Chapter 44 ■ Exchange Transfusions 317

(2) Blood may be anticoagulated with citrate phosphate dextrose (CPD or CPDA1) or heparin

(heparinized blood is not licensed for use in the

United States). Additive anticoagulant solutions

are generally avoided; if there is no other option,

packed red cells stored in additive solutions may

be washed or hard packed prior to reconstitution

for ET (24).

(3) Hematocrit (Hct) may be adjusted within the

range of 45% to 60%, depending on desired end

result.

(4) Blood should be as fresh as possible (<7 days)

(5) Irradiated blood is recommended for all ET to

prevent graft-versus-host disease. There is a significant increase in potassium concentration in

stored irradiated units, so irradiation should be

performed as close to the transfusion as possible

(<24 hours).

(6) Standard blood-bank screening is particularly

important, including sickle cell preparation, HIV,

hepatitis B, and CMV.

(7) Donor blood should be screened for G-6-PD

deficiency and HbS in populations endemic for

these conditions (25).

b. In presence of alloimmunization (e.g., Rh, ABO) special attention to compatibility testing is necessary (9)

(1) If delivery of an infant with severe HDN is

anticipated, O Rh-negative blood cross-matched

against the mother may be prepared before the

baby is born.

(2) Donor blood prepared after the infant’s birth

should be negative for the antigen responsible

for the hemolytic disease and should be crossmatched against the infant.

(3) In ABO HDN, the blood must be type O and

either Rh-negative or Rh-compatible with the

mother and the infant. The blood should be

washed free of plasma or have a low titer of antiA or anti-B antibodies. Type O cells may be used

with AB plasma, but this results in two donor

exposures per ET.

(4) In Rh HDN, the blood should be Rh-negative

and may be O group or the same group as the

infant.

c. In infants with polycythemia, the optimal dilutional

fluid is isotonic saline rather than plasma or albumin (26).

Volume of Donor Blood Required

a. Whenever possible, use no more than the equivalent of one whole unit of blood for each procedure,

to decrease donor exposure.

b. Quantity needed for total procedure = volume for

the actual ET plus volume for tubing dead space

and blood warmer (usually an additional 25 to

30 mL)

 

314 Section VIII ■ Transfusions

31. Mou SS, Giroir BP, Molitor-Kirsch EA, et al. Fresh whole blood

versus reconstituted blood for pump priming in heart surgery in

infants. N Engl J Med. 2004;351:1635.

32. Gruenwald CE, McCrindle BW, Crawford-Lean L, et al.

Reconstituted fresh whole blood improves clinical outcomes compared with stored component blood therapy for neonates undergoing cardiopulmonary bypass for cardiac surgery: a randomized controlled trial. J Thorac Cardiovasc Surg. 2008;136:1442.

33. Blood components. In: Roseff SD, eds. Pediatric Transfusion: A

Physician’s Handbook. 3rd ed. Bethesda, MD: American

Association of Blood Banks; 2009:1.

34. Cid J, Lozano M. Risk of Rh(D) alloimmunization after transfusion of platelets from D+ donors to D- recipients. Transfusion.

2005;3:453.

35. Sanchez R, Toy P. Transfusion related acute lung injury: a pediatric perspective. Pediatr Blood Cancer. 2005;45:248.

36. Kenton AB, Hegemier S, Smith EO, et al. Platelet transfusions in

infants with necrotizing enterocolitis do not lower mortality but

may increase morbidity. J Perinatol. 2005;25:173.

37. Mohan P, Brocklehurst P. Granulocyte transfusions for neonates

with confirmed or suspected sepsis and neutropaenia. Cochrane

Database Syst Rev. 2003;CD003956.

38. Poterjoy BS, Josephson CD. Platelets, frozen plasma, and cryoprecipitate: what is the clinical evidence for their use in the neonatal

intensive care unit? Semin Perinatol. 2009;33:66.

