Page 2058 - Hematology_ Basic Principles and Practice ( PDFDrive )

Chapter 121 Pediatric Transfusion Medicine 1827

and children who are immunosuppressed is paramount, so irradiation Hence glucose levels should be monitored during the first few hours
of cellular components can be performed to prevent this noninfec- of the exchange.
tious serious hazard of transfusion. There are differing expert opinions The goal of most exchanges is to exchange twice the blood volume
and practices, and local protocols based on patient populations, of the neonate. The volume needed can be calculated based on the
available equipment, and best practices at each institution should be fact that the blood volume of a neonate ranges from 100 mL/kg for
followed. The following patients should receive irradiated cellular the most premature to 85 mL/kg for term infants. Usually, one RBC
blood components: (1) premature infants with birth weight less than unit is sufficient for a two-volume exchange. The reconstituted whole
1200 g, (2) any child with known or suspected cellular immune blood should have a hematocrit of approximately 40% to 50% and
deficiency (e.g., severe combined immunodeficiency), (3) any child must be adequately mixed to maintain the intended hematocrit
with significant immunosuppression due to chemotherapy or radia- throughout the exchange transfusion.
tion treatment, (4) any child who receives blood components from The reconstituted whole blood should be transfused through a
blood relatives, and (5) any child who receives HLA-matched or standard filter and an inline blood warmer. In general, no more than
crossmatched platelet components. 5 mL/kg of body weight or 5% of the infant’s blood volume is to
be removed and replaced during a 2–5 minute cycle. The exchange
should be performed at a slow pace, so as to not cause sudden
Washing hemodynamic changes that can result in cerebral blood flow shifts
in intracranial pressure, precipitating an intraventricular hemor-
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Washing removes the supernatant from RBC or platelet units and is rhage. A double-volume exchange transfusion typically takes 1.5 to
usually performed to reduce the risk of allergic reactions related to 2 hours.
plasma. For very young children, washing may also be performed to
reduce the concentration of extraceullar potassium or to remove
anticoagulant-preservative solutions. Washing can also be used to REFERENCES
remove pathologic antibodies from a donor unit. Most donor units
lack such antibodies. However, if maternal RBC or platelet units are 1. FDA. INTERCEPT® Blood System for Platelets–Small Volume (SV)
used to treat her newborn with HDFN or neonatal alloimmune Processing Set. 2014: Intercept Package Insert.
thrombocytopenic purpura, respectively, then her plasma would 2. Beeck H, Hellstern P: In vitro characterization of solvent/detergent-
contain the pathogenic antibodies and the units should be washed treated human plasma and of quarantine fresh frozen plasma. Vox Sang
prior to transfusion. Indeed, because maternal blood contains patho- 74(Suppl 1):219–223, 1998.
logic antibodies in these settings, its use for these patients is not 3. Albisetti M: The fibrinolytic system in children. Semin Thromb Hemost
generally recommended. However, a maternal component may be 29:339, 2003.
used because it may be the only component available that lacks the 4. El Beshlawy A, Alaraby I, Abou Hussein H, et al: Study of protein C,
antigen recognized by her antibodies protein S, and antithrombin III in newborns with sepsis. Pediatr Crit
Care Med 11(1):52–59, 2010.
5. Bell EF, Strauss RG, Widness JA, et al: Randomized trial of liberal versus
Volume Reduction restrictive guidelines for red blood cell transfusion in preterm infants.
Pediatrics 115(6):1685–1691, 2005.
Volume reduction, involving removal of plasma, is primarily used for 6. Kirpalani H, Whyte RK, Andersen C, et al: The Premature Infants in
patients who cannot tolerate the volume of a blood component Need of Transfusion (PINT) study: a randomized, controlled trial of a
transfusion, such as some infants with compromised cardiac function. restrictive (low) versus liberal (high) transfusion threshold for extremely
However, it may also be employed for infants and children who low birth weight infants. J Pediatr 149(3):301–307, 2006.
receive ABO-mismatched platelet transfusions, because several deaths 7. Nickel RS, Josephson CD: Neonatal Transfusion Medicine: Five Major
have been reported in the literature of children who have received Unanswered Research Questions for the Twenty-First Century. Clin
38
out-of-group platelets (e.g., O platelet pheresis to A recipient). Not Perinatol 42(3):499–513, 2015.
all blood banks volume-reduce such platelets. 8. Fergusson DA, Hebert P, Hogan DL, et al: Effect of fresh red blood cell
transfusions on clinical outcomes in premature, very low-birth-weight
Reconstitution of RBCs for Neonatal infants: the ARIPI randomized trial. JAMA 308(14):1443–1451,
2012.
Exchange Transfusion 9. Patel RM, Josephson CD: Storage age of red blood cells for transfusion
of premature infants. JAMA 309(6):544–545, 2013.
During a neonatal exchange, the infant’s whole blood is replaced with 10. Lacroix J, Hebert PC, Hutchison JS, et al: Transfusion strategies for
reconstituted whole blood prepared from type-compatible RBCs and patients in pediatric intensive care units. N Engl J Med 356(16):1609–
plasma. Typically, RBCs less than 5 to 7 days old are used to minimize 1619, 2007.
the concentration of extracellular potassium and, theoretically, 11. Lightdale JR, Randolph AG, Tran CM, et al: Impact of a Conservative
provide transfused RBCs that will have maximal in vivo benefit, Red Blood Cell Transfusion Strategy in Children Undergoing Hemato-
although this has never been demonstrated. Because of theoretical poietic Stem Cell Transplantation. Biol Blood Marrow Transplant 2011.
concerns associated with large volumes of RBC additives transfused 12. Price TH, Boeckh M, Harrison RW, et al: Efficacy of transfusion with
to premature infants, nonadditive units are sometimes selected or granulocytes from G-CSF/dexamethasone treated donors in neutropenic
additives are removed from the RBCs prior to reconstitution. Most patients with infection. Blood 2015.
blood banks also provide RBC units that are negative for sickle 13. Heim KF, Fleisher TA, Stroncek DF, et al: The relationship between allo-
hemoglobin to avoid the rare potential of intravascular sickling. RBC immunization and posttransfusion granulocyte survival: experience in a
units should be leukoreduced, CMV seronegative, or both to reduce chronic granulomatous disease cohort. Transfusion 51(6):1154–1162,
the incidence of transfusion- transmitted CMV. The RBC unit 2011.
should also be irradiated to prevent TA-GVHD if the infant is con- 14. Wennberg RP, Depp R, Heinrichs WL: Indications for early exchange
sidered at risk of this by local criteria. If irradiated, the RBC or transfusion in patients with erythroblastosis fetalis. J Pediatr 92(5):789–
reconstituted whole blood should be irradiated just before the 792, 1978.
exchange to minimize liberation of potassium from intracellular 15. Davoren A, Curtis BR, Aster RH, et al: Human platelet antigen-specific
stores. Alternatively the RBC unit can be irradiated prior to volume alloantibodies implicated in 1162 cases of neonatal alloimmune throm-
reduction or washing. The glucose load during an exchange transfu- bocytopenia. Transfusion 44(8):1220–1225, 2004.
sion can be high due to the fact that banked plasma contains added 16. Friedman DF, Montenegro LM: Extracorporeal Membrane Oxygenation
dextrose and because glucose is added to RBC preservative solutions. and Cardiopulmonary Bypass. In Hillyer CD, Strauss RG, Luban NLC,