Blood Transfusion In

Pediatrics

Pontianak, 27 September 2015

Rini Andriani

Blood Products for Transfusion in

Clinical Practice
Whole blood
Blood component:
Packed red cells
Leukocytes
Thrombocytes
Fresh Frozen Plasma
Cryoprecipitates

Blood Product Definition

Blood product
Any therapeutic substance prepared from human blood

Whole blood
Unseparated blood collected into an approved container containing an
anticoagulant-preservative solution

Blood component
1. Constituent of blood, separated from whole blood, such as:

Red cell concentrate

Plasma
Platelet concentrates
2 .Plasma or platelets collected by apheresis
3 .Cryoprecipitate, prepared from fresh frozen
* Apheresis: a method of collecting plasma or platelets directly from the donor, usually by a mechanical method

World Health Organization. The Clinical Use of Blood. In Medicine Obstetric Paediatrics Surgery & Anaesthesia Trauma & Burns.

Blood Product Definition

Plasma derivative
Human plasma proteins prepared under pharmaceutical
manufacturing conditions, such as:

Albumin
Coagulation factor concentrates
Immunoglobulins

World Health Organization. The Clinical Use of Blood. In Medicine Obstetric Paediatrics Surgery & Anaesthesia Trauma & Burns.

World Health Organization. The Clinical Use of Blood. In

Medicine Obstetric Paediatrics Surgery & Anaesthesia
Trauma & Burns.

Whole Blood
Obtained from human blood donors by venesection.
During donation, blood is collected into a sterile,
disposable, plastic pack which contains an anticoagulantpreservative solution that usually contains (CPDA):
Citrate
Phosphate
Dextrose
Adenine

During storage, metabolism continues in the red cells

and platelets, while some plasma proteins lose their
biological activity.
World Health Organization. The Clinical Use of Blood. In Medicine Obstetric Paediatrics Surgery & Anaesthesia Trauma & Burns.

Red cells
Red cell transfusion is used both to
prevent complications of anemia and to
treat the symptoms and signs of hypoxia
due to anemia.

Recommendations for Transfusion

in Patients in ICUs
Critical Patients
Variables

Hemoglobin level
(g/dL)

No acute bleeding

7-9

Septic shock (<6h)

7-9

Septic shock (>6 h)

10

Chronic cardiac disease

7-9

Acute cardiac disease

10

Recommendations for RBC Transfusion

Guidelines for The anemia of Prematurity
Maintain >4045% hematocrit (Hct) for severe cardiopulmonary disease
Maintain >3035% Hct for moderate cardiopulmonary disease
Maintain >3035% Hct for major surgery
Maintain >2025% Hct for infants with stable anemia, especially if
accompanied by:
Unexplained breathing disorder
Unexplained tachycardia
Unexplained poor growth

Blood Transfusion in Blood Loss

Massive hemorrhage has been defined as:
the loss of one blood volume within a 24-hour
period
a 50% volume loss within 3 hours
a rate of loss of 150 mL/min.

Blood Transfusion in Blood Loss

Acute blood loss is initially treated by volume
support, consists of rapid infusion of crystalloid or
colloid solutions.
Red cell transfusion is usually required after 30 to
40% of blood volume has been lost or Hb
concentration has fallen to <6 g/dL
Transfusion when higher hemoglobin levels are
present may be dictated by a perceived risk of
complications from inadequate oxygenation.

Emergency Transfusion
uncross-matched blood, type O, Rhnegative blood is used for women of childbearing age or younger
type O, Rh-negative or Rh-positive blood
is used in males or older females.
The use of packed red blood cells is
preferable because it reduces the quantity
of anti-A or anti-B administered.

Blood Transfusions in Chronic Anemia

Adaptive physiologic mechanisms allow
most individuals to tolerate chronic
anemia.
Consequently, blood transfusion in most
patients with chronic stable anemia is
probably unjustifiable if the hemoglobin
level is above 7 g/dL.

