Transfusion: Practices in Nicu

TRANSFUSION
PRACTICES IN NICU
• DR.MANASWINEE
PRESENTATION:SAHOODr.Manaswinee Sahoo
GUIDED
• GUIDED BY : Dr Tapas
BY DR.NARENDRA Bandopadhyay
BEHERA
Overview:
• Introduction
• History
• PRBC Evidences
• Platelet evidences
• Plasma evidences
• IvIg evidences
• Transfusion reactions
Introduction:
• 50% of ELBW require transfusion during NICU stay

Seminars in Fetal & Neonatal medicine ;2016
• RML Data year 2020:

- 54% of VLBW
HISTORY OF BLOOD TRANSFUSION
• Prof. Karl Landsteiner
discovered that blood clumping
was an immunological reaction
• Karl Landsteiner's work made it
possible to determine blood
types
• For this discovery he was
awarded the Nobel Prize in
Physiology or Medicine in 1930
blood and blood transfusions 4
The ABO blood groups
• The most important thing is in assuring a safe blood transfusion.
• The table shows the four ABO phenotypes ("blood groups") present
in the human population and the genotypes that give rise to them.
Blood Antigens on
Antibodies in Serum Genotypes
Group RBCs
A A Anti-B AA or AO
B B Anti-A BB or BO
AB A and B Neither AB
O Neither Anti-A and anti-B OO
blood and blood transfusions 5
BLOOD COMPONENTS
Whole Blood
Slow Centrifugation
Packed Red Blood Cells Platelet Rich Plasma
High Speed Centrifugation
1 Unit of Random Donor 1 Unit of Fresh Frozen Plasma

Platelets
Thawing precipitates the
plasma proteins
Cryoprecipitate
Whole Blood:
• Storage
• 4° for up to 35 days
• 300 ml of 4:1 mixture of donor plasma and a nutrient
citrate anticoagulant solution
RBC Preparation:
• For viability and functional activity of RBC , Preservation in Additive

solution is required( meets the metabolic demand)
• All solutions contain:

# Citrate: Anticoagulant
# Phosphate: Buffer Shelf life 21 days
# Dextrose: Source of energy
Fanaroff & Martin; 11th ed

RBC Preparation:
• Addition of Mannitol/ Adeninine increases Shelf life

# CPDA = 35 days
# Preservative solution = 42 days
*Stabilises RBC membrane

*Maintains ATP
*Maintains 2,3DPG
• PRBC stored at 2-6 deg C
Volume Of Transfusion:
• RCTs on low(10-15ml/kg) vs High(20ml/kg) found no increased risk of

death with low volume Tx
Wong etal;2005, Mallet etal; 2016
• Transfusion volumes of 15 ml/kg are generally recommended for non-

bleeding neonates British Society for Haematology;2016
• Volumes greater than 20 ml/kg may increase the risk of volume overload in
non-bleeding patients.
• Neonates requiring PRBC Tx smaller volume 10-15ml/kg is preffered

Clinical practice guidelines; 2021
(Weak recommendation, low quality evidence)
Large vol Tx:
• Defined as equivalent to single circulating blood volume(80ml/kg) over

24hr
OR
50% of circulating blood volume within 3 hours
• May be required in craniofacial or liver surgery

• Monitor serum electrolytes for Hyperkalemia or Hypocalcemia
• RBC units <5 Day old & 24hrs within irradiation are recommended.
• Recommended using a blood warmer to prevent hypothrmia
British Society for Haematology;2016

Age of RBC for Neonatal Tx:
• Fresh (<7day old)
• Older(> or = 7day old)
• Use of “fresh (<7 days old) packed red blood cells only” for the
transfusion is NOT recommended.
• Neonatal units should follow the existing standard practice of blood bank
for issuing blood (oldest first approach).
(Strong recommendation, high-quality evidence)
• For Intrauterine transfusion, Fresh RBC (<5 Days is preferred)

ARIPI Trial 2012; JAMA Pediatrics
• Objective: To determine if RBCs stored for 7 days or less compared

