- HEMATOLOGY-

Blood Component
Transfusion
●1st Year Pediatric Resident
 01
Red Blood Cell Transfusion
 Red Blood Cells

• Increase oxygen-carrying capacity of the blood

• Increase or maintain tissue oxygenation

Hemoglobin
Hematocrit
Other factors affecting tissue oxygenation:
• Oxygen offloading from RBC
• Microvascular blood flow
• Diffusion of oxygen into tissue cells
 Red Blood Cells

• Physiologic indication vs. Degree of anemia

INVESTIGATIONAL
 RBC Transfusion in Children and Adolescents

• Guidelines:
• Maintaining a specified Hb or Hct level
• Clinical condition present at the time of transfusion

• Adults vs. Children/Adolescent

• Normal hgb in healthy children are lower
• Rarely have underlying multiorgan, cardiorespiratory or vascular diseases
• May compensate better than elderly adults
 RBC Transfusion in Children and Adolescents
• Guidelines:
• Perioeperative period
• >7mg/dL
• Clinical and laboratory circumstances
• Consider the estimated blood loss for the surgical procedure planned and rate of bleeding
• Postopereatively, continued bleeding with hemodynamic instability compels RBC transfusion
• Restore RBC mass with iron therapy

• Acute hemorrhage
• Control of bleeding, restore blood volume and tissue perfusion with crystalloid or colloids
• Estimated blood loss is >25% and clinical condition is unstable
• RBC and plasma transfusion at 1:1 ratio
 RBC Transfusion in Children and Adolescents
• Guidelines:
• Critically-ill with Severe Cardiac or Pulmonary Disease
• Patients during ECMO
• Maintain hgb level close to normal range
• Transfuse conservatively
• Allow modest anemia
• No disadvantage to conservative/restrictive transfusion

• Chronic Anemia
• RBC transfusion not based solely on blood hgb level
• Factors to consider in transfusing RBC:
• Signs and symptoms
• Underlying cardiorespiratory, vascular and CNS disease
• Cause and anticipated course of anemia
• Alternative therapies such as EPO
 RBC Transfusion in Preterm Infants and Neonates

• 1st week of life - decline in circulating RBC mass

• Healthy term infants, rarely falls <11g/L at age 10-12 weeks

• Premature infants
• Earlier and more pronounced
• Approx 7g/dL in <1kg
• Anemia of prematurity
• Diminished plasma EPO level in response to anemia
• Rapid disappearance of EPO from plasma

• Begin surgery >10g/dL (hct >30%)

 RBC Product and Dose
• Prestorage leukocyte-reduced RBCs suspended in anticoagulant/preservative storage solution at hct
of 60-70% for storage up to 35-42days

Usual dose:
10-15mL/kg

• Neonates
• Centrifuged RBC concentrate (Hct 70-90%)
• Transfused slowly over 2-4hours
 Storage Age of RBC Units
• Old practice: transfusing fresh RBC (<7 days of storage)
• No advantage in transfusing fresh blood vs. stored blood

• >30kg undergoing elective surgery, preoperative autologous blood collections from patient occur up
to 6 weeks before the surgery
 Storage Age of RBC Units
• 2 storages:
• citrate, phosphate, dextrose, adenine (CPDA) solution
• shelf life of 35 days
• hematocrit level is 65% to 80%

• adenine, dextrose, sorbitol, sodium chloride, and mannitol (ADSOL)

• shelf life of 42 days
• Hct level 55% to 65%

• pRBC units are stored at refrigerator shelf temperature of 1°C to 6°C

• Must be used for transfusion within 4 hours and otherwise discarded
• Usually given over 2 hours to stable patients; more slowly to those with very low hematocrit levels
from chronic anemia to avoid precipitating heart failure
• Smaller aliquots of 5 to 6 mL/kg of body weight should be given in such cases
 02
Platelet Transfusion
 Children and Adolescents
• In practice, prolonged thrombocytopenia (>1 week) leads to development of risk factors: fever,
antimicrobial therapy, GVHD, active bleeding, DIC, liver or kidney dysfuction with clotting
abnormalities
• >>>> prophylactic PLT transfusion to maintain high plt (>30 x 10^9/L)

• No data to justify true benefit of plt transfusions given at a plt count >50 x 10^9/L unless bleeding is
ongoing and the thrombocytopenia being the only cause of bleeding
 Children and Adolescent
• Inherited platelet disorders
• If risk of significant bleeding is quiet high or bleeding is overt
• Repeated plt transfusion may lead to alloimmunization or refractoriness
• Prophylactic transfusion for invasive procedure

