1. BLOOD COMPONENT THERAPY FOR THE NEONATE
Dehdashtian M.
Neonatologist, Associated professor of pediatrics
Ahvaz Jundi Shapur University of Medical Science

2. BLOOD COMPONENT THERAPY FOR THE NEONATE
RBC transfusion
Platelet transfusion
FFP transfusion
Cryoprecipitate transfusion
IVIG
Granulocyte transfusion

3. Red Blood Cell Transfusion
Anemia in newborn is indicated by:
Central venous hemoglobin<13gr/dl or capillary hemoglobin<14.5gr/dl
Anemia occurs when the red blood cell mass does not adequately meet the oxygen demands of the tissue

4. Risk of Transfusion Therapy
Metabolic Complications
Immunologic Complications
Transfusion-Related Necrotizing Enterocolitis
Transfusion-Related Intraventricular Hemorrhage
Infectious Complications

5. Metabolic Complications
Hypoglycemia
Hyperkalemia
Hypocalcemia

6. Immunologic Complication
Hemolytic Transfusion Reactions
Febrile Nonhemolytic Transfusion Reactions
Allergic Transfusion Reactions
Transfusion Associated Graft Versus Host Disease
Transfusion Related Acute Lung Injury
T-Antigen Activation

7. Transfusion-Related Necrotizing Enterocolitis
A temporal association may be exist between RBC transfusion and NEC
The risk of transfusion associated NEC increases with decreasing gestational age of the infant

8. Transfusion-Related Intraventricular Hemorrhage
Early RBC Transfusion may be play a role in IVH development or extension

9. Infectious Complications
CMV Infection
Hepatitis A Virus
Hepatitis B Virus
Hepatitis C Virus
HIV-1, HIV-2
West Nile Virus
Bebesiosis
Malaria
Trypanosoma Cruzi

10. CMV Infection
Neonates who at increased risk for post transfusion CMV related mortality and morbidity should be transfused with:
Seronegative Component
Leukoreduced blood products

11. These potential complications underscore the need to carefully evaluate a neonate's ability to deliver oxygen to tissues prior to ordering a nonemergent transfusion, and to document benefit following the transfusion

12. RBC TRANSFUSION INDICATIONS
It is often difficult to distinguish the neonate who is anemic and requires RBC transfusion from one who has adapted to a low hematocrit (Hct), and is best treated conservatively to avoid the associated risks of transfusion

13. Anemia occurs when the red blood cell (RBC) mass does not adequately meet the oxygen demands of the tissue
Oxygen supply to the tissue is defined as the product of cardiac output and arterial oxygen content (1.34×Hgb×Sao2)+(0.003×Pao2)

14. Suggested Guideline for Red Blood Cell Replacement in high risk neonates
Acute Blood loss
The need for transfusion in an infant with acute blood loss is generally dependent upon persistent clinical signs of inadequate oxygen delivery following intravascular volume restoration
Chronic Blood Loss
The need for RBC transfusion is, likewise, based upon clinical signs of inadequate oxygen delivery (increased resting heart rate, acidosis, poor growth, and apnea) and the degree of respiratory support needed by the infant

15. Acute blood loss
Neonates with significant acute blood loss require immediate fluid resuscitation
Term infants may tolerate perinatal blood loss up to one-third of their total blood volume
Infants with a hemoglobin level ≥10 gm/dL following volume expansion usually have adequate oxygen delivery and generally only require iron supplementation to replace iron losses due to the hemorrhage.