with usual standards decreased rates of major nosocomial infection
and organ dysfunction in NICU patients requiring at least 1 RBC
transfusion.
• Design, Setting, and Participants: Double-blind, randomized
Conclusion:
controlled trial in 377 premature infants with birth weights less than
In this trial, the use of fresh RBCs compared with standard blood bank
1250 g admitted to 6 Canadian tertiary NICU between May 2006 and
practice did not improve outcomes in premature, very low-birth-
June 2011
weight infants requiring a transfusion.
• Primary outcome: Composite of neonatal morbidities
(NEC,ROP,BPD,IVH & Death)
• Secondary outcome: Rate of nosocomial infection
Fresh RBC/Older RBC Tx:
Objective: To assess the effects of using fresher versus
older red blood cells in people requiring a red blood cell
transfusion.
• Included 5 neonatal studies
Primary outcomes:
Mortality measured at two time points: immediate
(occurring within seven days in hospital) and short term
(up to 30 days)
Authors' conclusions
No clear differences in the primary outcome - death - were
noted between 'fresher' and 'older' or 'standard practice' red
blood cells in trials
that reported this outcome.
• Several factors precluded firm conclusions. Several
2015 ongoing trials needed to be included in this review.
units
Irradiation or No Irradiation for Tx:
• Irradiation of packed red blood cells and other cellular blood

components for use in neonates is strongly recommended.
• It is even more important to use irradiated products in situations

where the volume transfused is large (>20 mL/kg).
• A strong recommendation is being made in the presence of low-quality

evidence because of the serious morbidity involved from using non-
irradiated components.
(Strong recommendation, low-quality evidence)
Hb Threshold in neonatal Transfusion:
Authors' conclusions:
The use of restrictive as compared to liberal haemoglobin thresholds in infants of very
Outcome:
Population:
Objective:
low birth weight results in modest reductions in exposure to transfusion and in
Four trials, enrolling a total of 614 infants enrolled.
RCTs comparing
haemoglobin the
levels. effects of
Restrictive
To determine if erythrocyte early versus
practice
transfusion late,
does notorappear
administeredrestrictive versus
to have
to maintain liberal erythrocyte
a significant
low as comparedimpact
There were no statistically significant differences in the combined outcomes of death
transfusion
on todeath
highor regimes
major in thresholds
low birth
morbidities
haemoglobin weight
at first infants
hospital
reduces applied
discharge
mortality within
or three
at follow-up.
or morbidity days
in very of birth,
birth with
However,
low
or serious morbidity at first hospital discharge (typical risk ratio (RR) 1.19; 95%
given the uncertainties
weightofinfants
these conclusions,
mortality enrolled it would
or majorwithin threeasbe
morbidity prudent
days .to. avoid haemoglobin
of birth
outcomes
confidence interval (CI) 0.95 to 1.49) or in component outcomes
levels below the lower limits tested here. Further trials are required to clarify the impact
of transfusion practice on long2011 term outcome.
Citation Study Methodology/ Objective/ Main Findings
design participants outcome
Bell et al, 2005 RCT (Unv of Iowa) 100 hospitalized preterm to determine if restrictive guidelines for Infants in the restrictive-transfusion
infants with birth weights red blood cell (RBC) transfusions for group were more likely to have
of 500 to 1300 g preterm infants can reduce the number of intraparenchymal brain hemorrhage
transfusions without adverse or periventricular leukomalacia, and
consequences. they had more frequent episodes of
apnea, including both mild and
severe episodes.
Kirpalani et al,2006 RCT (PINT) 451 preterm infants (BW Liberal versus restrictive red blood cell No difference in liberal compared
<1000 g), GA< 31 weeks transfusion strategies on composite with restrictive haemoglobin
and 48 hours old outcome of death or serious morbidity thresholds in outcomes of death or
serious morbidity
Restrictive transfusion group had
more cognitive delay at corrected
age 18–21 mo
Franz et al., 2020 RCT (ETTNO) 1013 infants (400-999 gms) Comparison of liberal versus restrictive No difference in liberal compared
red blood cell transfusion strategies on with restrictive haemoglobin
outcome of death or disability at 24 thresholds on likelihood of death or
months corrected age disability at 24 months of corrected
age
Kirpalani et al, 2020 RCT (TOP) 1824 infants, 22-28 weeks Comparison of liberal versus restrictive No difference in liberal compared
gestation< 1000 gm red blood cell transfusion strategies on with restrictive haemoglobin
outcome of death or neurodevelopmental thresholds on likelihood of death or
impairment at 22–26 months corrected neurodevelopmental impairment at
age 22–26 months of corrected age
Conclusion:
• No benefit of liberal RBC transfusion over restrictive transfusion

strategy.
• All these studies were conducted for infants <1000 gms.
• Most ELBW infants can be managed by restrictive strategy.
• One should consider GA, weight and respiratory morbidities while

considering transfusion of RBC.
Hb Transfusion thresholds:

Hb Transfusion thresholds:

Hb Transfusion thresholds
Post natal age Respiratory support* No respiratory support
Week 1 115 100
Week 2 100 85
Week 3 & older 85 75
Suggested hemoglobin levels and hematocrit thresholds for transfusing infants with anemia of prematurity
* Respiratory support means O2 requirement >25%
Canadian pediatric society; 2020

