First edition 2024

PEDIATRIC
TRANSFUSION
THERAPY
To The Point

Dr / Ehab Elsayed Abd Elhameid

Pediatric consultant , hematologist
Egyptian fellowship of pediatric
pediatric hematology unit obour insurance hospital
Kafrelshikh general hospital ,
Transfusion therapy in pediatric DR/ Ehab Elsayed Abd Elhamied
Blood Transfusion

• Blood transfusion is the process of transferring blood or blood-based products from one person (donor) into the
circulatory system of another (recepient).

General rules

• Transfusion of blood products continues to be an important and necessary part of therapy in children with
hematologic and oncologic diagnoses
• transfusion decisions are made on the basis of clinical context, rather than the level of hemoglobin alone
• anemia and bleeding are not enough indication to prescribe transfusion
• work hard to avoid allogenic transfusion so don’t transfuse except if it is absolutely indicated to save life as
blood and blood products transfusion is risky so think twice before requesting blood or blood products
• rationalize consumption is important to overcome shortage of supply
• Trained staff should monitor a patient undergoing transfusion and respond immediately there are signs of an
adverse effect
• our goal safe transfusion right blood right patient right time right place

types of blood donation

Blood collection Donation of whole blood (WB)

Approximately 450-500 mL of WB is collected that then undergoes centrifugation with subsequent processing to
separate it into RBCs, platelets, and plasma.

Apheresis is the process whereby blood is separated into specific components, via centrifugation or filtration, with
the remainder of the blood components returned to the donor

Processing of Blood Components at the Collection and Processing Facility

Fractionation: If whole blood is collected, individual components (i.e., RBCs, platelets, and plasma) are separated
through centrifugation

Preservation: The initial collection bag contains an anticoagulant/preservative solution, which is either CPD (citrate-
phosphate-dextrose) or CPDA-1 (citrate – phosphate – dextrose - adenine).

Citrate is the anticoagulant.

Phosphate is necessary to replenish 2,3-diphosphoglycerate (2,3-DPG) as decreased levels of 2,3-DPG shift the
hemoglobin-oxygen dissociation curve to the left and oxygen release from hemoglobin to the hypoxic tissues is
impaired.

Dextrose is necessary for RBC energy. Glucose is converted to lactate through glycolysis, producing adenosine
triphosphate (ATP) for the red blood cell,

adenine is necessary for ATP production

prestorage leukoreduction: Blood components undergo leukocyte depletion, also called leukoreduction or
leukofiltration, prior to storage and further processing, thus arriving at blood banks already leuko reduced, obviating
the need to use bedside leukocyte filters. Pre-storage leukoreduction of a blood component has several advantages,
including

1- minimizing the occurrence of febrile non-hemolytic transfusion reactions,

2- minimizing HLA (human leukocyte antigen) alloimmunization and platelet refractoriness, and prevention of
transmission of leukotropic viruses residing in white blood cells (WBCs), such as CMV or EBV (Epstein-Barrvirus).
In fact, leukoreduced blood components can be considered CMV-safe even if they have been obtained from a
CMV-seropositive donor.
Transfusion therapy in pediatric DR/ Ehab Elsayed Abd Elhamied
Post-storage leukoreduction may not have the above advantages as WBCs can still release cytokines or leukotropic
viruses into the component solution during storage, and leukocyte fragments containing HLA may pass through
bedside filters.

irradiation: Cellular blood components need to be irradiated prior to transfusing to certain patients to prevent
transfusion-associated graft versus host disease (TA-GVHD). Irradiation prevents the donor T lymphocytes from
proliferating in the recipient and launching a cellular immune attack on the recipient’s tissues

washing: Washing is a process that aims to reduce the plasma component of cellular blood components such as
PRBC units or platelet units. The indications for this processing include severe or multiple allergic reactions in the
recipient. The goal is to reduce exposure to the inciting allergen in the plasma. The washing process itself is
accomplished by infusing 1–2 liters of normal saline into the unit and then centrifuging the unit to remove the
supernatant. The process unfortunately leads to loss of the cellular product as well, and up to 20% of the RBC yield
and 33% of the platelet yield are also lost. This process is labor-intensive, takes time, and reduces the expiry to
24 hours for PRBCs and 4 hours for platelet units and therefore should not be ordered unless there is a strong
indication for its use

bacterial culture of platlet unit:

pathogen inactivation in platlet unit
plasma SD (solvent / detergent -treated plasma ) eliminates the risk of transmission of enveloped viruses HIV , HBV
,HCV
Several changes occur in PRBCs during storage:
a. The pH decreases from 7.4–7.55 to pH 6.5–6.6 at the time of expiration.
b. Potassium is released from the RBC. The initial plasma K concentration is 4.2 mM and increases to 78.5 mM in
CPDA-1 units at day 35 and 45 to 50 mM in additive solution units on day 42. CPDA-1 units contain about one third
the plasma volume as additive units so the total amount of extracellular potassium is similar in all units of the same
age.
c. 2,3-diphosphoglycerol (2,3-DPG) levels drop rapidly during the first 2 weeks of storage. This increases the affinity
of the hemoglobin for oxygen and decreases its efficiency in delivering oxygen to tissue. The 2,3-DPG levels replenish
over several hours after being transfused
Transfusion therapy in pediatric DR/ Ehab Elsayed Abd Elhamied

Blood components

Component /product Composition Storage length Storage condition

volume

Red blood cells (PRBCs) RBCs (~ 75% Hct) 50-70 ml plasma, 28 days 1-6c
109 -1010 white blood cells (WBCs) and
citrate-phosphate-dextrose-
platelets (nonfunctioning)
adenine anticoagulant
(CPDA-1) ~ (250 ml)

PRBCs (additive, ~300 ml) RBCs (~60% Hct); 40 ml plasma, 109- 35 – 42 days 1–6c
1010 WBCs and platelets
(nonfunctioning); 100 ml additive
solution

Filtered PRBCs, leukocytes Hcts (~60% Hct ,< 5 × 106 WBCs few 35 – 42 days 1-6c
reduced (~300 ml with dysfunctional platelets, 40 ml plasma;
additive- ~225 ml without should contain~ 85% of original red
additive cell content

washed RBCs (~180 ml) RBCs with Hct 75% , < 3 x106 WBCs, 24 hours 1-6 c
no plasma

Whole blood (~500 ml) RBCs (Hct 40%) , 200 ml plasma, 28 d 1-6 c
(deficient in labile clotting factors V
and VIII, platelets (dysfunctional at 72
h)

whole-blood-derived Platelets >5.5 ×1010/unit , plasma; 5 days Agitated, 20 -

platelets (~50 ml) Platelets RBCs , WBCs 24 c

apheresis platelets (~300 Platelets ( > 3.3 x1011/unit), plasma; 5 days Agitated, 20 -
ml) Platelets RBCs, WBCs 24 c

fresh frozen plasma (FFP) (~ all coagulation factors and 1 year -18 c
250 ml) Plasma complement (no platelets),

ptn c, ptn s

F24 (plasma frozen within Plasma, all stable coagulation factors 1 year -18c
24 h after phlebotomy, and complement ptn c , ptn s (no
platelets), decreased level of labile
~ 250 ml) coagulation factors v , viii

cryoprecipitate (~15 ml) Fibrinogen ~ 150 mg/unit; factor VIII 1 year -18 c

~80 IU/unit , factor XIII, fibronectin,

von Willebrand factor
Transfusion therapy in pediatric DR/ Ehab Elsayed Abd Elhamied
Blood grouping

• A total of 30 human blood group systems are now recognized

• There are more than 400 antigens

ABO system

ABO antigens are carbohydrate antigens. Individuals lacking a certain ABO antigen develop antibodies “naturally”
without prior exposure via transfusion

• 4 ABO main blood groups: A, B, AB, O according to the presence or absence of A & B antigens on the surface of the
RBCs.