16. Indications for a RBC transfusion in a term or preterm neonate following an acute blood loss include:
>20 percent blood loss
10 to 20 percent blood with evidence of inadequate oxygen delivery, such as persistent acidosis
Ongoing hemorrhage
Consider the rate of blood loss before transfusion

17. Chronic Anemia
Anemia of Prematurity
NICU care and phlebotomy

18. Restrictive (low) versus liberal (high) target hematocrit (Hct) thresholds
The restrictive (low) transfusion thresholds compared with a liberal (high) threshold resulted in modest reductions in exposure to transfusions, and there were no differences in mortality, major morbidities, and serious neurodevelopmental impairment at 18 to 20 month corrected age

19. Chronic Blood Loss Restrictive (low) transfusion thresholds
Week 1
With respiratory support – 11.5
No respiratory support – 10
Week 2
With respiratory support – 10
No respiratory support – 8.5
Week 3
With respiratory support – 8.5
No respiratory support – 7.5

20. Chronic Blood Loss Restrictive (low) transfusion thresholds
For severe cardiopulmonary disease(Fio2>40%, MAP>8cm H20)
Hematocrit <30% (Hgb 10)
For moderate cardiopulmonary disease(Fio2<40%, MAP≤8cm H20)
Hematocrit <25% (Hgb<8)
For infants with anemia (Need to oxygen without pressure support)
Hematocrit <25% (Hgb<8) with one or more of the following : HR>180/min, RR>60/min, pH<7.2, lactic acid>2.5meq/lit, weight gain<10gr/kg/day, major surgery within 72 hr
For asymptomatic infants
Hematocrit<18%(Hgb≤6) ) with an absolute reticulocyte <100,000/microL (<2 percent).

21. Suggested Guideline for Red Blood Cell Replacement in high risk neonates
For severe cardiopulmonary disease(Fio2>40%, MAP>8cm H20)
Maintain hematocrit 40%- 45%
For moderate cardiopulmonary disease(Fio2<40%, MAP≤8cm H20)
Maintain hematocrit 30%- 40%
For major surgery
Maintain hematocrit 30%- 35%
For infants with stable anemia
Maintain hematocrit >20%-25%

22. Leukoreduced and irradiated red cells
Leukoreduction filters remove approximately 99.9 percent of white blood cells from PRBCs
leukoreduction does not eliminate all lymphocytes and cannot prevent transfusion-associated-graft-versus-host disease (TA-GVHD)
Irradiation prevents TA-GVHD in susceptible recipients
The dose of radiation is not sufficient to kill viruses and irradiation does not provide a CMV-safe product
Leukoreduced PRBCs should be used in all neonates
CMV-seronegative PRBCs should be used
Infants awaiting or undergoing transplantation
Immunocompromised infants
Preterm infants of CMV-seronegative mothers

23. Pretransfusion Testing, Dose and Administration
Blood group and type
Wt (kg) X blood volume per kg X (Desired Hct - Observed Hct)/Hct PRBCs,10 to 20 mL/kg
Over two to four hours

24. Platelet Transfusion Indication Pretransfusion testing Dose
<30000 for stable term and preterm infants
<50000 for VLBW neonates within the first week of life, clinically unstable neonates and neonate with alloimmune thrombocytopenia
in neonates prior to major surgery if the platelet count is <100,000/microL
Pretransfusion testing
ABO Compatible
Dose
1EU/5-10kg
Administration of 10 to 15 mL/kg of platelet suspension will increase the platelet count from 50,000 to 100,000/microL.

25. Fresh Frozen Plasma
FFP is used primarily to treat acquired coagulation factor deficiencies
ABO compatible
ml/kg

26. Cryoprecipitate Transfusion
It is a useful product in infant who required higher concentration of factors 8, 13, vWF, or fibrinogen
It is the treatment of choice for factor 13 deficiency, congenital afibrinogenemia, dysfibrinogenemia, and severe hypofibrinogenemia(<150mg/dl) associated with bleeding
1u/5kg

27. Intravenous Immunoglobulin
Useful in fetuses and neonates with Rh and ABO immune hemolytic disease
mg/kg/2- 4hr
IVIG should be considered in neonates with DAT- positive immune hyperbilirubinemia who are not responding to intensive phototherapy and whose TB concentration is approaching exchange transfusion

28. Granulocyte Transfusion
Granulocyte transfusion may be considered in neonates with qualitative neutrophil defects with severe bacterial or fungal infection
ABO and Rh compatible, cross match
Complications