TANEC:
• Ischemic insult to GIT proposed major contributor to NEC
• Anemia may impaire blood flow to intestine

Subsequent RBC Tx
Reperfusion injury
• Wide fluctuations in mesenteric oxygenation pattern is also proposed
• NEC also seen as aimmunologic injury to Gut (=TRALI)

Withholding feed during Tx:
• 7 studies included
• All Observational studies
• TANEC defined as NEC Stage

Population: 2/more within 72hours of
transfusion
All included studies involved very-low-birth-weight infants, except for studies by
Meneses et al. (low birth-weight infants) and Rindone et al. (<34 wk of gestation).
• Moderate evidence (GEADE
Criteria)
• Small sample size(n=150)
American Society for Nutrition. Adv Nutr 2017

Result :
• Summary :
our results indicate that withholding feeds in the peri-transfusion period reduces
the incidence
Pending furtherofresearch,
TANECjudging
in preterm infants.
whether the potential benefits of preventing a
• potentially
Given the devastating
limitations of the studies
condition suchincluded
as TANEC in our meta-analysis,
outweigh adequatelyof
the consequences
powered RCTs
iatrogenic are needed
nutritional to confirm
deprivation thesehfindings
for 12–24 will depend on interpretation of
the current evidence by individual Clinicians.
2017 American Society for Nutrition. Adv Nutr 2017

Primary outcomes:
Authors' conclusions:
Objectives:
Resultsthe
• -Number
Randomised : controlled
To assess of infants with
benefits necrotising
trial
and evidence
risks enterocolitis
is insufficient
of stopping (as
to defined
compared show by modified
whether
to continuing Bellfeeds
stopping Stage
feed management II an
has or
effect only
III (Bell onewithin
1978)
onduring,
the RCT involving
incidence 48 22 preterm
hourstransfusion
after orinfants
death.was
transfusion eligible for inclusion in the
before, and afterof subsequent
blood NEC in preterm infants
review.
• -Incidence
Large,
To determine of NEC
adequately anytime
thepowered
effectivenessafter
RCTs transfusion
are
and neededoftostopping
safety address feeds
this issue.
around the time of a blood
transfusion in reducing the risk of subsequent necrotising enterocolitis (NEC) in preterm
-Mortality to 44weeks PMA
infants 2019
FEEDUR RCT:
Objective:
compared three different enteral feeding regimes during a single red cell
transfusion in preterm
Results:outcome:
primary was infants < 35 weeks gestational
mean splanchnic-cerebral age at birth.
oxygenation ratioInfants were
randomised
There
(SCOR) andtomean
were
Conclusion: 60either:
transfusion
splanchnicepisodes (20oxygen
fractional transfusion episodes
extraction in each
(FOE)
group)
before
There(1included
were no in
h prior), the analysis.
differences
during (1 hin
into
splanchnic
transfusion)
oxygenation
and after when
(end ofenteral feeds
(1) Withholding
41were
infants
transfusion; with
either enteral
24 h feeds
a median
12withheld,
and for 12orhrestricted
gestational
continued
post) from
age
transfusion at the start
birth of atransfusion
of 27
during weeks or 23–
(range
transfusion
(2)
32Continuing
weeks) were enteral feeds or;
enrolled
(3) Restriction of enteral feed volume to 120 ml/kg/day (maximum 20 kcal/30 ml)
for 12 h.
• Conclusion: Inadequate evidence on withholding feeds prevents

TANEC
• In our unit we follow continuation of feeds during transfusion; and no

baby has yet developed TANEC.
Diuretics during Transfusion:
Pre Tx testing:
• Fetal/neonatal ABO red cell antigens may be poorly expressed
• Red cell antibodies are not developed( naïve fetal immune system)
• Maternal IgG Antibody may be detected in neonatal plasma
• Red cell antibodies are not usually produced within the first four
months of life
• In infants >4months repeat testing for Blood group, Rh typing &
antibody screen can be performed
• Use of cord blood for blood type is discouraged because:
- Possible contamination with Wharton jelly
- Concern regarding proper identification of specimen
Fanaroff & Martin’s 11th ed.
Pre Tx testing:
• Maternal sample is prefrred for Ab testing :
- If maternal Ab is bound to fetal cells, then false negative
antibody test result can occur
- Large sample can be obtained for Ab screen & identification
- Sample from neonate can exacerbate anemia of prematurity
• Maternal sample should be collected within 3days delivery or post

delivery

Pre Tx testing:
• Investigation on maternal sample:
- ABO & D group
- Screen for the presence of atypical red cell antibodies
- Identification of the antibody/antibodies if the antibody
screen is positive
• Investigation on infant sample:
- ABO & D (Antigen – Forward testing)
- DAT in case of HDN/Hemolysis
- Atypical antibody screen (when mother’s sample N/A)
• Prior transfusion can affect blood group interpretation so any transfusion

history needs to be taken into account
Exchange Tx:
• To prevent bilirubin encephalopathy