39. Ramasethu J, Luban N. T activation. Br J Haematol. 2001;112:259.

40. Blood components. In: Roseff SD, eds. Pediatric Transfusion: A

Physician’s Handbook. 2nd ed. Bethesda, MD: American

Association of Blood Banks; 2006:1.

41. Elbert C, Strauss RG, Barrett F, et al. Biological mothers may be

dangerous blood donors for their neonates. Acta Haematol.

1991;85:189.

 

2004;121:590.

56. Roseff SD, Luban NL, Manno CS. Guidelines for assessing

appropriateness of pediatric transfusion. Transfusion. 2002;42:

1398.

315

Jayashree Ramasethu

44 Exchange Transfusions

Advances in prenatal and postnatal care have led a marked

decline in the frequency of exchange transfusions (ETs) in

United States (1), resulting in significantly less experience

in personnel performing the procedure (1). The reemergence of kernicterus as a public health problem underscores the importance of ET as a treatment modality that

could potentially prevent devastating neurodevelopmental

complications (2). In developing countries, ETs remain a

vital therapeutic intervention (3,4).

A. Definitions

ET: Replacing the infant’s blood with donor blood by

repeatedly exchanging small aliquots of blood over a short

time period.

B. Indications

1. Significant unconjugated hyperbilirubinemia in the

newborn due to any cause, when intensive phototherapy fails or there is risk of acute bilirubin encephalopathy (5).

a. Immediate ET may avert brain injury even when

there are intermediate or advanced signs of acute

bilirubin encephalopathy (6).

b. Figure 44.1 indicates the total serum bilirubin levels

at which ET is recommended for infants of 35 or

more weeks’ gestation.

c. Indications for ET in more immature infants are

variable and highly individualized, although some

countries have attempted to establish uniform

guidelines (7,8) (see Table 49.1).

2. Alloimmune hemolytic disease of the newborn (HDN)

(9)

a. For correction of severe anemia and hyperbilirubinemia

b. In addition, in infants with alloimmune HDN, ET

replaces antibody-coated neonatal red cells with

antigen-negative red cells that should have normal

in vivo survival and removes free maternal antibody

in plasma

3. Severe anemia with congestive cardiac failure or hypervolemia (10)

4. Polycythemia

Although partial exchange transfusion reduces the

packed cell volume and hyperviscosity in neonates

with polycythemia, there is no evidence of long-term

benefit from the procedure (11).

5. Uncommon indications for which ET has been used

a. Congenital leukemia (12)

b. Extreme thrombocytosis (13)

c. Neonatal hemochromatosis (14)

d. Hyperammonemia (15)

e. Organic acidemia (16)

f. Lead poisoning (17)

g. Renal failure (18)

h. Drug overdose or toxicity (19)

i. Removal of antibodies and abnormal proteins (20)

j. Neonatal sepsis or malaria (21,22)

C. Contraindications

1. When alternatives such as simple transfusion or phototherapy would be just as effective with less risk

2. When patient is unstable and the risk of the procedure

outweighs the possible benefit.

Partial ET, particularly to correct severe anemia

associated with cardiac failure or hypervolemia, can be

used to stabilize the patient’s condition before a complete or double volume ET is performed.

3. When a contraindication to placement of necessary

lines outweighs indication for ET. Alternative access

should be sought if ET is imperative.

D. Equipment

1. Infant care center (see Chapter 3)

a. Automatic and manually controlled heat source

b. Temperature monitor

c. Cardiorespiratory monitor

d. Pulse oximeter for oxygen saturation monitoring

 

edema, hypotension, fever, and severe hypoxemia.

(3) Reported only rarely in neonates due to the difficulty in distinguishing TRALI from other

causes of respiratory deterioration in sick infants;

however, it is documented in the setting of a

designated blood transfusion between mother

and infant (55).

c. Transfusion-associated circulatory overload

(1) Nonimmune alteration in pulmonary compliance and blood pressure due to volume overload

(2) Presents with respiratory distress, cardiogenic

pulmonary edema, and hypertension

5. Adverse metabolic effects

a. Hyperkalemia

(1) Blood that is irradiated and then refrigeratorstored may have K+

 levels of 30 to 50 mEq/L or

higher in the supernatant plasma.

