Transfusion in children Packed cell platelet FFP cryoprecipitate

Transfusion in children Packed cell, platelet, FFP, cryoprecipitate, WBC

Packed red cell Transfusion

Packed red cells • Average hematocrit of a unit is 65 -75% ( concentrated) • Estimated unit size : 250 -350 cc • Stored at 2 -6 C • Mixed with preservation ( shelf-life of 35 days) • Infusion should take maximum 4 hours

General guidelines • Oncology: Hb, 8 gr/dl increased O 2 requirement patient symptomatic • Bone marrow failure: Hb<7 gr/dl increased O 2 requirement • Hemoglobinopathies: clinical situation(thalassemia major or intermediate, sickle cell

Contraindication: • Anemia that can be corrected by nontransfusion therapy( iron, recombinants erythropoietin) • Hypovolemia

Recommendation • CMV seronegative, irradiated, leukopoor preparation should be used per clinical guidelines

Platelet transfusion

Descriptions: • 1 random donor unit is concentrate of platelet separated from a unite of whole blood (5. 5× 1010 platelet in 40 -70 cc plasma) • A single donor unit is a unit collected by apheresis that contain 4 -8 time the number of platelet in 1 random donor unit (3 × 1011 platelet in 100 -500 cc plasma)

Platelet dosages • Dose of random donor unit platelet is one unit per 5 -10 kg, ( or 10 cc/kg for small infant) • Dose of single donor platelet is 10 cc/kg per infusion to maximum 1 unit apheresis(up to the adult dose) • Transfusion may proceed as quickly as tolerated: 10 cc/ kg/hour

General guideline • Hematology patients: Platelet<10, 000 Actively bleeding ( and platelet < 50, 000) Preparation for invasive procedure (IT , LP, liver biopsy…. ) • Oncology patients: Platelet<20, 000 Actively bleeding ( and platelet < 50, 000) Preparation for invasive procedure

Contraindication: • Thrombocytopenia and platelet distraction in patient with autoimmune disorder(ITP) and no active bleeding • TTP : Platelet transfusions are contraindicated unless there is life-threatening haemorrhage, • Heparin-induced thrombocytopenia : HIT is frequently associated with severe thrombosis (acute arterial thrombosis !)

Recommendation: • Infuse relatively quickly(10 ccc/kg/hour) to reduce clumping and adherence in bag and tubing • If concern over platelet response, obtain posttransfusion platelet count at 15 minute to 1 hour

Blood group and platelet transfusion • Identical ABO group as the patient are the components of choice and should be used as far as is possible (but not always available). • Administration of ABO non-identical platelets is acceptable transfusion practice (but may result in hemolysis) • In general, ABO-matched is best, but mismatched can be used when necessary

Blood group and platelet transfusion • Group O platelets may be used for group A, B and AB patients if they have been tested and labelled as negative for high-titre anti-A and anti-B • Rh. D-negative platelet concentrates should be given, where possible, to Rh. D-negative patients,

Blood group and platelet transfusion • If Rh. D-positive platelets are transfused to a Rh. D-negative woman: a dose of 250 i. u. anti. D cover five adult therapeutic doses of Rh. Dpositive platelets (it should be given subcutaneously in thrombocytopenic patients) • It is not necessary for men or women without childbearing potential

Fresh Frozen Plasma Transfusion

Fresh Frozen Plasma(FFP) • Contain coagulation factors in physiologically amounts( each ml contain I IU of each coagulation factor • Contain anticoagulation's such as protein C and S • Contain albumin, immunoglobulins, and complement proteins

Indications for FFP • Patients who require replacement of multiple plasma coagulation factors( e. g. liver disease, DIC. . ) • Massive transfusion ( have clinically significant coagulation deficiencies) • Patient taking warfarin who are bleeding or need to undergo an invasive procedure before Vit. K could reverse the warfarin effect • Transfusion or plasma exchange in patient with TTP • Management of patients with selected coagulation factor deficiencies , for which no specific coagulation concentrates are available

Contraindications FFP • Don’t use when coagulopathy can be corrected with specific therapy( Vit. K, cryoprecipitate, coagulation factor concentrate) • Don’t use when blood volume can be safely and adequately replaced with other volume expander • Don’t use as a source of albumin

Dosing FFP • Hemostasis can be achieved when the activity of coagulation factors is at least 25 -30% of normal: Unless there is coagulation inhibitor( heparin, etc. ), hyperfibrinogenemia • Plasma volume is approximately 40 cc/kg • 10 -15 cc/kg of FFP will replace coagulation factors to 20 -30%

FFP storage • Frozen at -18 C for 1 year or at -65 for 7 years • Once thawed should be infused within 4 hours

Cryoprecipitate

Cryoprecipitate • Cold soluble remnant of FFE • Concentrated preparation that contain : Factor 8 (80 -100 IU/bag), Fibrinogen(200 mg/bag), Factor 13, von Willwberand factor

Cryoprecipitate Indication: • First line therapy for control of bleeding with : fibrinogen deficiency, factor 13 deficiency • Second line therapy for : von Willebrand disease Factor 8 deficiency