• A single blood volume EBT will remove 75% of the neonatal red cells
• a double volume(160-200 ml/kg depending on gestational age) up to
85-90% red cells and up to 50% of circulating bilirubin
Forfar et al, 1958.
• While these babies still have evidence of haemolysis they should

receive folic acid supplementation
• Blood for neonatal exchange are irradiated and ‘fresh’ (before the end
of Day 5 following donation)
British Society for Haematology; 2016

PRBC Selection:
• Red cell units should be ABO & D compatible
• Units that are ABO compatible with both mother and baby must be selected
.
• Group O D-negative red cells are used for most neonatal top-up and
exchange transfusions
• Its important to minimize donor exposure(Use pedipacks)
• If it is not possible to obtain a maternal sample
It is acceptable to crossmatch antigen-negative units against the

infant’s plasma.
Neonatal PRBC Tx:
• Red cells up to the end of Day 35

• Hct approx 0.5-0.7
• Transfusion volume: typically 15 ml/kg (for non-bleeding patients) or
use transfusion formula
• Transfusion rate: 5 ml/kg/h
• Transfusion rate in cardiac failure <= 2ml/kg/hour
• Expected increase in Hb by 2-3g/dL

Neonatal PRBC Tx:
• recommended that a post-transfusion Hb no more that 20 g/l above the

threshold be aimed for
• Volume to transfuse (ml) = Desired Hb (g/l) - Actual Hb (g/l) x Blood

Volume (ml/kg)
Hematocrit of transfused RBC
• CMV seronegative components are required for IUTs & neonates up to 28

days post-expected date of delivery (i.e. 44 weeks corrected GA)
When to check Hb levels post Tx?
• Equilibration of Hemoglobin Concentration after Transfusion in
Medical Inpatients Not Actively Bleeding
• The hemoglobin measurements made 15 minutes after transfusion

reflect steady state values. Such measurements should be of great
value in decreasing patient waiting time after outpatient blood
transfusions and decreasing the need to repeat blood tests in 24 to 48
hours. Annals of internal Medicine; 1994
• we suggest that posttransfusion PCV be checked by 12 hours and

recommend further studies involving larger sample sizes for further
validation. International journal of paediatrics;2015
Neonatal Platelet Transfusion:
• Thrombocytopenia defined as platelet count <1.5 Lakhs
• Platelet is available as concentrates from single or multiple donors
• Manual Thrombapheresis is done either by ‘soft spin’ centrifugation

or re-centrifugation of buffy coat layer.
• Can also be prepared from single donor by an Automated Apheresis

machine
Neonatal Platelet count:
Conclusion:
the long-held definitions of neonatal thrombocytopenia (<150 000 ml1) and neonatal
thrombocytosis (>450 000 ml1) require revision. Depending on the pre- and
postnatal age of the subject tested, normal platelet counts can fall
Population:
below counts
Platelet 150 000were
and obtained
considerably above
between the450
first000
andyet
thebe90th
within
daythe reference
after range
birth, from
(5th to 95th percentile).
47,291Using thesedelivered
neonates new reference ranges,
at 22 to the number
42 weeks gestationof neonates
qualifying for the definitions of thrombocytopenia or thrombocytosis will be
fewer than previous estimates.
• Platelets have very short shelf life, typically 5 days & are stored
under constant agitation at 20-24 deg C.
• No effective preservative solutions, lose potency very quickly, best

when fresh
• 1 unit of SDP is equivalent to 5-10 units of RDP

Difference between RDP & SDP:
RDP (Random Donor Platelet) SDP ( Single Donor Platelet)
Platelet concentrate from whole blood by From a single donor by Apheresis technique
centrifugation
One unit has about 4.5 × 10^10 platelets One unit has about 3× 10^11 platelets
Low cost High cost
Increased donor exposure ;increased infection Single exposure; decreased risk of infection
transmission rate transmission
Increased risk of transfusion reactions Decreased risk of transfusion reactions
Lower increment in platelet count following Tx Higher increment in platelet count
Increased risk of alloimmunisation Reduced risk of alloimmunisation
Not useful in cases of platelet refractoriness Useful in cases of platelet refractoriness