Introduction
Proper uses of red blood cell (RBC) transfusion
Treatment of symptomatic anemia
Prophylaxis in life-threatening anemia
Restoration of oxygen-carrying capacity in case of
hemorrhage
RBC are also indicated for exchange transfusion

Sickle cell disease

Severe parasitic infection (malaria, babesiosis)
Severe methemoglobinemia
Severe hyperbilirubinemia of newborn

American Society of Hematology. 2012 Clinical Practice Guide on Red Blood Cell Transfusion. 2012

Function of Anticoagulant-preservative
Solution in Blood Collection Pack
Solutions

Functions

C Sodium citrate

Binds with calcium ions in blood in

exchange for the sodium salt so the
blood does not clot

P Phosphate

Supports metabolism of the red cells

during storage to ensure they release
oxygen readily at tissue level

D Dextrose

Maintains the red cell membrane to

increase storage life

A Adenine

Provides energy source

World Health Organization. The Clinical Use of Blood. In Medicine Obstetric Paediatrics Surgery & Anaesthesia Trauma & Burns.

Effects of Storage on Whole Blood

Reduction in the pH (blood becomes more acidic)
Rise in plasma potassium concentration (extracelular K +)
Progressive reduction in the red cell content of 2,3
diphosphoglycerate (2,3 DPG) which may reduce the
release of oxygen at tissue level untik 2,3 DPG is
restored
Loss of all platelet function in whole blood within 48
hours of donation
Reduction in Factor VIII to 10-20% of normal within 48
hours of donation. Coagulation factors such as VII an IX
are relatively stable in storage
World Health Organization. The Clinical Use of Blood. In Medicine Obstetric Paediatrics Surgery & Anaesthesia Trauma & Burns.

Advantages & Disadvantages

Advantages
Requires only simple and inexpensive single
collection packs
No special equipment is needed for processing
For patients with haemorrhage, whole blood supplies
red cells volume and stable coagulation factors.

Disadvantages
For patients at risk of circulatory overload, whole
blood contains a higher volume than red cell
concentrate.
World Health Organization. The Clinical Use of Blood. In Medicine Obstetric Paediatrics Surgery & Anaesthesia Trauma & Burns.

Major Red Cell Products for

Transfusion
Most RBC products are derived by
collection of 450-500 (10%) mL of whole
blood from volunteer donors and removal
of the plasma by centrifugation.
After removal of the plasma, the resulting
product is red blood cells (referred to
informally as packed red blood cells).

American Society of Hematology. 2012 Clinical Practice Guide on Red Blood Cell Transfusion. 2012

Special Processing of RBC for

Transfusion
Process

Indication

Technical Considerations

1. Washing (removes residual

plasma)

Decrease risk of anaphylaxis in

IgA-deficient patient with anti-IgA
antibodies
Decrease reactions in patients with
history of recurrent, severe allergic
or anaphylactoid reactions to blood
product transfusion

Wash fluid is 0.9% NacL

dextrose
Shelf life of washed RBC
24 hours at 1-6oC
4 hours at 20-24oC
May lose 20% of red cells in
washing process

2. Leukocyte Reduction

Decrease risk of recurrent febrile,

nonhemolytic transfusion reactions
Decrease risk of cytomegalovirus
(CMV) transmission (marrow
transplant)
Decrese risk of HLAalloimmunization
Does not prevent transfusion
associated graft-versus-host
disease (TA-GVHD)

Most commonly achieved by

filtration
Usually soon after collection
(prestorage)
May be performed at bedside
<5x106 leukocytes per product (per
FDA)

American Society of Hematology. 2012 Clinical Practice Guide on Red Blood Cell Transfusion. 2012

Special Processing of RBC for

Transfusion
Process

Indication

Technical Considerations

3. Irradiation

Prevention of TA-GVHD in
certain circumstances:
Donor categories
Pediatric practice
Acute leukemia :HLAmatched or family-donated
products
Allogeneic hemopoietic
progenitor cell (HPC)
transplant recipient
Hodgkin disease
History of treatment with
purine analogues and elated
drugs
History of tratment with
alemtuzumab

Radiation dose:
2500 cGy to center
of product Gamma or
Xirradiation
Shelf life of irradiated product:
up
to 28 days unless original
expiration date is sooner
NB: Supernatant K+ may be
higher than usual