Cryoprecipitate Contraindications: • Don’t use unless result of laboratory studies indicate a specific hemostasis defect for which this product indicated • Don’t use if virus inactivated factor 8 concentrates or recombinants factor preparation are available for patient with v. W. disease or hemophilia A • Don’t use for DIC( dose not contain all necessary factors(factor 5)

Cryoprecipitate dose • Hyperfibrinogenemia: 0. 2 bag /kg( increase fibrinogen approximately 50 -100 mg/dl) • Factor 13 deficiency: 1 bag/10 kg once • Bleeding in v. WD : 1 bag/10 kg every 6 -12 hours

WBC transfusion

WBCs • Administered as soon after collection as possible • If stored, maintain at room temperature(20 -24 C) without agitation, for no more than 24 hours • Donor preparation with G-CSF increased harvest yield

WBCs : need to • Be cross-matched with the recipient's serum • Irradiated because of the large number of lymphocytes present. • Considered for patients with an absolute neutrophil count <0. 5 x 109/L and a good chance of marrow recovery.

Indication : • Documented sever bacterial of fungal infections with an ANC<500 , • Functional granulocyte defect and unresponsiveness to antimicrobial therapy

Contraindication: • Irreversible BM failure • Prophylaxis's in non infected patients

Pediatric dosage • 1 -2× 109 cell/kg • Once initiated, WBC therapy should continue on daily basis until infection is cured, patient defervesce, or ANC is>500

Processing Leukodepletion, Gamma irradiation, washing, CMV negative

Processing: Leukodepletion

Processing: Leukodepletion • Leukodepletion is a technical term for the removal of leucocytes (white blood cells) from blood components using special filters. • Leukodepletion of blood components removes ≥ 99% of contaminating leucocytes • Prestorage or bedside filter?

Processing: Leukodepletion • Reduced risk of platelet refractoriness(HLA alloimmunization) • Reduced risk of febrile non-haemolytic transfusion reactions • Reduced risk of CMV transmission • Possible reduced risk of transfusion-associated GVHD (reduce risk but not prevent)

Processing: Gamma irradiation

Processing: Gamma irradiation • Gamma irradiation of blood product to stop donor lymphocyte proliferation • Prevent transfusion induced GVHD (100% fatal)

Gamma irradiation: indication • Intrauterine transfusion • Neonates with a birth weight of ≤ 1, 200 g and/or gestational age ≤ 30 weeks. • Congenital cellular immunodeficiency. • Aplastic anaemia receiving ATG

Gamma irradiation: indication Autologous BMT • Bone marrow or peripheral blood stem cell autologous transplantation (in the 7 days before collection of bone marrow or PBSC and up to 3 months after BMT, or 6 months for patients undergoing TBI).

Gamma irradiation: indication Allogeneic BMT • All recipients of allogeneic haemopoietic stem cell transplantation (SCT) must receive irradiated blood components from the time of initiation of conditioning chemoradiotherapy • Irradiated components should be continued while the patient continues to receive GVHD prophylaxis (until the end of GVHD prophylaxis) • Allogeneic blood transfused to bone marrow and peripheral blood stem cell donors 7 days prior to or during the harvest should also be irradiated.

Gamma irradiation: indication chemotherapy • Hodgkin’s lymphoma • chemotherapy (should be decided on an individual basis) • It is not necessary to irradiate red cells or platelets for adults or children with acute leukaemia, except for HLA-selected platelets or donations from first- or second-degree relatives

Gamma irradiation: indication other indications • All transfusions from first- or second-degree relatives should be irradiated, even if the patient is immunocompetent • All HLA-selected platelets should be irradiated, even if the patient is immunocompetent. • All granulocytes should be irradiated before issue and transfused with minimum delay

Gamma irradiation: not necessary When none of the above conditions are present, it is not necessary to irradiate blood components transfused to: • HIV infection, • Aplastic anaemia • Solid organ transplantation, • Chemotherapy for NHL, acute leukaemia and solid tumours • It is not necessary to irradiate red cells for routine 'top-up' transfusions of premature or term infants unless eithere has been a previous IUT, or the donation has come from a first- or second-degree relative

Processing: washing

Processing: washing • Help to remove extra K from red cell • Remove Ig. A form plasma • Extra plasma containing antigens and cytokine • Should be used within 24 hr.

Processing: washing Ø Indication : • Patients with Ig. A deficiency • Prevention of allergic reactions • Post-transfusion febrile reactions, present even when leukodepleted RBCs are used

Processing: CMV negative components

CMV negative components: Are recommended for the following recipients to reduce the risk of CMV transmission : Ø CMV negative recipients of allogeneic stem cell and bone marrow transplants CMV negative pregnant women Ø Intrauterine transfusions Ø Infants weighing less than 1200 g at birth

CMV negative components : May be recommended for CMV negative individuals: Ø HIV infection Ø Conditions likely to require an BMT or Solid organ transplant recipients Ø Severe neutropenia