(2) Small-volume transfusions of stored red cells do

not cause clinically significant elevations in

serum K+

 levels.

(3) Life-threatening hyperkalemia has been

described in sick infants and in those receiving

rapid infusions of large volumes of stored red

cells (24).

(4) Washed or fresh (<14 days) red cells are recommended for infants with profound hyperkalemia, renal failure, or when large volumes are

transfused rapidly.

b. Hypoglycemia or hyperglycemia

c. Hypocalcemia

d. Alterations in acid–base balance with large transfusions

References

1. Carson TH, ed. Standards for Blood Banks and Transfusion services. 27th ed. Bethesda, MD: American Association of Blood

Banks; 2011.

2. Josephson CD. Neonatal and pediatric transfusion practice. In:

Roback JD, eds. Technical Manual of the American Association of

Blood Banks. 16th ed. Bethesda, MD: American Association of

Blood Banks; 2008:639.

3. Wong EC, Paul WM. Intrauterine, Neonatal, and Pediatric

Transfusion Therapy. In: Mintz PD, eds. Transfusion Therapy:

Clinical Principles and Practice. Bethesda, MD: American

Association of Blood Banks; 2011:209.

4. Ferguson D, Hebert PC, Lee SK, et al. Clinical outcomes following institution of universal leukoreduction of blood transfusions of

premature infants. JAMA. 2003;289:1950.

5. Strauss RG. Data-driven blood banking practices for neonatal

RBC transfusions. Transfusion. 2000;40:1528.

6. Wong EC, Schreiber S, Criss VR, et al. Feasibility of red blood

cell transfusion through small bore central venous catheters used

in neonates. Pediatr Crit Care Med. 2004;5:69.

7. Nakamura KT, Sato Y, Erenberg A. Evaluation of a percutaneously placed 27-gauge central venous catheter in neonates weighing less than 1200 grams. Jpen. 1990;14:295.

8. Oloya RO, Feick HJ, Bozynski ME. Impact of venous catheters on

packed red blood cells. Am J Perinatol. 1991;8:280.

9. Frey B, Eber S, Weiss M. Changes in red blood cell integrity

related to infusion pumps: a comparison of three different pump

mechanisms. Pediatr Crit Care Med. 2003;4:465.

10. Strauss RG. How I transfuse red blood cells and platelets to infants

with the anemia and thrombocytopenia of prematurity. Transfusion.

2008;48:209.

11. Widness JA. Treatment and prevention of neonatal anemia.

NeoReveiws. 2008;9:e526.

12. Kirpalani H, Whyte RK, Andersen C, et al. The Premature Infants

in Need of Transfusion (PINT) study: a randomized, controlled

trial of a restrictive (low) versus liberal (high) transfusion threshold for extremely low birth weight infants. J Pediatr. 2006;149:

301.

13. Bell EF, Strauss RG, Widness JA, et al. Randomized trial of liberal versus restrictive guidelines for red blood cell transfusion in

preterm infants. Pediatrics. 2005;115:1685.

14. Whyte RK, Kirpalani H, Asztalos EV, et al. Neurodevelopmental

outcome of extremely low birth weight infants randomly assigned

to restrictive or liberal hemoglobin thresholds for blood transfusion. Pediatrics. 2009;123:207.

15. Blau J, Calo JM, Dozor D, et al. Transfusion-related acute gut

injury: necrotizing enterocolitis in very low birth weight neonates

after packed red blood cell transfusion. J Pediatr. 2011;158:403.

16. El-Dib M, Narang S, Lee E, et al. Red blood cell transfusion,

feeding and necrotizing enterocolitis in preterm infants.