American Society of Hematology. 2012 Clinical Practice Guide on Red Blood Cell Transfusion. 2012

Factors in Selecting Blood Components

for Neonatal Transfusion
Product

Indication

Special Requirements for

Neonates

Whole blood

Exchange transfusion for HDN

Freshest blood available (less

than 5 days after collection),
free of relevant alloantibodies

Red cells

top-up transfusion to raise

haemoglobin concentration in
symptomatic chronic anaemia,
often due to blood sampling in
sick premature infants

Small dose unit (paediatric

pack from a single donation) to
minimize exposure to different
donors

Specially-processed cellular
components

Intrauterine transfusion:
- Risk of GvHD may be
greater in premture infants
- Risk of GvHD is greater if
donor is a blood relative

Avoid graft-versus-host
disease:
- Irradiate: 250 Gy
- Do not use donation from
blood relative

World Health Organization. The Clinical Use of Blood. In Medicine Obstetric Paediatrics Surgery & Anaesthesia Trauma & Burns.

Factors in Selecting Blood Components

for Neonatal Transfusion
Product

Indication

Special Requirements for

Neonates

Avoid CMV infection in

recipient

CMV infection or
reactivation may complicate
the management of sick
infants. CMV may be
transmitted by blood or
infection reactivated by
allognic leucocyte
transfusion

Use CMV-negative donation

and/or
Leucocyte-depleted
component

World Health Organization. The Clinical Use of Blood. In Medicine Obstetric Paediatrics Surgery & Anaesthesia Trauma & Burns.

Indications for Transfusion of Children with

Severe (Decompensated) Anaemia
Haemoglobin concentration of 4 g/dl or less (or
haematocrit 12%) whatever the clinical
condition of the patient
Haemoglobin concentration of 4-6 g/dl (or
haematocrit 13-18%) if any the following clinical
features are present:
Clinical features of hypoxia
Acidosis (usually causes dyspnoea)
Inpaired consciousness

Hyperparasitaemia (>20%)
American Society of Hematology. 2012 Clinical Practice Guide on Red Blood Cell Transfusion. 2012

Adverse Effects of Red Cell Transfusions

Blood transfusion therapy carries significant risks
and should be regarded as a temporary organ
transplant.
In the late 1980s, acute transfusion reactions
were estimated to occur in 20% of total
transfusions, with severe reactions observed in
approximately 0.5%
Subsequently, the rate has declined because of
the introduction of leukoreduction.

Adverse Effects of Red Cell Transfusions

Adverse reactions may occur within minutes to hours
as in:
acute hemolytic reactions
acute lung injury
may be delayed by days to weeks as in:
delayed hemolytic reactions
multiorgan failure
Thrombosis
tumor recurrence,
infections.

Adverse Effects of Red Cell Transfusions

Most acute transfusion reactions are mild and

manageable.
Many of the reported transfusion-related fatalities
are caused by human errors.
In one study of 70 transfusion-related deaths, 75
percent resulted from administration of correctly crossmatched blood to the wrong patient

The rate of a technical error was estimated to be

1:18,000 transfusions.

Immediate Transfusion Reactions

Chills

Vomiting

Fever

Chest tightness

Urticaria

Chest and back pain

Tachycardia

hypotension

Dyspnea

bronchospasm

Nausea

Angioneurotic edema

Pulmonary edema

Congestive heart failure

anaphylaxis

shock

Immediate Transfusion Reactions

Immediate immunologic transfusion
reactions in an anesthetized patient may
manifest signs such as generalized oozing
of blood from the operative site,
hypotension, and shock.
In general, immediate transfusion
reactions are more dangerous than
delayed reactions.

Acute Hemolytic Transfusion Reactions

caused by the immune-mediated destruction of

ABO-incompatible transfused blood
The incidence of ABO-incompatible transfusions
is estimated to occur in 1 in 38,000 to 1 in 70,000
red cell transfusions
The mortality rate is approximately 2 percent.