Neonatal Platelet Transfusion evidences:
Citation Study Methodology Objective/ma Findings
design /participants in outcome
Stanworth et al., 2009 Prospective 169 neonates, Median GA Frequency and timing of One third of neonates developed
observational 27 and birth weight 822 gm haemorrhage and thrombocytopenia 0f <20000, 91% did not
study with platelet counts of <60 utilisation of platelet develop major haemorrhage.
(PLANET1) ×109 platelets per litre transfusions Most platelet transfusions were given to
neonates with thrombocytopenia with no
bleeding or minor bleeding only
Curley et al., 2019 Multicenter 660 neonates born <34 Comparison of low Higher threshold group had higher rate of
RCT weeks’ GA (25000) vs high threshold death or major bleeding than lower threshold
(PLANET 2) for (<50000)prophylactic within 28 days
platelet transfusion on
composite outcome of
death or major bleeding
Platelet Transfusion evidences:
Aims & Objectives:

Inclusion:
1)Conclusion:
whether (and how) platelet count is associated with major bleeding in
preterm
Sixthere
studies; infants;
with total ofevidence
is insufficient 1580 neonates
to assessborn <37 platelet
whether weeks’ GA, were included
(42)case
whether
counts areprophylactic
control platelet
studies,related
causally total transfusions
[n=456],1
to major RCT [ndecrease
bleeding, risk ofstudy
=152],1cohort major[nbleeding
=972])
orinwhether
pretermplatelet
infants;transfusions reduce bleeding risk in thrombocytopenic
3)preterm
whetherneonates.
(and how) other platelet indices such as
plateletstudies
Several mass or mean platelet
suggests volume
that platelet are associated
transfusions withreduce
may not major
bleeding
bleeding in preterm
risk, neonates.even increase it.
or may perhaps
2019
NAIT:
• NAIT results most commonly from maternally derived anti- HPA1a or

5b platelet antibodies
• suggested threshold of 25 x 109/l in the absence of bleeding is the
same as that for neonates without NAIT
• Consider intravenous immunglobulin in NAIT refractory to platelets
negative for HPA-1a/5b antigens or if antigen-matched platelets are
unavailable

NAIT:
Conclusion:
# the optimal approach for a neonate with FNAIT and severe thrombocytopenia is
to increase the platelet count as soon as possible with compatible antigen-negative
platelets.
# In neonates treated antenatally with IVIG, a single matched platelet transfusion is
generally sufficient.
#In our cohort, the use of IVIG in neonatal management did not show a beneficial
effect.
Platelet Transfusion threshold:
• Conclusion: Lower transfusion thresholds are safe
• A lower threshold (platelet count <25 000/mm3) should be used for

prophylactic platelet transfusions for prevention of major bleeding in
preterm neonates.
(Strong recommendation, moderate-quality evidence)
Platelet Transfusion threshold:

• Platelets should match the recipient ABO blood group wherever
possible (Don’t Express Rh D antigen)
• If D-positive platelets must be given in emergency, prophylactic anti-

D should be considered if the recipient is female
• Typical transfusion volume: 10-20 ml/kg

• Typical administration rate: 10-20 ml/kg/hr
• This dose should yield an increment of 50,000-1lakh/micL .

Platelet facts:
• Don’t store platelets in refrigerator
• After infusion life span of platelet is few hours to 24hrs
• Only ABO matching ; no Rh matching
• Procure platelets from blood bank only prior to Tx and transfuse
immediately
• Administer platelets through a separate IV line from blood
• Check platelet count post transfusion at: 1hr and 24hr

• Start infusion slow and advance rate if no reaction
Neonatal FFP Transfusion:
• Prepared by whole blood separation/Apheresis
• Fresh means plasma is frozen within 8hours of collection

• Produced from a Single donation
• 200-300 ml of plasma with 40-60 ml of citrate anticoagulant nutrient

mixture
• Stored at -30 deg C (shelf life of 12 months)

• Neonates have a different balance of pro-coagulant and anticoagulant

proteins compared to older children
• Overall haemostasis may be functionally adequate
• This results in different postnatal and gestational age-related

coagulation ranges in the first months of life
• Disseminated intravascular coagulation(DIC) is a poorly defined entity

in neonates.
Neonatal Plasma Tx:
• neonates exhibit hyporeactive platelets and decreased levels of

coagulation factors, the latter translating into prolonged clotting times
(PT and PTT)
• Counteracted by other factors in neonatal blood that promote

hemostasis (i.e., high levels of vWF, high hematocrit and MCV,
reduced levels of natural anticoagulants), resulting in a well-balanced
neonatal hemostatic system
• slightly tilted toward a prothrombotic phenotype

