
Can the transfusion be restarted?
• It depends
• limited urticaria
• fever due to underlying illness (difficult to ascertain)

•Do not restart without consulting a more

experienced colleague/blood bank
•If in doubt, do NOT restart
•Be mindful of 4-hour time limit
Safe blood saves lives
Correct blood Clear
Safe donors
product indication

Correct Correct
Safe
cross- identification
collection
matching of patient

Effective
Thorough Appropriate
storage monitoring
testing
during & after