Acute Hemolytic Transfusion Reactions

Pathophysiology
Anti A or Anti
B Antibodies
in Recipient

activated

Ag-Ab
complexes
Bradykinin:
Increase capillary
permeability and
arteriolar dilatation

Hypotension
Renal failure

Complement and
coagulation system
C3a and C5a

Activation of
factor XII
DIC
HEMOGLOBINURIA
First sign

Leukocytes

Infflammatory cytokines
(IL-1, IL-6, IL-8 and TNF
Fever
Nausea and vomiting
Wheezing
Chest pain

AHTR: Laboratory evaluation

Check for technical and identification
errors, examine a posttransfusion
specimen for hemolysis, and perform a
direct antiglobulin test (DAT) to detect any
incompatibility.

AHTR: Management
Immediate discontinuation of transfusion should
always be the first step in any transfusion
reaction.
Maintaining vascular access with slow infusion of
normal saline, monitoring vital signs, and
assessing urine output are key early steps.
A blood specimen should be collected
immediately for laboratory evaluation.

AHTR: Management
If severe hemolysis has occurred, therapy
focuses on management of hypotension,
coagulation disorders, and renal function.
Intravenous administration of furosemide
(4080 mg) promotes diuresis and
improves blood flow to the renal cortex.

AHTR: Management
In severe cases of hypotension, dopamine,
which dilates renal vasculature and increases
cardiac output, can be used at a dosage of 1
mg/kg of body weight per hour.
Patients with coagulopathy and active bleeding
may require administration of platelets, freshfrozen plasma, and cryoprecipitate.

AHTR: Prevention
The common causes of AHTR are errors in
identifying the patient, labeling the
pretransfusion sample, and identifying the
correct red cell unit for the patient.
It is recommended to use at least two patient
identifiers whenever administering blood
products or collecting blood samples.

Febrile Nonhemolytic Transfusion Reactions

a temperature increase of 1C (1.8F) or
more associated with transfusion in the
absence of other identifiable causes for
fever.
This reaction may occur either during or
within 1 to 2 hours following the
transfusion.

Febrile Nonhemolytic Transfusion Reactions

Signs and symptoms

Chills

Increase RR

Rigor

Change in blood
pressure

Fever/ low grade

fever

Nausea or vomiting

Febrile Nonhemolytic Transfusion Reactions

Incidence
FNHTRs are commonly encountered
transfusion reactions.
FNHTRs occur in approximately 0.5 to
2.0% of units transfused and are more
likely to occur following transfusion of
platelets (138%) than following
transfusion of red cells (0.016%).

Febrile Nonhemolytic Transfusion Reactions

Incidence
Leukocyte reduction decreases the
incidence of FNHTRs with both wholeblood-derived and apheresis
Individuals with a history of repeated
transfusions and women with a history of
multiple pregnancies are at higher risk of
FNHTRs

Febrile Nonhemolytic Transfusion Reactions

Pathophysiology
Fever is triggered by the action of
cytokines (e.g., IL-1, IL-6, TNF-) on the
thermoregulatory center of the anterior
hypothalamus inducing production of
prostaglandin E2.

Febrile Nonhemolytic Transfusion Reactions

Pathophysiology
Activation of DONOR leucocytes by antiHLA/Ab in RECIPIENTs
Activation of RECIPIENTs leucocytes and endothelial
cells by transfused DONOR leucocytes

Transferred of cytokines that accumulated

in the unit during storage

Febrile Nonhemolytic Transfusion Reactions

Management
As mentioned above, the first step in the
management of any transfusion reaction is
to discontinue transfusion procedure
immediately.
FNHTRs are typically benign, and usually
resolve completely within 1 to 2 hours
after the transfusion is discontinued.

Febrile Nonhemolytic Transfusion Reactions

Management
The remainder of the transfused unit and
a posttransfusion blood sample from the
patient should be sent to the laboratory for
investigation.
Acetaminophen 325 to 650 mg orally for
adults or 10 to 15 mg/kg per dose orally
for children is effective for ameliorating
symptoms.