Group A : A Ag and anti B igM ab Group B :B ag anti A igM Ab

Group O : no Ag anti A anti B IgG Ab Group AB: A Ag B Ag no Ab

The Rh system is second to the ABO system in importance in transfusion medicine. Antibodies against RhD antigen,
however, require previous exposure to the antigen . The RhD gene may be either present or absent, giving the Rh D
+ or Rh D- phenotype respectively

Rh +ve : D Ag no anti D Ab Rh -ve : no Ag no Ab

• The Rh blood group system includes five important antigens D, C, c, E, and e, coded by two highly homologous
genes on chromosome 1

• Other blood groups are less frequently of clinical importance.

• Kell system • Duffy system • The Kidd gene • The Diego antigens

• The MNSs system • Lewis antigens • P group • Ii group

Typing and crossmatching• Each unit of donated blood is routinely typed prior to storage for both ABO and Rh (D)
antigens. In addition, the plasma from the unit is tested for the presence of anti-A and anti-B and for other minor
blood group antibodies using the indirect antiglobulin test.

Patient (Recipient) Compatible Components

Blood Group Plasma Contains Red Cells Plasma, Cryo
O Anti-A, Anti-B O O, A, B, AB
A Anti-B O, A A, AB
B Anti-A O, B B, AB
AB - O, A, B, AB AB

Patients who are Rh(D)-negative routinely receive Rh(D) negative RBC to prevent formation of anti-D antibodies

In life saving you can give Rh -ve patient Rh +ve blood and Ab will be formed after 3 monthes

Considerations for neonates :

1- During 1st weeks of life all neonates experience a decline in circulating RBC mass caused by physiologic factors.
2 - The drop of Hb near 9 g/dl in healthy term infants at the age of 10-12 wks. dose not require transfution
3 - In premature infants the Hb level can falls to 8 g/dl in infants of 1-1.5 kg of B.Wt and to 7 g in infants less than 1 kg
4- in the first four months of life:
Pre‐transfusion testing: – Maternal samples for ABO and RhD group and Antibody screen (5 mL clotted blood) –
Infant samples: ABO and RhD group, Direct antiglobulin test (DAT) and Antibody screen if maternal sample
unavailable (1‐2 mL clotted blood)
If the maternal antibody screen is negative and the infant’s red cells are DAT negative, cross matching is
unnecessary and blood of the baby’s group can be issued.
Transfusion therapy in pediatric DR/ Ehab Elsayed Abd Elhamied
If the maternal antibody screen and/or the neonatal DAT are positive, serological investigation and full
compatibility testing will be necessary.
Alloantibodies are rare in the first four months of life and are related to repeated massive transfusions and to
the use of fresh blood .After the first four months of life, cross matching procedures should conform to the
requirements for older children/adults

Choice of the blood group for neonate transfusion

mother baby Preferred Mother Preferred

baby
exchange exchange
A+ A+ A+ A- A+ A-
A+ B+ O+ A- B+ O-
A+ O+ O+ A- O+ O-
A+ AB+ A+ A- AB+ A-
A+ A- A- A- A- A-
A+ B- O- A- B- O-
A+ O- O- A- O- O-
A+ AB- A- A- AB- A-
B+ A+ O+ B- A+ O-
B+ B+ B+ B- B+ B-
B+ O+ O+ B- O+ B-
B+ AB+ B+ B- AB+ B-
B+ A- O- B- A- O-
B+ B- B- B- B- B-
B+ O- O- B- O- O-
B+ AB- B- B- AB- B-
O+ A+ O+ O- A+ O-
O+ B+ O+ O- B+ O-
O+ O+ O+ O- O+ O-
O+ AB+ O+ O- AB+ O-
O+ A- O- O- A- O-
O+ B- O- O- B- O-
O+ O- O- O- O- O-
O+ AB- O- O- AB- O-
AB+ A+ A+ AB- A+ A-
AB+ B+ B+ AB- B+ B-
AB+ O+ O+ AB- O+ O-
AB+ AB+ AB+ AB- AB+ AB-
AB+ A- A- AB- A- A-
AB+ B- B- AB- B- B-
AB+ O- O- AB- O- O-
AB+ AB- AB- AB- AB- AB-
Transfusion therapy in pediatric DR/ Ehab Elsayed Abd Elhamied

Minimum time for blood to be available

Turnaround Time Type of RBC’s Testing Performed Risk for Hemolysis

Available
5 minutes – extreme O Rh D Neg none Low life threatening
emergency RBC hemolysis rare
15 minutes - emergency ABO, Rh ABO, Rh type. RBC antibody Low
compatible screen not done.
30-45 minutes ABO, Rh ABO, Rh type. RBC antibody Negligible
For the majority of compatible screen negative; immediate
patients who lack RBC spin or computer crossmatch
antibodies. performed.

2-36 hours ABO, Rh ABO, Rh type. RBC antibody Negligible

For patients with RBC compatible screen positive; full
antibodies. crossmatch performed.

PRBCS
• The basic indication for PRBC transfusion is treatment of severe anemia that disrupts oxygen delivery to
tissues.
• Transfuse only and only if it is absolutely necessary. Avoid transfusing for arbitrary “triggers. Transfusion
should be prescribed only when the benefits to the patient are likely to outweigh the risks.
• Transfuse only as much as needed. If one unit will achieve the clinical goal, a second unit does not need to
be given
• The patient’s hemoglobin (Hb) value, although important, should not be the sole deciding factor in the
decision to transfuse blood. This decision should be supported by the need to relieve clinical signs and
symptoms and to prevent significant morbidity or mortality.
• Transfusion of blood and products should be undertaken only to treat a condition that would lead to
significant morbidly or mortality that cannot be prevented or managed effectively by other means.
▪ Must be ABO and RhD compatible with the recipient.
▪ In the peri-operative period it is unnecessary for children to maintain Hb level of 8g/dl, without continued
bleeding ( because children can quickly restore their RBC loss if given iron therapy).

. Monitoring the transfusion

• Take baseline observations and to ensure that the patient is monitored during the transfusion in order to
detect any adverse event as early as possible
• Monitor the patient 15 minutes after starting the transfusion and at least every hour during transfusion.
• Ask the patient to notify a nurse or doctor immediately if he or she becomes aware of any discomfort such
as shivering, flushing, pain or shortness of breath or begins to feel anxious. Use of medication at time of
transfusion
• It is generally not recommended to routinely use pre‐medication like anti‐histamines, steroids or other
medication before transfusion. This practice may mask or delay the signs and symptoms of an acute
transfusion reaction and therefore delay recognition and action to stop the transfusion
▪ It is indicated if the estimated blood loss is greater than 25% of the circulating blood volume OR > 17 ml /kg ,
and the patient's condition is unstable.
▪ In acutely ill children with sever pulmonary disease, requiring assisted ventilation, it is recommended to
maintain the Hb close to the normal range.
Transfusion therapy in pediatric DR/ Ehab Elsayed Abd Elhamied
dose
Packed RBCS (Hct 0.55‐0.75) should be used for top‐up transfusions at dose 10- 15ml/kg max 1 unit at 4hr. This will
increase Hb concentration by approximately 2‐3 g/dL unless there is continued bleeding or hemolysis.
Other method for calculation Wt x 3 x (hgb desired – hgb actual)

a. In critical cases, give the first 5 mL/kg of PRBS rapidly to relieve the acute signs of tissue hypoxia and cardiac
decompensation. Subsequent transfusion should be given slowly at rate of 5 mL/kg of red cells over 1 hour.
b. No routine Lasix .
c. Give frusemide (Lasix) 1 mg/kg by mouth or 0.5 mg/kg by slow IV injection to a maximum dose of 20 mg if
the patient is likely to develop cardiac failure and pulmonary edema
d. Any pack of RBCS should be given within 30 min after removal from blood bank fridge . Compete
transfusion within 4 hr minimum 2 hr at rate 5 ml / kg / hr will raise hgb 1-3 g/dl Be sure to take this into
account when ordering blood and calculating the time required for the transfusion. For example:
e. If a patient needs to receive 275 mL of blood, one unit of PRBCs should be ordered.
f. If a rate of 50 mL/hr is chosen, it will take 6 hours for the blood to be given, during which time the unit will
expire. It will therefore be necessary to order the unit split into 2 "pedi-packs".
g. PRBCs are an expensive and valuable resource. Investigate if blood bank can 'divide' units prior to release
and thus keep remainder of unit for possible subsequent transfusion. Always attempt to avoid discarding
PRBCs.
h. Never add medication to a unit of blood.
Whole blood is indicated
1. Red cell replacement in acute blood loss with hypovolemia.
2. Exchange transfusion.
Whole blood is contraindicated
Risk of volume overload in patients with:
1. Chronic anemia. 2. Incipient cardiac failure