Frontiers in paediatrics; 2019
Neonatal Plasma Tx Evidences:
Thao T H et al., Cohort study Extreme PT(<26WK Does risk-based Early' risk-based coagulopathy
2012 GA) coagulation screening may identify preterm
-compared two screening predict infants at risk of severe IVH;
cohorts of infants who intraventricular however, the study failed to show
either had 'early' risk- haemorrhage in any benefit of early treatment of a
based coagulopathy extreme premature coagulopathy with FFP in a small
screening (within first infants? but high-risk population.
48 h, n = 47) or 'late'
screening (n = 55).
Pakvasa etal ; Retrospective 98 neonates with Evaluate the .Among neonates with moderate-
BMJ Open 2017 observational moderate-to-severe relationship to-severe HIE, haemostatic
Cohort study HIE who underwent between initial dysfunction is prevalent and
haemostatic testing haemostatic associated with an increased risk
within 12 hours of parameters and the of bleeding and high transfusion
birth and were born frequency and burden. Further studies are
from 1 January 2008 severity of bleeding needed to determine the
to 31 December 2013 in neonates with appropriate transfusion
hypoxic–ischaemic approaches in this population to
encephalopathy prevent bleeding
(HIE).
Authors' conclusions: 2004

Selection criteria:
Result: with normal saline, fresh frozen
Randomised trials of early volume expansion
Objectives:
There isComparing
no evidence from randomised
volume trials to
and no treatment, supportwith
4 studies the routine use940
a total of of early volume
very preterm
plasma, albumin, plasma substitutes or blood compared to no treatment or another
expansion in very
To determine
infants preterm
the effect
reported no infants
of earlywithout
volume
significant cardiovascular
expansion
difference in compromise.
on morbidity
mortality (RR and 95%
1.11, mortality
CI in
0.88,
form of volume expansion in preterm infants ≦ 32 weeks gestation or ≦ 1500 g
very preterm infants. If volume expansion is effective, to
were included. Volume expansion was 1.40). defined as at least 10 ml/kg given in the first
There is insufficient
determine the typeevidence
of volumeto determine
expansionwhether infants
that is most with cardiovascular
effective .
72 hours after birth.
compromise benefit from volume expansion.
2016
Neonatal Plasma Tx:
• no evidence to support the routine use of fresh frozen plasma (FFP) to

try to correct abnormalities of the coagulation screen alone in non-
bleeding neonates
• FFP may be of benefit in neonates with clinically significant bleeding
• Prior to invasive procedures with a risk of significant bleeding those
who have an abnormal coagulation profile(PT/APTT 1.5 times median
value)
• FFP should not be used for simple volume replacement or routinely
for prevention of IVH

Fetal & neonatal physiology; 5th ed ;Polin & Fox
Fetal & neonatal physiology; 5th ed ;Polin & Fox
Coagulation indices in very preterms:
Parameter <28wk >28wk

( n= 62) ( n= 44)
PT(s) 18.1 (12.9 - 28.5) 16.9 (12.5 - 25.5)
PTT(s) 87.2 (53.7 - 139.3) 72.6 (43.6 - 101.1)
Fibrinogen(g/L) 1.4 (0.7 - 3.8) 1.3 (0.8 - 4.0)
Journal of Thrombosis and Haemostasis, 13: 2021–2030

• coagulopathy is often defined as a PT or APTT greater than 1.5 times
the mid-point of normal range
• Not well defined in a neonate
• Coagulation screening should therefore only be undertaken for selected

neonates with
-- Evidence of bleeding or
-- At high risk of DIC, such as those with NEC or severe sepsis

• FFP should be ABO compatible with the recipient’s blood group
• D compatibility is irrelevant for FFP and cryoprecipitate due to

negligible residual red cells
• Dose = 10-15ml/kg
• Rate = 10-20ml/kg/hr
• This dose will replace approx. 10-30% of most factors immediately

(Increase of about 10% of factor is needed to achieve hemostasis)
FFP Transfusion Facts:
• FFP must be thawed in water bath at 30-37 deg C under agitation
• Transfuse immediately post thawing OR can be stored for 24hrs at 2-4deg
• FFP need to be ABO compatible; No need for Rh compatibility
• PT/INR may be repeated within 8hours of transfusion
• If hemostasis not achieved, readministartion may be needed every 6-8

hourly (Due to short t1/2 of factor VII; 2-6hrs)
• Transfusion frequency depends on half life of deficient Factor(s)

