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  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 ...

  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. Ma...

  (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 drug...

  (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) Mala...

  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. Precaution...

  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...

  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...

  3. Attach, aseptically, in sequence a. Platelet concentrate or bag aliquot b. Platelet administration set, including filter c. Three-way stopcock d. Transfusion syringe 4. Draw volume of platelets for transfusion and tubing dead space into syringe. Clear air bubbles. 5. Remove syringe from three-way stopcock and attach to connecting tubing. 6. Establish IV access. If infant is at risk for hypoglycemia with interruption of continuous glucose source, start new IV or monitor closely throughout infusion. 7. Clear IV of glucose solution with 1 mL or more of normal saline. 8. Attach connecting tubing and syringe to IV line. 9. Monitor patient’s vital signs. 10. Infuse platelets over 1- to 2-hour period, faster if tolerated by infant. 11. After infusion is complete, flush IV line with 1 mL of normal saline before restarting glucose solution. 12. Determine survival time of transfused platelets by obtaining platelet counts at 1 and/or 24 hours if concern for platelet refractoriness. F. Co...

  Chapter 43 ■ Transfusion of Blood and Blood Products 309 D. Equipment and Technique 1. Platelets a. Random donor platelet concentrate (5.5 × 1010 platelets in 40 to 70 mL of plasma) (1) Separated from WB by centrifugation within 8 hours of blood draw and resuspended in plasma (2) Shelf life of 5 days b. Volume-reduced platelets (1) Standard platelet concentrate further concentrated to a volume of 15 to 20 mL by centrifugation (2) Associated with loss of platelets and possible decrease in platelet function (3) Shelf life reduced to 4 hours (4) Use only if infant has oliguria, severe volume load sensitivity c. Apheresis platelets (3 × 1011 platelets in volume of 250 mL plasma) (1) Removes only platelets, returns RBCs and plasma to donor (2) Usually LD before storage (3) Permits repeated donations from same donor every 48 hours under select circumstances (4) High yield of platelets (5) More expensive product (6) Useful when multiple platelet transfusions of a particular antigen spec...

  B. Contraindications 1. None absolute 2. Exert caution in patient with: a. Volume overload b. Congestive heart failure c. T-activation d. Increased risk for NEC (especially extremely lowbirthweight infants) C. Technique 1. Determine total amount of blood needed. a. Calculate volume of blood for transfusion. Most infants are transfused 10 to 15 mL/kg of RBCs, which will increase the hemoglobin by 3 g/dL. b. RBC volume required: [EBV × (Hct desired – Hct observed)] Hct of RBC unit (1) Hct is hematocrit (2) EBV is the estimated patient’s blood volume 80 to 85 mL/kg in full-term infants and approximately 100 to 120 mL/kg in preterm infants (3) RBC units collected in citrate-phosphatedextrose-adenine (CPDA-1) have a Hct of approximately 70%, RBCs in extended-storage AP solutions (AS-1) have a Hct ≤60% 2. Include volume of blood needed for dead space of tubing, filter, pump mechanism (varies from system to system; may be as much as 30 mL). 3. Obtain blood product (see Appendix C). a. S...