PEDIATRIC TRANSFUSION GUIDELINES

Acute blood loss
a. Loss of greater than 15% total blood volume in children greater than four months of age (estimated blood volume
= 70 mL/kg body weight) or greater than 10% blood volume in infants less than four months of age (estimated blood
volume = 85 mL/kg).
b. With signs or symptoms of hypovolemia (tachycardia, tachypnea, hypotension) unresponsive to crystalloid or
colloid infusion.
c. Blood loss of lesser severity with signs and symptoms of cerebral or myocardial hypoxia , fatigue, weakness,
dizziness or respiratory distress
oncology patients
In general, a hemoglobin of 7 g/dl is used as the threshold for transfusion in pediatric oncology patients.
Infants with effects on growth and development due to anemia should be maintained at a higher hemoglobin;
similarly, adolescents may complain of headache and fatigue and be less symptomatic with hemoglobin in the 8–10
g/dl range. Those with cardiopulmonary dysfunction and those requiring procedural sedation with anticipated blood
loss should be kept in the 8–10 g/dl range as well.
Autoimmune hemolytic anemia
In patients with an autoimmune hemolytic anemia, immunosuppressive therapy is usually sufficient to abate the
underlying process. In those patients who are symptomatic with a continuing drop in hemoglobin or resultant
significant cardiopulmonary dysfunction, phenotypically matched blood may be given with close observation
knowing that hemolysis is likely to continue and may even be augmented. (AIHA)).
Note that in patients with AIHA, the blood bank may require more time to investigate the involved antibody and to
crossmatch units. Because rapidly evolving AB.
Transfusion therapy in pediatric DR/ Ehab Elsayed Abd Elhamied
severe anemia could easily decompensate, patients with severe anemia may not be able to wait for perfectly
matched blood. In such situations, even an incompatible unit may be transfused. Slow transfusion, warming the
patient and the unit in the presence of cold antibodies, providing fluids, and immunosuppressive therapy such as
steroids (methylprednisolone30mg iv) may slow the hemolysis and provide the patient with a more stable
hemoglobin until the autoimmune hemolysis is controlled
chronic anemia
Symptomatic anemia ( regardless of etiology),
✓ Hb ≤4 g/dL or Hct 12%.
✓ Hb 4‐6 g/dL (or Hct 13‐18%) if any of following clinical features are present:

▪ Clinical features of hypoxia. or heart failure

▪ Acidosis (usually causes dyspnoea).
▪ Impaired consciousness. pre-syncope, syncope
▪ Headache
▪ Evidence of inadequate oxygen delivery Indications for urgent blood Transfusion in children
▪ The transfusion should be undertaken very slowly and in small volumes in such patients. Typically the
volume for transfusion is 5mL/kg given over 3 hours, with careful monitoring of cardiovascular status

Asymptomatic

• Don’t think you should transfuse unless symptoms appear.

• Such children with chronic anemia can tolerate very low levels of hemoglobin, and it is not unusual for
severe anemia to be discovered during a routine blood count check For such asymptomatic patients,
transfusion could be held even for hemoglobin levels as low as 5 gm/dL
• If no other medical therapy (e.g., iron, folate, etc.) is likely to correct the anemia. If the etiology of the
anemia is due to iron, folic acid, or vitamin B12, supplementation should be started in addition to the
transfusion.
• Emergency surgery scheduled in patients more than four months of age when time precludes evaluation of
cause of anemia and specific replacement therapy.

Neonates
Premature infant
A .Stable, growing, Hgb < 7 g/dL
b. RDS, without oxygen requirement, Hgb < 10 g/dL
c. RDS, with oxygen requirement, Hgb < 12 g/dL
d. Mildly symptomatic anemia (e.g., apnea, tachycardia, poor wt. gain), Hgb <10 g/dL
e. Severely symptomatic (e.g., worsening apnea, hypotension, acidosis, heart disease), Hgb < 12g/dL.
Infants ≤ 4 monthes old
1. Maintain hemoglobin >12.0 g/dL and severe pulmonary disease
2. Maintain hemoglobin >12.0 g/dL during extracorporeal membrane oxygenation
3. Maintain hemoglobin >10.0 g/dL and moderate pulmonary disease
4. Maintain hemoglobin >12.0 g/dL and severe cardiac disease
5. Maintain hemoglobin >10.0 g/dL preoperatively and during major surgery
6. Maintain hemoglobin >7.0 g/dL postoperatively
7. Maintain hemoglobin >7.0 g/dL and symptomatic anemia
8. Perioperative anemia, Hgb < 10 g/dL
Transfusion therapy in pediatric DR/ Ehab Elsayed Abd Elhamied
EXCHANGE TRANSFUSION
Indications for exchange transfusion
1. When phototherapy fails to prevent a rise in bilirubin to toxic levels.
2. To correct anemia and improve heart failure in hydropic infants with hemolytic disease.
3. To stop hemolysis and bilirubin production by removing antibody and sensitized RBCs.,
immediate exchange transfusion is usually indicated if:
a. The cord bilirubin level is 4.5 mg/dL and the cord hemoglobin level is under 11 g/dL.
b. The bilirubin level is rising 1 mg/dL/hour despite phototherapy.
c. The hemoglobin level is between 11 and 13 g/dL, and the bilirubin level is rising 0.5 mg/dL/hour despite
phototherapy.
d. The bilirubin level is 20 mg/dL, or it appears that it will reach 20 mg/dL at the rate it is rising
e. There is progression of anemia in the face of adequate control of bilirubin by other methods (e.g., phototherapy).
5. Repeat exchanges are done for the same indications as the initial exchange. All infants should be under intensive
phototherapy while decisions regarding exchange transfusion are being made.
Blood for exchange transfusion
We use fresh (7 days old), irradiated, and reconst`21`ituted whole blood ( hematocrit 45–50%) made from packed
red blood cells (PRBCs) and fresh frozen plasma collected in citrate-phosphate-dextrose (CPD)
1 neonatal hyperbilirubenemia with the obstetrician and the blood bank is essential in preparing for the birth of an
infant requiring exchange transfusion
2. In Rh hemolytic disease, if blood is prepared before delivery, it should be type O Rh-negative, cross-matched
against the mother. If the blood is obtained after delivery, it also may be cross-matched against the infant.
3. In ABO incompatibility, the blood should be type O Rh-negative or Rh compatible with the mother and infant, be
cross-matched against the mother and infant, and have a low titer of naturally occurring anti-A or anti-B antibodies.
Usually, type O cells are used with AB plasma to ensure that no anti-A or anti-B antibodies are present.
4. In other iso immune hemolytic disease, the blood should not contain the sensitizing antigen and should be cross-
matched against the mother.
5. In nonimmune hyperbilirubinemia, blood is typed and cross-matched against the plasma and red cells of the
infant.
6. Exchange transfusion usually involves double the volume of the infant’s blood and is known as a two-volume
exchange. If the infant’s blood volume is 80 mL/kg, then a two-volume exchange transfusion uses 160 mL/kg of
blood. This replaces 87% of the infant’s blood volume with new blood.
Pt > 4 months of age
a. Postoperatively with signs of anemia (e.g., apnea) Hgb < 10 g/dL
b. Severe cardiopulmonary disease, Hgb < 12 g/dL
c. Patients receiving chemotherapy or irradiation, or patients with chronic anemia not responsive to medical
therapy, Hgb < 7 g/dL (symptomatic patients may be transfused at a higher hemoglobin level)
d Complications of SC disease (e.g., CVA or acute chest syndrome) or for preoperative preparation of such patients;
chronic transfusion regimen for thalassemia or other red cell disorders ( will be discussed later )
e. Circuit prime for plasma exchange, or stem cell collection.
f. Maintain hemoglobin > 8.0 g/dL in the perioperative period
g. Maintain hemoglobin > 12.0 g/dL during extracorporeal membrane oxygenation
h. Maintain hemoglobin > 7.0 g/dL and symptomatic chronic anemia