 

J Perinatol. 2011;31:183.

17. Paul DA, Mackley A, Novitsky A, et al. Increased odds of necrotizing enterocolitis after transfusion of red blood cells in premature

infants. Pediatrics. 2011;127:635.

18. Singh R, Visintainer PF, Frantz ID 3rd, et al. Association of necrotizing enterocolitis with anemia and packed red blood cell

transfusions in preterm infants. J Perinatol. 2011;31:176.

19. Josephson CD, Wesolowski A, Bao G, et al. Do red cell transfusions increase the risk of necrotizing enterocolitis in premature

infants?. J Pediatr. 2010;157:972.

20. Jain R, Jarosz C. Safety and efficacy of AS-1 red blood cell use in

neonates. Transfus Apher Sci. 2001;24:111.

21. Luban NL, Strauss RG, Hume HA. Commentary on the safety of

red cells preserved in extended-storage media for neonatal transfusions. Transfusion. 1991;31:229.

22. Strauss RG, Burmeister LF, Johnson K, et al. Feasibility and safety

of AS-3 red blood cells for neonatal transfusions. J Pediatr.

2000;136:215.

23. Luban NL. Massive transfusion in the neonate. Transfus Med Rev.

1995;9:200.

24. Pisciotto PT, Luban NLC. Complications of Neonatal

Transfusion. In: Popovsky MA, eds. Transfusion Reactions. 3rd ed.

Bethesda, MD: American Association of Blood Banks Press;

2007:459.

25. Luban NL. Neonatal red blood cell transfusions. Vox Sang.

2004;87:184.

26. Mangel J, Goldman M, Garcia C, et al. Reduction of donor exposures in premature infants by the use of designated adenine-saline

preserved split red blood cell packs. J Perinatol. 2001;21:363.

27. Luban NL, Mikesell G, Sacher RA. Techniques for warming red

blood cells packaged in different containers for neonatal use. Clin

Pediatr (Phila). 1985;24:642.

28. Strauss RG, Bell EF, Snyder EL, et al. Effects of environmental

warming on blood components dispensed in syringes for neonatal

transfusions. J Pediatr. 1986;109:109.

29. Blood components. In: Gottschall J, eds. Blood Transfusion

Therapy: A Physician’s Handbook. 8th ed. Bethesda, MD: American

Association of Blood Banks; 2005.

30. Fasano RM, Luban NL. Blood Component Therapy for the

Neonate. In: Martin R, Fanaroff A, eds. Fanaroff & Martin’s

Neonatal-Perinatal Medicine. 9th ed. St. Louis: Elsevier; 2010:

1360.

 

(1) Commonly observed in premature infants with

NEC and/or sepsis (39)

(2) Suspect T-activation in neonates at risk with

intravascular hemolysis, hemoglobinuria, hemoglobinemia following transfusion of blood products, or unexpected failure to achieve posttransfusion hemoglobin increment.

(3) Routine cross-matching techniques will not

detect T-activation when monoclonal ABO antiserum is used.

(4) Diagnosis: Minor cross-match of neonatal

T-activated red cells with donor anti–Tcontaining serum, discrepancies in forward and

reverse blood grouping, confirmed by specific

agglutination tests using peanut lectins Arachis

hypogea and Glycine soja.

(5) Use washed red cells, platelets, and low-titer

anti-T plasma (if available) only when hemolysis is confirmed.