Febrile Nonhemolytic Transfusion Reactions

Prevention
Approximately 10 to 15% of patients who
experience a FNHTR will have a similar
reaction to the next transfusion.
Administration of antipyretics
(acetaminophen) 30 to 60 minutes before
starting transfusion is often recommended
for a patient who has had two or more
FNHTRs.

Febrile Nonhemolytic Transfusion Reactions

Prevention
The routine use of premedication for all intended
transfusion recipient is unnecessary, as is the
routine use of antihistamines.
FNHTRs to red cell transfusions are almost
completely prevented by leukocyte reduction

Allergic Transfusion Reactions

Allergic transfusion reaction (ATR) is the
most common adverse reaction to
transfusion therapy.
Depending on the severity of these
reactions, different forms are recognized:
mild, anaphylactoid, and anaphylaxis.

Allergic Transfusion Reactions

Incidence
The mild form of ATR occur in 1 to 3% of
transfusions of plasma or platelets and in
0.1 to 0.3% for red cells.
Severe anaphylactic reactions are
estimated to occur in 1:20,000 to 1:50,000
transfusions.

Allergic Transfusion Reactions

ATRs usually begin during or within an hour of
starting a transfusion.
Common findings include hives, rash, pruritus,
and flushing.
More severe reactions occur sooner and may
include chest tightness, dyspnea, cyanosis,
hoarseness, stridor, or wheezing.

Allergic Transfusion Reactions

In addition, gastrointestinal symptoms

such as abdominal pain, nausea,
vomiting, and diarrhea may also occur.
Unlike other acute transfusion reactions,
fever is usually absent.

Allergic Transfusion Reactions

.
The clinical evaluation of ATRs should include
preexisting conditions such as atopy to drugs,
food, and other allergens, as well as asthma.
Classically anaphylaxis occurs immediately after
starting the transfusion. Symptoms can include
bronchospasm, respiratory distress, nausea,
vomiting, abdominal cramps, diarrhea, shock,
and loss of consciousness

Allergic Transfusion Reactions

In anaphylactic reactions, it is recommended to
test the patient for complete IgA deficiency and,
if possible, for the presence of anti-IgA
antibodies. However, life-threatening
anaphylactic reactions mandate use of washed
red cells and platelets and avoidance of freshfrozen plasma and other plasma transfusions
regardless of the results of these tests, so antiIgA antibody testing is superfluous unless IgA
deficiency is documented.

Allergic Transfusion Reactions

In anaphylactic reactions, it is recommended to
test the patient for complete IgA deficiency and,
if possible, for the presence of anti-IgA
antibodies. However, life-threatening
anaphylactic reactions mandate use of washed
red cells and platelets and avoidance of freshfrozen plasma and other plasma transfusions
regardless of the results of these tests, so antiIgA antibody testing is superfluous unless IgA
deficiency is documented.

Allergic Transfusion Reactions

Most ATRs are mild, self-limited and respond well to discontinuation
of transfusion and to administration of antihistaminic drugs such as
diphenhydramine hydrochloride.
In simple cases of urticaria and hives, resuming transfusion of the
blood product may be possible 15 minutes after treatment with an
antihistamine. Transfusion should never be resumed in patients with
severe ATR especially in atopic patients. In acute anaphylaxis, fluid
resuscitation may be needed to maintain blood pressure followed by
administration of subcutaneous or intramuscular epinephrine (0.3
mL of 1:1000 dilution), as well as airway management and intensive
care. For shock, a higher concentration of intravenous epinephrine
(35 mL of a 1:10,000 dilution) can be administered.102
Glucocorticoids are usually not helpful in acute crises.

Allergic Transfusion Reactions

Patients with a history of mild ATRs can be
premedicated with an antihistaminic drug
30 to 60 minutes prior to transfusion. In
case of repeated reactions, patients may
be premedicated with a glucocorticoid
several hours before transfusion. Plasmadepleted or saline-washed red cells may
benefit patients with repeated ATRs. In IgAdeficient patients with a history of
anaphylaxis to transfusion, plasma
products from IgA-deficient donors
sometimes can be provided. Extensively
saline-washed red cells are an alternative
for such patients.

Allergic Transfusion Reactions