Blood transfusion in congenital anaemias Clinical guidelines

Haemolytic Anemia Due to Corpuscular Defects:

Membrane defects:
Hereditary spherocytosis , Hereditary elliptocytosis , pyropoikilocytosis , stomatocytosis
Indication for simple transfusion: < 8 g/dl
Transfusion therapy in pediatric DR/ Ehab Elsayed Abd Elhamied
In patients with hereditary spherocytosis, the abnormal RBCs are broken down in the spleen, while severe anemia
results in extramedullary hematopoiesis in the spleen and further splenomegaly, leading to a vicious cycle of
hemolysis causing anemia causing splenomegaly causing more hemolysis and more severe anemia. The aim of the
transfusion is to break this cycle by both elevating the hemoglobin and thus suppressing extramedullary
erythropoiesis and providing red blood cells that will not be destroyed in the spleen

Enzyme defects:
G6PD Pyruvate Kinase
• Hb less than 7 gm/dl
• If persistent hemoglobinuria < 9 gm /dl
Hemoglobin defect:
Globin: qualitative hemoglobinopathies : HbS,C,H,M
Quantitative hemoglobinopathy: Thalassemia Syndromes
Thalassemia blood transfusion guidelines :
Transfusion dependent thalassemia
Regular transfusions are also not justified only on the basis of Hb levels. Clinical parameters need to be assessed before
putting a thalassemia patient on chronic transfusion therapy because chronic transfusion therapy unless optimized
can cause red cell allosensitization, iron overload, viral transmission, etc
Objectives of chronic red cell transfusions
• To ensure adequate Hb level so that O2 delivery to the tissue is not affected. This will be indicated by:
• Normal growth spurt
• Increased energy and improved academic purpose
• Improved appetite
• To suppress over active erythropoiesis leading to bone deformities.
Dose
• Packed RBC 15ml / kg
• Blood transfusion every 2 - 5 weeks to maintaining the pre transfusion Hb level from 9 - 10.5 g / dl or higher
(11 – 12 g /dl) for patient with cardiac complications.
• Maintain an average Hb of 13 g/dl Maximum Hb level should be 14 – 15 g\dl.
What pretransfusion testing should be done before starting chronic transfusion therapy:
• Alloantibbody screening at regular intervals in necessary and ideally it should be done during pretransfusion
testing. Once an alloantibody is detected, it should be identified and antibody negative blood should be
crossmatched
• Extended phenotyping of patient's red cells (ABO, CcDEe, Fy, Kell) is desirable. It would be desirable to
establish an extended phenotyped donor registry
• Confirmation of a diagnosis of thalassemia major or severe thalassemia intermedia
• If the family is interested in stem cell transplantation, then counseling and early referral to such a centre is
justified
• Before starting chronic red cell transfusions, Hepatitis B vaccination should be completed
• Every 3 months, virus serology should be done to detect viral infection at the earliest
• Ideally patient should receive NAT tested blood product
• Detailed record of red cell transfusions should be kept, that is, date, number of units, origin of those units,
any complication, management, etc
• All precautions of grouping/crossmatching and transfusion as is applied to any patient on chronic transfusion
therapy should be taken
• Close relatives blood should not be transfused

Suggested Periodic Evaluations:

• LFT , KFT , ACR in urine , Abd / Us , Echo , Thyroid profile

• Serum ferritin levels should be recorded at regular intervals (3 months) after first 10 units of red cells have
been transfused and iron chelation should be started and the dose should be adjusted so as to maintain
serum ferritin between 500 and 1000 ng/ml , Serum ferritin level is not needed if the child is < 2 years
• Evaluation for iron overload every 1–2 years by validated liver iron quantification methods such as liver
biopsy, magnetic resonance imaging (MRI) R2 or MRI T2* or R2*
• Hepatitis and HIV Screening annually .
Transfusion therapy in pediatric DR/ Ehab Elsayed Abd Elhamied

Blood transfusion in sickle cell disease (SCD)

can be potentially lifesaving but can also be associated with morbidity.
The decision to transfuse or not should have the input of a clinician with expertise in managing patients with SCD.
All hospitals likely to admit patients with SCD should have access to manual exchange procedures. Larger centers
should have access to automated red cell exchange
Type of Blood
packed red blood cells (PRBCs) that are leukocyte-reduced / filtered, sickle hemoglobin (Hb S) negative, and
phenotype/antigen matched.

Acute or episodic transfusions:

The purpose of a simple transfusion is to increase the patient's red blood cell mass and oxygen carrying capacity.
Simple transfusion will increase Hb/Hct and decrease % Hb S in a heterocellular manner, but not to the extent of
exchange methods
Genral rules
1- Hb less than 5 g/L will need transfusions
2- Hb more than 7 rarely need transfusion( but other considerations will be taken into account)
3-Hb between 6-7 g/L on clinical grounds.
4- The volume of PRBCs transfused is calculated to raise the patient's hematocrit to 30% (target range 28-33%) or Hb
to 10g/dl.
5- Do not exceed Hct of 36% due to theoretical risk of hyperviscosity.
Indications of episodic or simple transfusion
1- Acute haemolytic crises Hb less than 5gm/dl or symptomatic
2-Acute splenic sequestration plus severe anemia Hg <5gml/dl or cardiovascular instability.
3-Severe aplastic crises Hb less than 5gm/dl or symptomatic
4-Acute chest syndrome as an initial when they are symptomatic (as defined by an
oxygen saturation less than 90% despite supplemental oxygen)
5-Sever painful crises not responding to all measures ( as a last solution).
6-Patient symptomatic from anemia, regardless of hematocrit
7-Severe, acute anemia compared to patient’s baseline: consider at Hb decrease of 2 g/dl, Hct decrease of 10%,
especially without compensatory reticulocytosis
8-Prior to surgery with general anesthesia
9-In children with hemoglobin SC disease (HbSC) or HbSβ+-thala
Exchange transfusions in sickle patient
Exchange transfusion allows the removal of sickle cells and their replacement by normal red cells and is the
preferred option where an immediate or sustained reduction in complications of SCD is required without an
undesirable increase in blood viscosity
Exchange transfusions are performed by removing the patient's own blood and replacing it with an equal volume of
transfused PRBCs and/or normal saline.
o Manual exchange transfusion – Remove patient whole blood (sickle hemoglobin) and replace with donor RBC
o Automated erythrocytapheresis- Remove patient sickled RBCs though automated centrifugation and replace with
donor PRBCs
The purpose of an acute exchange transfusion is to reduce the percentage of RBCs that contain hemoglobin S (i.e.,
reduce the "percent sickle") to 30-40%.
Advantages:
• Safe and rapid
Prevents iron overload
In the setting of chronic transfusion, patients can be kept in negative iron balance
Disadvantages:
Increased volume of PRBC required therefore increased donor exposure and increased alloimmunization and
infection risk
Increased red cell utilization
Requires special IV access (2 large bore IV catheters, 16 gauge, or central pheresis catheter)
Requires specialized equipment and personnel
Done in conjunction with transfusion medicine specialists and therapeutic apheresis team.
Transfusion therapy in pediatric DR/ Ehab Elsayed Abd Elhamied

Indications
1- Stroke or transient ischemic attack
2-Severe hepatic sequestration crisis not responding to simple transfusion
3-Multisystem organ failure.
4-Severe Intrahepatic cholestasis (sickle cell hepatopathy ) .
5-Priapism
6-Acute chest syndrome: symptomatic patient (hypoxia, respiratory distress), episode involving multiple lobes, not
responsive to simple transfusion
7-Prior to general anesthesia in patient with high baseline Hb (e.g. Hb SC disease) or h/o severe ACS or pulmonary
disease
8-Chronic transfusion protocol
Criteria for blood:
1-Plasma-reduced red cells with Hct 0.50-0.60 should be suitable for exchange
2-CMV negative.
3-Blood should be less than 7 days old
4-Irradiated (essential if previous IUT) and transfused within 24 h