3. Nonimmunologic causes of hemolysis

a. Mechanical, through excessive infusion pressure

through small needles or 20- to 40-mm filters

b. Accidental overheating or freezing of blood

c. Simultaneous administration of incompatible drugs

and fluids

d. Transfusion of abnormal donor cells (glucose

6-phosphate dehydrogenase deficiency, hereditary

spherocytosis)

4. Other immunologic/nonimmunologic reactions

a. TA-GVHD (See processing with irradiation for risk

factors and prevention page 306)

(1) Seen 3 to 30 days following transfusion of a cellular component. Symptoms include fever; generalized, erythematous rash with/without progression to desquamation; diarrhea; hepatitis

(mild to fulminant liver failure); respiratory distress; and severe pancytopenia

(2) High mortality rate (80% to 100%)

b. TRALI:

(1) Secondary to transfusion of donor blood containing anti-HLA or neutrophil antibodies

directed against recipient leukocytes, causing

complement activation with microvascular lung

injury and capillary leak.

(2) Presents within 4 hours of transfusion with respiratory distress due to noncardiogenic pulmonary

Chapter 43 ■ Transfusion of Blood and Blood Products 313

 

(2) Frequency:

Approximately 1 per 38,500 U transfused

with low prevalence of septic reactions (1 in

250,000) for RBCs.

Approximately 1 per 5,000 U transfused with

septic reactions in 1 in 116,000 for platelets,

when pretransfusion bacterial screening (i.e.,

BacT/ALERT system) is employed. Lower bacterial contamination rates and septic reactions

exist for apheresis platelets compared to WBderived platelets (53).

(3) Organisms:

Common RBC contaminants include

Yersinia enterocolitica, Serratia

Spp., and Pseudomonas spp., Enterobacter

spp., Campylobacter spp., and Escherichia coli.

All have the potential to cause endotoxinmediated shock in recipients.

Common platelet contaminants include

Staphylococcus aureus,

Staphylococcus epidermidis, Bacillus spp.

diphtheroid bacilli and Streptococci. Most fatal

cases of bacterial contaminated platelets involve

gram-negative organisms.

(4) Treponema pallidum: No new transfusiontransmitted cases reported in >30 years (48).

c. Protozoa

(1) Malaria: Rare in the United States but reported

even in nonendemic areas (45)

(2) Babesiosis

(3) Chagas disease (Trypanosoma cruzi)

d. Prions: Creutzfeldt—Jakob

(1) Few proven cases of transfusion-transmitted

new-variant Creutzfeldt–Jakob disease at present. Those described have been in the United

Kingdom (54).

(2) Most blood collection centers attempt to minimize the risk by excluding donors considered to

be at higher risk for possibly harboring the infection, by family and travel history and specific

medical history (47).

2. Hemolytic reactions

a. Acute hemolytic immunologic reactions: Rare,

because of absence in infant of naturally occurring

anti-A or anti-B antibodies, and infrequent posttransfusion red cell alloimmunization despite multiple

transfusions.

b. T-activation: A form of immune-mediated hemolysis

associated with the transfusion of adult blood containing naturally occurring anti-T antibodies, into

neonates with exposure of a normally masked

Thomsen–Friedenreich (T) cryptantigen on their

RBC surface. T-activation can present with evidence

of intravascular hemolysis following transfusion of

blood products, or unexplained failure to achieve

the expected posttransfusion hemoglobin increment

(24,30).

 

Chapter 43 ■ Transfusion of Blood and Blood Products 311

1. Possible increased risk of transmitting infectious disease

because directed donors are often first-time or infrequent donors with no track record of safety, unlike

established volunteer donors, whose screening tests are

negative repeatedly.

2. Possibility of serologic incompatibility between the

recipient baby and the family donors.

a. Maternal plasma may contain alloantibodies directed

against paternal RBC, leukocyte, platelet, and HLA

antigens, which may result in significant hemolytic,

thrombocytopenic, or pulmonary reactions (41).

b. Paternal blood cells may express antigens to which

the neonate may have been passively immunized by

transplacental transfer of maternal antibodies.

c. Routine pretransfusion testing may not detect these

serologic incompatibilities.

3. Although biologic parents may be interested in donating for their infants, many are likely to be ineligible for

medical or serologic reasons.

B. Precautions

1. Directed donations must be screened as stringently as

volunteer donations.