• Prophylactic fresh frozen plasma transfusion (FFP) is not recommended in

nonbleeding neonates receiving therapeutic hypothermia and having
deranged coagulation parameters
(Strong recommendation, moderate quality evidence)
• Neonates with deranged coagulation parameters and planned for

surgical or invasive procedure should receive fresh frozen plasma.
• Surgical and invasive procedures carry a substantial risk of major
bleeding in presence of coagulopathy.
• Hence, a strong recommendation in spite of very low-quality
evidence.
(Strong recommendation, very low-quality evidence)
Neonatal Cryoprecipotate Tx:
• The product is manufactured by slowly thawing a unit of FFP at

temperatures just above freezing (1-6 °C) and then centrifuged to
remove the majority of the plasma
• The precipitate is resuspended in the remaining plasma or in sterile

saline
• Stored at -30 deg C (shelf life 12 month).
• volume usualy 5 ml/kg

• One unit of cryoprecipitate contains:
- 80-100 U of factor VIII
- 150mg Fibrinogen
- Varying amount of factor XIII
• Indication:
* Congenital factor VIII def ( when factor conc not available)
* Congenital factor XIII def with active bleeding
* Afibrinogenemia/dysfibrinogenemia with bleeding
* Uremic bleeding
* Von-Willebrand disease
• Cryo may be indicated in neonatal cardiac surgery and major

hemorrhage
• Fresh frozen plasma (FFP) transfusion is preferred over
cryoprecipitate in the management of disseminated intravascular
coagulation.
• Cryoprecipitate may be used if there is persistent hypofibrinogenemia
(<1.0 g/L) despite FFP transfusion, rapidly falling fibrinogen, or major
hemorrhage.
(Weak Conditional recommendation, low-quality evidence)

Neonatal IvIg Evidence:
2019
Objectives: Conclusion:
ToBased
assessonthe
alleffect
Nine and studies,
studies
included complications of IVIg
with 658weparticipants
could innonewborn
makewere includedinfants
conclusions on with
in the alloimmune
study.
the benefit of
HDN on the need Onlyfor
2and
IVIg innumber
studies of exchange
provided
preventing ET transfusions
evidence with
or top-up low risk
transfusion
. of
. bias.
Neonatal IvIg Evidence:
Conclusion:
Objectives:
#No reduction in mortality during hospital stay, or death or major disability at two
To assess the eHects of IVIG on mortality and morbidity caused by suspected
or proven infection
years at infants
of age in study entry
with in neonates.
suspected or proven infection.
To assess in a subgroup
#Routine analysis
administration the eHects
of IVIG of IgM-enriched
or IgM-enriched IVIG IVIG on mortality
to prevent
from suspected
mortality infection.
in infants with suspected or proven neonatal infection is not
recommended.
Pretransfusion responsibilities:
• Assess values and verify prescription
• Assess vital signs, urine output and skin colour 15min prior to
transfusion
• Obtain venous access; no diuretic indicated
• Verify if patient needs special requirement
• Obtain blood products from blood bank within 30min of Tx
• Check and verify name, number, compatibility & note expiration time
• Administer blood product ad check vitals within 15 min then hourly
till 1 hour post transfusion.
Adverse transfusion reactions:
A.INFECTIOUS
B.NON INFECTIOUS
Acute Delayed
Non- Non-
Immunologic Immunologic
immunologic immunologic
Acute adverse reaction(<24hours):
Acute immunologic:
.Immune mediated hemolysis
.TRALI
.FNHTR
.Allergic reaction
.Anaphylaxis
Acute non immunologic:
.Fluid overload
.metabolic complication
i) Hyperkalemia
ii)Hypoglycemia
iii)Acid base derangement
iv)Hypocalcemia and hypomagnesemia
Delayed adverse reaction(>24 hour)
Immunologic reactions:
• Alloimmunization to RBC,WBC, platelets, Plasma
protein & HLA
• Haemolytic reactions
• TA-GVHD
• Post transfusion purpura
Non immunologic reactions:

• Iron overload
• Transfusion transmitted diseases
Acute haemolytic transfusion reaction:
• Most common cause: ABO incompatible blood Tx.