PRE-EXCHANGE CHECKLIST –
1- Ensure availability of trained personnel and facilities. For urgent indications discuss with pediatric Intensive Care
Unit (PICU).
2- Obtain informed consent from parents before starting procedure explaining the purpose and risks –
3- FBC, reticulocyte count, HbS%, U&E, LFT, crossmatch (coordinate with transfusion laboratory for history of red cell
alloantibodies, previous transfusion requirement and extended red cell phenotype),
4- Hep BSag, Hep C Ab, HIV I+II Ab (if not done previously),
5- capillary/arterial blood gas –

PROCEDURE

1- Two large bore access lines are required (peripheral venous, central venous or arterial for venesection only) for
simultaneous venesection / infusion Single access may be used in the discontinuous technique with alternating
withdrawal of blood and infusion. This should be reserved for patients where it is difficult to gain 2 access lines.
2- Blood is exchanged in aliquots according to the patient’s weight and clinical condition – provided the patient is
cardiovascularly stable, aliquots of 20 mls should be used in patients 30kg. Each aliquot for removal of blood should
not exceed 5% of the child’s circulating volume (80mls/kg).
3- Hb > 7g /dl, and Hb within 2g /dl of steady state level and cardio-respiratory state stable Venesection 5ml/kg in
boluses of 20ml (wt30kg) – maximum rate 5ml/kg/hr. Replace with equal volume of Normal Saline Check Hb
4- Hb < 6g / dl or Hb 2g/dl below steady state, or cardio-respiratory state unstable Top-up transfusion 10ml/kg –
maximum rate 5ml/kg/hr Check Hb
5- For an isovolaemic exchange, a total of 15ml/kg of patient’s blood is to be exchanged with 5ml/kg of NS and
10ml/kg RBC (1:2 NS: RBC). Hb 20g/l below steady state, or cardio-respiratory state unstable
6- Start by venesecting the patient’s blood from cannula A as aliquot 1 (OUT) and then infuse the NS then RBC
sequentially (discontinuous) or concurrently (continuous) into cannula B as aliquot 1 (IN) according to table below.
7- Use infusion rates of no more than 100-150mls / hr or maximum of 5ml/kg/hr Do this in turns until the exchange
is completed.
Transfusion therapy in pediatric DR/ Ehab Elsayed Abd Elhamied
Out In

Aliquot 1 20 ml 20 ml NS

Aliquot 2 20 ml 20 ml Prbcs

Aliquot 3 20 ml 20 ml Prbcs

Aliquot 4 20 ml 20ml NS

Aliquot 5 20 ml 20 ml Prbcs

Aliquot 6 20 ml 20 ml pRBCS

Examples:
Child 1 wt =30kg, Hb 8g /dl
1. Initially venesect 5ml/kg = 150ml, replace with NS
2. Venesect 15ml/kg = 450ml, replace with 150ml NS and 300ml RBC (1:2 NS: RBC)
Child 2 wt =20kg, Hb 6.5g/dl
1. Venesect 15ml/kg = 300ml, replace with 100ml NS and 200ml RBC (1:2 NS: RBC)
• Monitor BP, pulse, O2 saturations every 15 minutes and temperature hourly throughout the procedure.
• Keep strict fluid balance chart throughout procedure as these unwell patients may require additional
maintenance fluids.
Repeat bloods post exchange : -

• Ensure Hb is >70g/l and <110g/l

• Beware of hyperkalaemia / hypocalcaemia / hypoglycaemia
• Ensure normal clotting
• The total HbS% should be <30% and a 30ml/kg exchange is usually required to achieve this
• In a stable child following a 30ml/kg exchange, leave a 4-6-hour break if further exchange is required. Very
unwell children may require continuous exchange

For those on regular exchange programmes, a single 15ml/kg exchange is usually adequate.

Chronic Transfusion
Long term (6 months – lifetime) PRBC transfusions used to suppress endogenous erythropoiesis, maintain a lower
level of sickle RBC and thus prevent certain complications of sickle cell disease.
Can be done with simple or exchange transfusion (manual or automated).
Can lead to iron overload, alloimmunization and other transfusion-related complications.
Relative Indications
1-Secondary stroke prevention. History of previous stroke (CVA).
2-Primary Stroke prevention for high risk patients based on elevated transcranial Doppler ultrasound (TCD) and/or
diffusion/perfusion MRI/MRA.
3-Multiple, severe episodes of acute chest syndrome requiring transfusion and/or PICU admission (at least 2 in past
year).
4-Chronic lung disease secondary to multiple episodes of acute chest syndrome or severe reactive airway disease not
responsive to maximal pharmacological management.
5-Two or more episodes of splenic sequestration syndrome either awaiting or deferring surgical splenectomy.
6-Recurrent and severe episodes of vaso-occlusive crisis (at least 6 admissions in past year).
7-Organ failure
8-Controversial indications include leg ulcers, priapism and pregnancy
Transfusion therapy in pediatric DR/ Ehab Elsayed Abd Elhamied
Protocol
• Consider starting protocol with a single exchange transfusion to decrease % Hb S to < 30%.
Simple or exchange (manual or automated) transfusion with goal hct of 33-36%. Volume depends on starting % Hb S,
if low, may transfuse higher with less risk of increased viscosity).
Goal % Hb S :
• Keep pretransfusion % Hb S <30% for patients with CVA, consider increasing to 50% after 2 years of chronic
transfusions in select patients.
• Keep pretransfusion % Hb S <50 for patients with other indications (adjust in accordance with clinical
improvement).
• Frequency is usually q 3-6 weeks and depends upon patient’s endogenous erythropoesis as well as goal %
HbS.
• Consider automated erythrocytapheresis for patients with transfusion related iron overload or to prevent
iron overload
• Chronic transfusions should be based on an initial exchange transfusion.
• Transfusion to HbS<30% will prevent or reverse most acute sickle complications and significantly reduce
long-term complications in chronically transfused patients.
• Baseline Hb and % HbS should be taken into consideration in setting the target post-transfusion Hb in order
to avoid hyperviscosity.
• Patients with baseline Hb<9 g/dl and not on regular transfusions, the post-transfusion Hb should not exceed
100 g/l, particularly if %HbS is greater than 30%.
• The post-transfusion Hb can be set at a higher target in chronically transfused patients or if %HbS is low, but
should be individualised to each patient.
• Patients with high baseline Hb (>100 g/l) should not be transfused above their steady state Hb
Sickle cell anemia and surgery :
• Target HbS of less than 30% before major surgery (cardiothoracic, neurosurgery), typically requiring
exchange transfusion;
• medium-risk or low-risk surgery might need simple transfusion to increase haemoglobin concentration to 10
g/dl
• Patients with initial hemoglobins greater than 10 (such as in many patients with SCD-SC) should receive
exchange transfusion for major surgeries
Transfusion is not recommended in uncomplicated painful crises but should be considered if there is a substantial drop
in Hb from baseline (e.g. >20 g/l or to Hb<50 g/l), haemodynamic compromise or concern about impending critical
organ complications
Specific indication
Cellular blood products should be for the following transfusions
• Intrauterine transfusions.
• Transfusions given to newborns or infants younger than 4 months of age (some centers irradiate only for
transfusions given to low-birth-weight preterm infants).
• Transfusions from blood-related donors.
• Transfusions following hematopoietic stem cell transplantation.
• Transfusions given to individuals with congenital immunodeficiency.
• Transfusions given to patients receiving chemotherapy or radiation treatment for cancer.
• Transfusions given to patients receiving intense immunosuppressive treatment.
• Transfusions of HLA-matched blood components.
• All granulocyte transfusions.
• All cellular transfusions need to be irradiated in homogenous populations where there is very little HLA variability.
For example, the Japanese population is relatively homogenous, and there is very little HLA variability, and cases of
TA-GVHD have occurred even after transfusions from unrelated donors to immunocompetent individuals
fresh PRBCS up to 7 days indicated in
• exchange transfusion
• massive transfusion
• hyperkalemia
• liver & kidney disease
Transfusion therapy in pediatric DR/ Ehab Elsayed Abd Elhamied