2. If maternal RBCs or platelets are transfused, they

should be given as washed cells or should be plasma

reduced and irradiated.

3. Fathers and paternal blood relatives should preferably

not serve as donors for blood components containing

cellular elements (RBCs, platelets, or granulocytes); if

their use is unavoidable, a full antiglobulin cross-match

should be performed to detect incompatibilities.

4. All blood components obtained from first- or seconddegree relatives should be irradiated prior to transfusion

of the neonate to prevent TA-GVHD.

Autologous Fetal Blood Transfusions

The placenta contains 75 to 125 mL of blood at birth

depending on the gestational age of the infant. Autologous

transfusion in an infant can occur by collection, storage,

and reinfusion of autologous cord blood, or by delaying

cord clamping, a successful variation of autologous transfusion. Both maneuvers potentially provide a substantial volume of fetal blood for the neonate, eliminating the potential risks of transfusion transmitted diseases and TA-GVHD

(42). Protocols for proper collection of autologous cord

blood with appropriate anticoagulation, without bacterial

contamination, are still being refined for these indications.

A. Indications

1. Autologous cord blood is a convenient source of autologous RBCs for elective transfusion to preterm infants.

2. Delivery room resuscitation of infants with shock and

profound anemia, when O Rh-negative RBCs are not

immediately available. Delaying cord clamping has

been shown to instantly increase RBC mass and circulating blood volume, while decreasing the immediate

need of RBC transfusions and possibly the incidence of

intraventricular hemorrhage in the preterm infant

(43–45).

3. Source of cord blood for freezing for hematopoietic

reconstitution.

B. Contraindications

1. Maternal infection

2. Chorioamnionitis

3. Sepsis

4. Hepatitis, HIV

5. Prolonged rupture of membranes >24 hours

C. Complications

1. Bacterial sepsis from contaminated collection (46).

2. Insufficient collection volumes from infants <1,000 g.

3. Over-/undercollection for volume of anticoagulant

used

 

C. Precautions

1. Storage of product for >8 hours is associated with a

rapid decrease in WBC function, making this a less

than useful product.

2. Fever, alloimmunization, TRALI, and CMV infection

have all been reported complications.

Fresh Frozen Plasma, Frozen Thawed

Plasma, and Cryoprecipitate

A. Indications (2,38)

1. FFP, Frozen Thawed Plasma

Clinically significant bleeding or for correction of

hemostatic defects prior to invasive procedures in the

presence of

a. Complex factor deficiency unresponsive to vitamin K

b. Isolated congenital factor deficiency for which virusinactivated-plasma-derived or recombinant factor

concentrates are unavailable

c. Support during the management of disseminated

intravascular coagulation

2. Cryoprecipitate

a. Congenital or acquired dys- or hypofibrinogenemia*

b. Congenital FXIII deficiency in the absence of FXIII

concentrate*

c. Bleeding associated with von Willebrand disease,

hemophilia A when virally inactivated plasmaderived or recombinant factor products are unavailable.

B. Contraindications

1. None absolute

2. Exert caution when possibility of volume overload

exists.

3. Use with caution in the setting of NEC and/or

T-activation as it may aggravate hemolysis (39).

4. Not indicated for hypovolemic shock in the absence of

bleeding, nutritional support, treatment of immunodeficiency, or prevention of intraventricular hemorrhage.

C. Equipment and Technique

See Platelet Transfusion.

1. Cross-matching is not required because type-specific or

AB-negative product is usually issued.

2. Dose of FFP is 10 to 20 mL/kg; multiple transfusions

may be required until the underlying condition

resolves.

3. Once thawed, FFP should be transfused within 6 hours

for labile factor replacement.

4. In cases for which repeated FFP transfusions are

required, a thawed unit from a single donor may be

divided into smaller aliquots and used within 24 hours

if stored between 1°C and 6°C.

5. A dose of 1 U/5 kg of cryoprecipitate will increase the

total fibrinogen by approximately 100 mg/dL in the

absence of ongoing consumption.