• Other : Hemolysis due to shear/heat stress by blood warmer, filter,
phototherapy lights.
Management:
Symptoms/Signs
Immediately stop Tx
Fever
Blood culture(Patient and
Chills
component)
Diaphoresis
Notify transfusion services
Hypotension
Send samples for: Hb, Hct,
Hemoglobinuria
Lactate, LDH, Urobilinogen
DIC
Ensure adequate Urine output
Acute Renal failure
Transfusion-related acute lung injury (TRALI)
• Fatal acute( within 4-6hrs) immune mediated Tx reaction

• Etiology:
Transmission of HLA or Neutrophil antibodies directed against
recipient leukocyte antigen
Sequester recipient neutrophils in lungs endothelium
Vasoactive mediators & capillary leak
FFP & Platelets are commonly implicated

Symptoms/Signs Management:
Respiratory distress Supportive
Non cardiogenic pulmonary
Respiratory support
edema
Hypotension Fluid
Fever vasopressor support
Severe hypoxemia (Hypotension)
Transient leukopenia Improves within 48-96hrs
Differentiate from TACO: Non-immune mediated, Cardiogenic pulmonary
edema, Hypertension by fluid overload
Treatment: Aggressive diuresis
Prevention
• Avoid use of plasma from multiparous females
• Use washed RBC
• Use leucocyte filters
For safe Transfusion in neonates:
• Leukocyte reduduction: Dec FNHTR, HLA Alloimmunisation,TRALI,

Transmission of leukotropic viruses
• Gamma irradiation: Dec TA-GVHD
• Washed RBCs: Reduces chance of hyperkalemia
• CMV Reduced: Prevents Transfusion acquired CMV

THANK YOU

Transfusion: Practices in Nicu

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Transfusion: Practices in Nicu

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TRANSFUSION

• 50% of ELBW require transfusion during NICU stay

• RML Data year 2020:

Packed Red Blood Cells Platelet Rich Plasma

High Speed Centrifugation

1 Unit of Random Donor 1 Unit of Fresh Frozen Plasma

• For viability and functional activity of RBC , Preservation in Additive

• All solutions contain:

Fanaroff & Martin; 11th ed

• Addition of Mannitol/ Adeninine increases Shelf life

*Stabilises RBC membrane

• RCTs on low(10-15ml/kg) vs High(20ml/kg) found no increased risk of

• Transfusion volumes of 15 ml/kg are generally recommended for non-

• Neonates requiring PRBC Tx smaller volume 10-15ml/kg is preffered

• Defined as equivalent to single circulating blood volume(80ml/kg) over

• May be required in craniofacial or liver surgery

British Society for Haematology;2016

• For Intrauterine transfusion, Fresh RBC (<5 Days is preferred)

• Objective: To determine if RBCs stored for 7 days or less compared

• Irradiation of packed red blood cells and other cellular blood

• It is even more important to use irradiated products in situations

• A strong recommendation is being made in the presence of low-quality

• No benefit of liberal RBC transfusion over restrictive transfusion

• All these studies were conducted for infants <1000 gms.

• Most ELBW infants can be managed by restrictive strategy.

• One should consider GA, weight and respiratory morbidities while

Clinical practice guidelines; 2021

British Society for Haematology;2016

Week 1 115 100

Week 3 & older 85 75

Canadian pediatric society; 2020

• Anemia may impaire blood flow to intestine

• NEC also seen as aimmunologic injury to Gut (=TRALI)

Fanaroff & Martin; 11th ed

• All Observational studies

• TANEC defined as NEC Stage

• Small sample size(n=150)

American Society for Nutrition. Adv Nutr 2017

2017 American Society for Nutrition. Adv Nutr 2017

• Conclusion: Inadequate evidence on withholding feeds prevents

• In our unit we follow continuation of feeds during transfusion; and no

• Maternal sample should be collected within 3days delivery or post

British Society for Haematology;2016

• Prior transfusion can affect blood group interpretation so any transfusion

• To prevent bilirubin encephalopathy

• While these babies still have evidence of haemolysis they should

British Society for Haematology; 2016

It is acceptable to crossmatch antigen-negative units against the

• Red cells up to the end of Day 35

• Expected increase in Hb by 2-3g/dL

British Society for Haematology;2016

• recommended that a post-transfusion Hb no more that 20 g/l above the

• Volume to transfuse (ml) = Desired Hb (g/l) - Actual Hb (g/l) x Blood

• CMV seronegative components are required for IUTs & neonates up to 28

• The hemoglobin measurements made 15 minutes after transfusion

• we suggest that posttransfusion PCV be checked by 12 hours and

• Thrombocytopenia defined as platelet count <1.5 Lakhs

• Platelet is available as concentrates from single or multiple donors

• Manual Thrombapheresis is done either by ‘soft spin’ centrifugation

• Can also be prepared from single donor by an Automated Apheresis

• No effective preservative solutions, lose potency very quickly, best

• 1 unit of SDP is equivalent to 5-10 units of RDP

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