Criteria for RBC transfusion :

1- History of anaphylactic reaction to blood components.
2- IgA deficiency with documented IgA antibodies.
3- Recurrent severe urticarial reaction not prevented by pre-transfusion administration of antihistamines.
4- Febrile reactions associated with red cell administration not prevented by white cell reduction.
5- Neonatal alloimmune thrombocytopenia when the mother is the donor for the fetus or neo born infant.
6- For patients with hyperkalemia with poor renal function (until hyperkalemia
resolves)
7-Paroxysmal nocturnal hemoglobinuria
8-Intrauterine transfusion (fetal transfusion)
Frozen red blood cells :
• Frozen deglycerolized RBCs RBCs can be frozen by adding the cryoprotective agent glycerol to the RBCs before
freezing. RBCs are then thawed and washed with successively lower concentrates of sodium chloride to
remove the glycerol. Recovery of 80% of the red cells present from the original unit of blood is expected.
• The deglycerolization process is not universally available and can take several hours to perform. The RBC
product must be transfused within 24 h postthawing if prepared in an open system and within 2 weeks if a
closed system is used.
• A major indication for this product is the need for rare, multiple RBC antigen-negative products
A. IgA-deficient patients with Anti IgA antibodies if IgA-deficient product is unavailable (see Section XI)
B. Intrauterine transfusions
C. Paroxysmal nocturnal hemoglobinuria
CMV-negative components :
A CMV seronegative patients who are immunoincompetent and at risk for CMV disease, including:
1. Intrauterine transfusions
2. Infants < 6 months of age
3. Bone marrow or solid organ transplant candidates
4. Bone marrow or solid organ transplant recipients of a CMV-negative graft
5. Congenital or acquired immunodeficiencies

Appendix
• 1 ml of PRBC ↑ Hb 0.35g/dl.
• 1 U of PRBC adds 180 mg of iron to the body.
• 1 liter of whole blood contains 470 mg of iron.
• 3mL/kg PRBC will increase Hb by 1g/dl, Hct by 3%
• 10 mL/kg PRBC will increase Hb by 3g/dl, Hct by 10%

• the transfusion factor is approximately 5 (assuming no hemolysis of transfused blood or blood loss). The
estimated hemoglobin (hgb) increase can be derived utilizing this transfusion formula: Estimated
hemoglobin rise g/dl Volume of PRBC transfusion ml/kg Transfusion factor For example, for a transfusion of
15ml/kg, the estimated hemoglobin increase should be 3 g/dl. Of note,
• waiting a certain period of time for a post transfusion “reequilibration” prior to rechecking the hemoglobin
is not necessary
• There are several general features of products selected for transfusion to pediatric patients. All cellular
components, RBCs and Platelets, are leukoreduced (usually prior to storage but rarely with bedside filter) to
a residual WBC content of <5 X 106
• Donor exposures should be limited to the greatest degree possible. All blood products should be infused
using a “large pore” filter via standard blood administration set with the intrinsic 170-260 micron filter or,
for smaller pediatric units only, the Baxter blood component infusion set with the intrinsic 80 micron filter.
• A low potassium unit is less than 5 days old with irradiation no more than 3 days prior OR washed OR
deglycerolized. A non-irradiated adult (250mL) CPDA-1 unit ≤ 5days old will contain <1 mEq of K+ but the
same unit, if irradiated and stored for 3 days, will contain < 5 mEq
Transfusion therapy in pediatric DR/ Ehab Elsayed Abd Elhamied

PLATELETS
Platelets are made available in two types:
Pheresis platelets (“plateletpheresis”), a platelet concentrate (250-400 mL) obtained by plateletpheresis of
a single donor who is connected to a blood processor for 1½ hr, collecting enough platelets for an effective
transfusion dose.
Whole blood-derived platelet concentrate; a platelet concentrate (45-65 mL) separated from a whole blood
donation by centrifugation. A pool of five is needed to make an effective transfusion adult dose.
A single plateletpheresis and a pool of 5 platelet concentrates are therapeutically equivalent and will be provided by
the blood bank interchangeably as available.
Contents: A single plateletpheresis contains 3-5 X 1011 platelets. Volume is usually 180-450 mL
Each random donor platelet concentrate (derived from whole blood donation) contains greater than 6-9 X 1010
platelets. A pool of five contains approximately 3-5 X 1011 platelets. Volume is usually 45-65 mL
. RDP units have a volume of ~50 mL and contain at least 55 billion platelets per unit, but the larger apheresis units
have a volume of 200 – 250 mL and contain at least 300 billion platelets per unit
Dose: For small adults and older children, one platelet concentrate unit per 10 kg body weight is expected to raise
the platelet count by 50,000 platelets/microliter.
For neonates and infants, 5-10 mL per kg body weight is commonly used.
Expected result: Expect a rise of approximately 50,000/uL.
Rh antigens are not on platelets and Rh matching is not necessary unless there is RBC visibly present in the
component. In 95% of blood donors, A and B antigens are very weakly present on platelets. Generally platelet
transfusions are selected to be ABO identical or compatible but mismatched ABO platelets can be given. There is
little adverse affect of ABO mismatched platelets on the post-transfusion increment except in some repeatedly
transfused patients. (so Preferable to give Rh matching platelets)
• Platelets transfusion is appropriate to prevent or control bleeding associated with deficiency in platelets
number or function.
• Each 1 U of platelet / 10 kg will raise the platelet count by 40.000 to 50.000 / mm2 within one hour
following the infusion.
• Amount of platelets expected to raise if one U of platelets was given 10.000 / BSA
Administration
• Platelet should be infused as soon as possible to decrease the risk of bacterial proliferation.
• Depending on the condition of the recipient, a unit should be infused over a period of not more than 30 minutes
Slower transfusion compromises post-transfusion platelet count and activity.
• Do not give platelets prepared from RhD positive donors to an RhD negative female with childbearing potential.
• Give platelet concentrates that are ABO compatible, whenever possible. Complications: Febrile non‐hemolytic and
allergic urticarial reactions can occur, especially in patients receiving multiple transfusions
Volume and Rate
• Most experts do not recommend transfusing more than six random donor units or one single apheresis unit
at a time
• Because PLT concentration/quantity varies in different PLT products made available for transfusion, each
hospital should monitor post transfusion PLT counts to determine the dose that works best locally. PLT
concentrates should be transfused as rapidly as the patient’s overall condition permits
PLATELET TRANSFUSION GUIDELINES
1-Identify cause & treat first
2-Major bleeding from a patient with qualitative platelets defect regardless of platelets count
3-Maintain platelet count >100 x 109 /L for neurological and ophthalmic surgery.
4-Platelet count less than 10,000/uL
5-Platelet count less than 50,000/uL in patients with:
a. Severe active bleeding.
b. Major surgery (preoperative and 48 hour’s post-op) or impending invasive procedure. A patient undergoing a
surgical or other invasive procedure is unlikely to benefit from prophylactic platelet transfusion if the platelet count
is 50,000/uL or more and thrombocytopenia is the sole abnormality.
c. Coagulopathy, including DIC, with bleeding
d- Platelet count < 20.000 / mm2 with no evidence of bleeding ( except in ITP) .
e Active major bleeding or suspected CNS bleeding
Transfusion therapy in pediatric DR/ Ehab Elsayed Abd Elhamied
f-invasive procedure.
g- Platelets count < 30.000 before L.P, or IM injection
h- Prevention of bleeding due to thrombocytopenia as in bone marrow failure Use in bone marrow failure:
• Maintain platelet count >10 x 109 /L in non‐bleeding, non‐infected patient.
• Maintain platelet count >20 x 109 /L in infected/pyrexial patient.
● Criteria for platelets transfusion for infants within 1st 4M of life :
1- Platelets count < 20.000 and clinically stable.
2- Platelets count < 50.000 and invasive procedure.
3- Platelets count < 100.000 with bleeding or clinically unstable.