6. 1 U of cryoprecipitate equals approximately 12 to

20 mL.

Directed Donor Transfusions

A. Potential Problems

Directed donations provide no known benefit in terms of

increased safety and may pose unique immunologic and

serologic risks to the neonate (30,40).

*In the presence of active bleeding or planned invasive procedures.

 

a. Low hematocrit of RBC unit (extended-storage AP

vs. CPDA-1 units)

b. Inappropriate calculation of transfusion requirement

c. Ongoing blood loss

d. Transfusion reaction

Fig. 43.1. Neonatal syringe set with filter. (Courtesy of Charter

Medical Ltd., Winston-Salem, North Carolina). This system,

when used with sterile connection technology, provides a closed

delivery system that maintains primary unit outdate. Syringe blood

aliquots (PRCBs, plasma) must be administered to the patient

within 24 hours and syringe platelet aliquots within 4 hours.

Chapter 43 ■ Transfusion of Blood and Blood Products 307

e. Hemolysis due to ABO or other RBC incompatibility

(1) Infant has circulating anti-A, anti-B, and antiAB, which is bound to A or B antigens on transfused RBCs.

(2) Direct antiglobulin test negative initially but

now positive

(3) Unexpected increase in bilirubin

(4) Infant has RBC antibody other than ABO.

(5) Hemolysis from extrinsic damage (mechanical)

to RBCs or donor has hemolytic disorder.

(6) Hemolysis from T-activation

E

C

A B

D

Fig. 43.2. Use of a sterile connecting device. A: An adult RBC

unit is shown along with a set of pediatric transfer bags. The transfer

bags can be attached by spiking the unit, causing it to expire in

24 hours; alternatively, the transfer bags can be connected using a

sterile connection device. B, C: The separate tubings are loaded

into the tubing holders of the device. The covers are closed. D: A

welding wafer heated to about 500°F melts through the tubing.

The tubing holders realign and the welding wafer retracts allowing

the tubing ends to fuse together. E: The unit can now be aliquoted

as needed. Because a functionally closed system has been maintained, the expiration date of the blood has not changed.

308 Section VIII ■ Transfusions

Whole or Reconstituted Whole Blood

Transfusions

A whole blood (WB) unit contains approximately 450 to

500 mL of blood and 70 mL of AP solution. WB stored longer than 48 hours has decreasing levels of coagulation factors

V and VIII, does not contain functional platelets or granulocytes, and concentration of K+

 is high. Reconstituted WB is

prepared by adding a unit of RBCs to a compatible unit of

FFP and is preferable to the use of stored WB (29,30).

A. Indications

1. Massive transfusion as in acute blood loss, in excess of

25% of total blood volume (TBV) when restoration of

blood volume and oxygen-carrying capacity are needed

simultaneously.

2. Exchange transfusions

3. Cardiopulmonary bypass (CPB)

4. Extracorporeal membrane oxygenation

5. Continuous hemofiltration

6. There currently exists no consensus within the United

States on the use of fresh WB, reconstituted WB, or

reconstituted fresh WB (RFWB) for CPB pump priming or postoperative transfusion support in neonates

with congenital heart disease.

a. Recent studies have questioned the use of WB (31)

and have suggested an advantage in clinical outcomes in infants with congenital heart disease

receiving RFWB during CPB surgery (32).

b. Additional prospective studies are warranted to

determine optimal age of reconstituted WB units for

neonates undergoing CPB surgery.

c. Fresh WB (<48 hours old) is not universally available.

B. Precautions

1. Not suitable for simple transfusion for anemia

2. Not suitable for correction of coagulation factor deficiencies

3. Hyperkalemia may result from rapid transfusion of

large volumes (24).

4. Anticoagulant (citrate) effects must be considered for

large volume transfusion (21,24).

C. Equipment and Technique

1. Same as for RBCs