• Remember:
• Abnormal bleeding time or other laboratory test determining plt function is poorly predictive of
hemorrhagic risk or the need to transfuse platelet
Infants and Neonates
 Infants and Neonates
• Thrombopoetin (TPO) levels higher in neonates than in older children
• Fetal or neonatal megakaryocytes are smaller in size and lower ploidy — Produce less platelet

• When there’s an increase demand for platelet:

• Adult - megakaryocytes increase in size and ploidy
• Neonates - megakaryocytes increase in numbers but not in size

• After 17 weeks AOG

• >150 x 10^9/L

• Extremely small preterm

• Lower limit 120,000/uL
 Infants and Neonates
• Premature with birthweight <1500g, plt count <100 x 10^9/L, bleeding may be prolonged

• No documented benefit for prophylactic PLT transfusion to maintain PLT counts within normal or to
correct mod thrombocytopenia (>50 10^9/L)

• Inherited platelet dysfuction/during ECMO transfusion if

• >100 10^9/L
 Platelet Product and Dosing
• Platelet Concentrates -
• whole blood-derived platelets
• 5.5-10 x 10^10 plt in approx 50mL

• Pheresis Platelet -
• Platelet units collected by apheresis
• At least 30 x 10^10 platelet in 300-600mL
• Needs to be prepared as aliquots

• Storage:
• generally 5 days; for pheresis paletelet, can be stored up to 7 days
• Room temperature
• Constant agitation
• platelet units are the components most often associated with bacterial sepsis in the recipient
• Some institution culture platelet units before issuing them to blood banks
 Platelet Product and Dosing
• 2 ways developed to avoid infection:
• Pathogen Inactivation
• Treating the platelets with Amotosalen, are exposed to UV-A rays, breaking down the
DNA of viruses, bacteria, and white blood cells
• Being anuclear, platelets are not affected by this process

• Screening for bacterial growth before being issued for transfusion

 Platelet Product and Dosing
• Post transfusion goal: >50 x 10^9/L to >100 x10^9/L
• Dose:
• <30kg, 5-10mL/kg (unmodified)
• Larger children, 4-8 pooled PLT concentrates or 1 apheresis unit

• Rapid transfusion, not more than 4hours

• leukocyte-reduced; irradiated (for <1,500g)

• A dose of 10-15ml/kg unmodified platelet

• Adds approx 10 x 10^9 plt to 70mL blood (BV of a 1kg neonate)
• Increase plt count by 100 x 10^9/L
• Not an excessive volume
 Platelet Product and Dosing
• Remember…

• Platelets carry ABO antigens

• Transfusion to a recipient with a major incompatibility may lead to “platelet refractoriness”
• unexpectedly low rise in the platelet count after transfusion

• Platelets are also contaminated with minute amounts of RBCs

• Rh sensitization is a risk if a unit obtained from an Rh-positive donor is transfused to an Rh-negative
recipient
 03
Neutrophil Transfusion
 Granulocyte Transfusions for Children
• In practice, most patients with neutropenia with bacterial infections usually show response to
antibiotics alone
• Newly diagnosed ALL shows response to induction therapy and rarely require GTX

• Infected children with more sustained bone marrow failure and consequent neutropenia may benefit
from GTX added to antibiotics
• AML
• Malignant neoplasm resistant to treatment
• Severe aplastic anemia
• placental/cord blood hematopoetic progenitor cell transplant recepient

• No definitive studies have stablished GTX efficacy in patients with neutrophil dysfunction
syndrome
 Granulocyte Transfusions for Neonates
• Neonates with fulminant sepsis who exhibit relative neutropenia (blood neutrophil count <3.0 x
10^9 during the first week of life and <1.0 x 10^9 thereafter) and severely diminished neutrophil
marrow storage pool (<10% nucleated marrow cells) has increased risk of dying

• GTX has not provided definite solution

• Current data are insufficient to conclude that recombinant myeloid growth factors have a role in
treating septic neonates
 Granulocyte Products
• Neutrophils/granulocytes collected by leukopheresis must be transfused as shortly after collection as
possible
• Donors must be negative for HIV and hepatitis; seronegative for CMV
• Donors should be ABO/Rh crossmatch compatible with recipient

• Granulocyte Product Dosing:

• Infants/neonates weight <10kg dose: 1-2 x 10^9/kg neutrophil per treatment
• Larger infants and small children minimal dose: 1 x 10^10
• Adolescent dose: 5-8 x 10^10 per treatment (this dose requires donor to be stimulated with G-
CSF and dexamethasone)

• Should be given daily until infection resolves or blood neutrophil count sustained >1.5 x
10^9/L
• May be necessary to skip 1-2 days to accurately assess whether endogenous myelopoesis
and neutrophil production have recovered
 04
Plasma Transfusion
 Plasma Transfusion
• Prolonged clotting time alone is not an indication of plasma transfusion, instead determined by
actual bleeding or a significant risk of bleeding

• Plasma is transfused to replace clinically significant congenital or acquired deficiencies of plasma

protein
 Plasma Products and Patient Testing
• Types of Plasm
• Fresh Frozen Plasma (FFP) - Plasma frozen within 8 hours of collection
• F24 - Plasma frozen within 24 hours of collection
• Reduced levels of Factor V and VIII (not >25%)

• Equally efficacious

• Dose varies with the specific protein being replaced

Starting dose:
15mL/kg

• Indicated for treatment of deficiencies of clotting factors II, V, X and XI

 Plasma Products and Patient Testing
• Cryoprecipitate - Factor XIII and fibrinogen deficiencies
• In large amounts of plasma transfusion, fibrinogen may be sufficient

• Cryoprecipitate - a concentrate of cold and insoluble high-molecular-weight plasma proteins

• Precipitates when plasma is thawed slowly at 1-6°C
• Contains:
• Fibrinogen (more concentrated than plasma)
• Von Willenbrand factor
• Factor VIII
• Factor XIII

• Dose of 1-2u/kg can increase fibrinogen level by 60-100mg/dL

 Plasma Products and Patient Testing
• Storage and handling
• Stored at freezing temperatures of less than or equal to 18°C
• Can be stored for up to a year
• Should be transfused at a rate of 10 to 20 mL/kg per hour
• Clotting factors start degrading with every passing hour at room temperature
 Plasma Transfusion in Children
• Not recommended in SEVERE Hemophilia A or B, von Willebrand disease or Factor VII deficiency
since recombinant factor products are available

• Mild to moderate Hemophia A and certain types of von Willebrand Disease can be treated with
intranasal or intravenous desmopressin

• Indications:
• Rapid reversal of warfarin effects in patients who are actively bleeding or requires emergency
surgery
• Abnormal coagulation tests with bleeding or with risk of bleeding
• Chronic liver disease and prolonged clotting time with bleeding or invasive surgery is planned
• Plasma exchange in patients with TTP; other diseases: plasma exchange in Goodpastures, vasculitis
with over bleeding; other disorders with significant severe coagulopathy that would substantially
worsen with albumin replacement
 Plasma Transfusion in Neonates
• In neonates, clotting times are physiologically prolonged because of the developmental deficiency of
clotting proteins
• Normal values depends on birthweight and age of the infant

• Indications:
• Reconstitution of RBC concentrates to simulate whole blood for use in massive transfusion
• Hemorrhage secondary to vitamin K deficiencies
• Disseminated intravascular coagulation with bleeding
• Bleeding in congenital coagulation factor deficiency when specific treatment is unavailable

• Not used to adjust hgb or hct levels

• Not used in partial exchange transfusion for hyperviscosity
 05
Risk of Blood Transfusion
 Risk of Blood Transfusions
• Greatest risk of BT is mistakenly receiving blood products intended for another patient

• Misidentification resulting from wrongly labeling patient’s blood sample or not accurately matching
the unit

• High risk for infants

 Risk of Blood Transfusions
• Other infectious risks:
• Hepa A,B,E
• Syphilis
• Parvovirus B19
EBV
• Human herpesvirus
• West Nile virus
• Yellow fever vaccine virus
• Malaria
• Babesiosis
• Chagas disease
• Zika virus
 Risk of Blood Transfusions
• TRALI - risk is reduced by avoding female donors (possible alloimmunization to leukocyte antigen
during pregnancy); donors who are negative for HLA antibodies

• Immunologic adverse effects including immunosuppression, immunomodulation and

alloimmunization may be reduced by leukoreduction/leukodepletion
• Leukoreduction - removal of leukocytes by gross removal method
• Leukodepletion - removal of leukocytes with the help of certain specific filters or devices

• Irradiation - All cellular blood components should be irradiated, except those frozen without
cryoprotectant agent and to be rendered as “acellular” such as plasma and cryoprecipitate
• Prevents GVHD
THANKS!
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