Contraindications:
• Idiopathic autoimmune thrombocytopenic purpura (ITP).
• Thrombotic thrombocytopenic purpura (TTP).
• Untreated DIC.
• Thrombocytopenia associated with septicemia, or in cases of hypersplenism.
Refractoriness to platelets
Defition
• Platelet transfusion refractoriness is an inability to achieve an expected incremental
response to platelet transfusion &/or an early or rapid decline to pretransfusion levels.
Evaluation of response
• Platelet recovery : increment in platelet count measured 10 minutes to 1 hour following transfusion
• Platelet survival : platelet count obtained 18 to 24 hours post transfusion
• Studies have shown that:
• A 10 min post transfusion level correlates closely with the 1 hr level
• This 10 min platelet count is convenient to obtain and very useful before the surgical procedures.
Formula
• PPI (post transfusion platelet increment) = Post transfusion platelet – pretransfusion
platelet
• CCI (corrected count increment) = PPI / L x BSA (m2)
Platelets transfused (1011)
Practical formula
• rise in platelet count x 109/ l = no. of platelet units infused x P(CCI) BSA (m2)
• P or CCI practically is 10,000x 109 /l
• For refractoriness,
• At 1 hr, count < 30% of predicted and At 18 – 24 hr , count < 20% of predicted
• Or 20 hr is roughly 64% of 1 hr count
• 1 hr count correlates with recovery and some have associated it with alloimmunization as the etiology
• Normal increment at 1 hr and decline at 24 hr correlates more with shortened platelet survival due to sepsis,
BMT, DIC & drugs.
causes
Non-alloimmune factors Alloimmune factors
fever/infection HLA antibodies
diffuse intravascular coagulation ABO antibodies
circulating immune complex HPA antibodies
bone marrow transplantation
splenomegaly
drug-related antibodies
autoantibodies
Platlet amount
• Amount : roughly 1 unit random gives 0.7 x 1011 platelets and 1unit aphaeresis gives
4 x 1011 platelets
• 1unit aphaeresis is equivalent to approx 5- 6 random units
• increment ≤ 2,000 for a random unit and ≤ 10,000 for an aphaeresis unit to diagnose refractoriness
Transfusion therapy in pediatric DR/ Ehab Elsayed Abd Elhamied

External factors
• External factors are the factors related to transfusion service in any hospital.
Platlet storage
• Significant decrease in CCI was documented after 72 hrs of storage
• In vitro markers of quality significantly decrease by day 5 of storage
• Stored in special gas permeable plastics at room temperature under constant
agitation (platelet rotator) to prevent clumping

mangment of refractoriness
the best to be prevented by giving SDU
giving HLA or HPA matched platlets
treatment of the cause if non immune
most experts recommend attempting transfusion with ABO-identical platelet units less than 3 days
prior to embarking on a search for other causes, such anti-HLA antibodies.

Fresh Frozen Plasma

Frozen Plasma is separated and frozen within 24 hours of donation, (keeping plasma for 24 hours time in our hot
climate no longer make it fresh,
White blood cells are killed or made nonfunctional during the freezing process; therefore, leukoreduction and
irradiation are unnecessary
plasma frozen within 8 hr of collection (fresh-frozen plasma) and plasma frozen within 24 hr of collection.
Content: The volume is 250-350 mL and contains citrate. Frozen Plasma contains all the coagulation proteins in
plasma except approximately 50% of the normal amount of Factor VIII or approximately 150 IU of Factor VIII.
Storage: Stored frozen at -18 C or colder for up to 1 year

Dose:: 10-20 mL/kg body weight. FFP should be ABO‐matched

Fresh frozen plasma transfusion guidlines
• Active bleeding or prophylactically prior to surgery in a patient with a coagulation factor deficiency, when
specific factor concentrates are unavailable.
• Emergency reversal of Warfarin therapy in a patient who is bleeding or requires emergency surgery, when
time does not permit reversal by stopping the drug and administering Vitamin K. (Vitamin K can have an
effect in 2 hr and INR normalized in 12-24 hours .
• Massive blood transfusion dilutional coagulopathy and bleeding
• Plasma exchange for thrombotic thrombocytopenic purpura (TTP) or HUS.

• PT and APTT > 1.5 X mean normal value in a non-bleeding patient scheduled for surgery or invasive
procedure
• Diffuse microvascular bleeding, transfusion of > 1 blood volume, and PT, APTT > 1.5 X the mean normal
value.
• Treatment of plasma anticoagulant deficiencies such as protein C, protein S, or antithrompin III, when
specific therapy is not available.
• In patient with liver disease, major hepatic resection and severe liver injuries
• factor XI deficiency (hemophilia C).
• C1 esterase inhibitor deficiency where specific concentrate is unavailable
In neonates :
1- Reconstitution of RBC concentrates to simulate whole blood for use in massive transfusion.
2- Hemorrhage secondary to vit. K deficiency.
3- DIC with bleeding.
4- Bleeding in congenital coagulation factors deficiency.
Transfusion therapy in pediatric DR/ Ehab Elsayed Abd Elhamied

● It is not recommended the use of prophylactic FFP transfusion to prevent I.V.H. in premature infants.
● It is not recommended the use of FFP to treat polycythemia.
● FFP has not been proven to have clinical benefit when given to septic patients. Indeed the use of FFP in sepsis
may increase mortality, and the reason for this is not clear
Lab tests should be used to monitor the patient with a suspected clotting disorder and repeated (e.g., INR, PTT)
following plasma transfusion. If the PTT is less than 45 seconds or INR less than 1.5, plasma transfusion is rarely
indicated. Plasma transfusions are not warranted when the INR is 1.2-1.4 and do not lower the INR when it is 1.2-1.3.
Do not transfuse plasma for its colloidal properties (use albumin), volume expansion,prophylactically
with cardiopulmonary bypass, since you are using heparin plasma doesnnt neutralize overdose of heparin

Cryoprecipitate
Content: One unit contains 150-250 mg of fibrinogen, 40-70% von Willebrand Factor, 80-120 units Factor VIII and
20-30% Factor XIII.
Volume: Approximately 5-20 mL per unit (it is probably up to 50 ml per unit.).

Storage. Cryo is stored at –18 C or colder for up to 1 year. A unit of thawed Cryo can be stored up to 6 hours at
room temperature. After multiple units are pooled (NO POOLING BUT ARE TRANSFUSED AS SINGLE UNITS ONE
AFTER ANOTHER) prior to transfusion they must be used within 4 hours at room temperature storage(within 4 hours
from thawing).

Children: 1 to 2 units/10 kg.

Expected result: 1 to 2 units/10 kg will raise fibrinogen level by approximately 60 to 100 mg/dL.

CRYO TRANSFUSION GUIDELINES

1. Hypofibrinogenemia: Consumptive coagulopathy with recent or active bleeding or prior to invasive procedure or
massive transfusion and fibrinogen level less than 100 mg/dL. Fibrinogen levels greater than 100 mg/dL are
generally considered adequate for hemostasis.
2. Patients with von Willebrand’s disease who are bleeding, when bleeding is unresponsive to desmopressin
(DDAVP) or prophylactically prior to surgery. The use of DDAVP is preferred to cryo, especially for patients with
mild to moderate von Willebrand’s disease (but not in patients with von Willebrand’s disease, Type IIb, in whom
DDAVP may cause platelet aggregates and thrombocytopenia).
3. Factor VIII deficiency (Hemophilia A) only if Factor VIII concentrates are not available, and no inhibitor is
present. Commercial freeze-dried Factor VIII concentrates are virally-inactivated and preferred because they have
less risk for transmitting viral infection.
4. Factor XIII deficiency.
Transfusion therapy in pediatric DR/ Ehab Elsayed Abd Elhamied

Adverse complications of transfusion

Adverse complications of transfusion may be classified into several categories:
Haemolytic versus non-haemolytic:
Haemolytic reactions result in the destruction of red blood cells – Immune – Non-immune

Non-hemolytic reactions, do not involve the destruction of red blood cells – Such as febrile and allergic reactions.

Acute (immediate) versus delayed:

Acute transfusion reactions manifest themselves either during the transfusion of the unit or soon after the
transfusion is completed, and reactions occurring within 24 hours after the start of the transfusion are included
within this category

Delayed adverse complications are usually referred to as “post-transfusion complications” and occur within days,
months, or years after the transfusion

Immune-mediated versus non-immune-mediated •

Immune-mediated reactions occur as a result of antigen-antibody interactions. These reactions may involve
antibodies with specificities toward antigens of the red blood cells, white blood cells or platelets

Infectious versus noninfectious - Bacterial, viral, and parasitic blood-borne agents have been linked to
complications of transfusion

Signs and Symptoms of a Transfusion Reaction

• Temperature rise of 2 F (or 1.5 C) or more and resulting in a temperature of at least 101 F (or 38.5 C)
• Chills, rigors
• Dyspnea, wheezing, cyanosis, hypoxia, pulmonary edema
Ventilation difficulty ( Unconscious or Intubated Patient )
• Hypotension, hypertension
• Hives, itching, angioedema
• Red urine, vomiting, pain in back, chest or at IV site, severe headache
• Bleeding from multiple sites
• Severe bradycardia or tachycardia
Immediate management of Category1
Mild reactions in the form of localized urticarial or rash.
• Slow the transfusion.
• Administer antihistamine IM pheniramine (avil 45mg/2ml) not used <2 years
2-5 y 0.7 ml 5-11 y 1-1.5 ml >12 y 2ml
• If no clinical improvement within 30 minutes or if signs and symptoms worsen, treat as Category2
• If improved, restart transfusion at a slower
Immediate management of Category 2:
Moderately severe reactions: anxiety, pruritis, palpitations, dyspnea, headache with signs like Urticaria, flushing,
rigors, fever, restlessness, tachycardia.
• Stop the transfusion and keep IV line open with normal saline in another site.
• Discard the blood unit with transfusion administration set, Send freshly collected urine and new
blood samples (1 clotted and 1 anticoagulated), drawn from a vein opposite to the transfusion
site for:
- Repeat ABO and RhD group. O
- Repeat antibody screen and cross match. o Full blood count.
- Coagulation screen. o Direct antiglobulin test.
- Urea and creatinine.
- Electrolytes.
Transfusion therapy in pediatric DR/ Ehab Elsayed Abd Elhamied

• Administer antihistamine IM and oral or rectal antipyretic.

• Avoid aspirin in thrombocytopenic patients.
• Give IV corticosteroids and bronchodilators if there are anaphylactoid features (e.g. bronchospasm, stridor).
• If clinical improvement occurs, restart transfusion slowly with new blood unit and observe carefully.
• If no clinical improvement within 15 minutes or if signs and symptoms worsen, treat as Category 3.
• Collect urine for next 24 hours for evidence of hemolysis and send for laboratory investigations
• If available, a leucocyte reduction filter (WBC filter) may be used in repeated transfusion.
Immediate management of Category 3:
Life‐threatening reactions As in category 2 plus chest pain, loin or back pain, pain along the transfusion line with
hypotension, hemoglobinuria, unexplained bleeding (DIC)
• Stop the transfusion and keep IV line open with normal saline in another site.
• Infuse normal saline to maintain systolic BP.
• Maintain airway and give high flow oxygen by mask.
• Give adrenaline (as 1:1000 solution) 0.01 mg/kg body weight by slow intramuscular injection.
• Give IV corticosteroids and bronchodilators if there are anaphylactoid features.
• Give diuretic: e.g. frusemide 1 mg/kg IV or equivalent.
• Check a fresh urine specimen visually for signs of hemoglobinuria. 39
• Send fresh urine sample and new blood samples (1 clotted and 1 anticoagulated), drawn from a vein
opposite the infusion site for investigations (mentioned in category 2).
• Start a 24‐hour urine collection and record all intake and output. Maintain fluid balance chart.
• Assess for bleeding from puncture sites or wounds. If there is clinical or laboratory evidence of DIC,
give platelets (adult: 4‐6 units) and either cryoprecipitate (adult: 12 units) or FFP (adult: 3 units).
• Reassess. If hypotensive: Give further saline and give inotrope, if needed.
• If urine output falls or there is laboratory evidence of acute renal failure (rising K+, urea, creatinine): –
Maintain fluid balance accurately. – Give further diuretic: e.g. frusemide 1 mg/kg IV or equivalent. –
Consider dopamine infusion, if available.
• If bacteraemia is suspected (rigor, fever, collapse, no evidence of a haemolytic reaction), start a broad‐
spectrum antibiotic IV.
 Transfusion therapy in pediatric DR/ Ehab Elsayed Abd Elhamied

Cause Signs & Symptoms Management

Acute Haemolytic Infusion of incompatible 1. fever, chills and rigors or both 1. Stop transfusion immediately and spigot off the unit. (save the
transfusion blood components 2. pain at the infusion site or blood units and blood giving set for investigation)
reaction Clerical error localized to the loins, abdomen, 2. Use a new giving set and keep vein open with normal saline
(1 in 250,000 – Undetected antibodeis chest or head 3. Inform clinician for urgent assessment
1,000,000) 3. hypotension, tachycardia or 4. Clerical check for compatibility between recipient and blood
both unit(s) given
4. agitation, distress and 5. Inform blood bank to return blood units for investigations and
confusion; collect additional blood samples
5. nausea or vomiting Visual inspection for plasma Hb
6. dyspnoea Tests as indicated to determine RBC incompatibility DAT
7. flushing Tests to monitor hemolysis (Hb/Hct, haptoglobin , Bilirubin 6 hr post
8. haemoglobinuria transfusion, plasma-free Hb ,LDH, urinalysis as indicated)
9- renal failure with oliguria Tests to monitor renal function if urine analysis indicates
10- DIC hemoglobinuria (BUN, creatinine)
Tests to monitor coagulation status if DIC is clinically
suspected (PT/PTT, platelet count, fibrinogen)
6. Treat shock if present treatment: Supportive treatment for
hypotension and renal perfusion (maintain output 1 ml/kg/h)
may include
• IV crystalloid ( 10 -20 ml/kg normal saline)
• Furosemide
Neonate: 0.5-1 μg/kg/dose IV every 24 h (maximum dose IV:
2 μg/kg). Premature infants will require less frequent dosing
Children: 0.5-2 μg/kg/dose IV every 6-12 h (maximum dose
6 μg/kg/dose) or continuous infusion 0.05 μg/kg/h titrating
dose to clinical effect
• Low-dose dopamine (25 μg/kg/min)
Supportive treatment of DIC withactive bleeding
• Hemostatic components : platelets, plasma ,cryoprecipitate
7. Collect urine samples
. Insert indwelling catheter to monitor hourly urine output. Patient
may require dialysis if renal failure occurs
Prevention:
• Ensuring proper sample and recipient identification
• Reviewing historical records
 Transfusion therapy in pediatric DR/ Ehab Elsayed Abd Elhamied

• Providing antigen-negative units as appropriate

Delayed haemolytic previous primary immune 5- 7 days post transfusion Most are asymptomatic and found to have a failure to have a
reaction response but has a low predicted response from blood transfusion. Therefore, management
(1 in 1000) 1. Fever
concentration of is in general supportive and investigated for the antibodies involved
alloantibody; anamnestic 2. Mild jaundice and underlying reason for failure of detection in pre-transfusion
response on reexposure to compatibility testing. DAT may be positive or negative
red blood cell antigens 3. Hb level does not increase or
However, haemolysis may be severe in some enough to result in
Alloantibody not even drop after transfusion active treatment.
demonstrable by and continued blood loss is Provide antigen negative donor units
conventional antibody
detection techniques excluded. Prevention check patient record
Alloantibodies to Rh ,Duffy
and Kidd antigens

Hemolytic (nonimmune) physical or chemical Hemoglobinuria • DAT (should be negative)

destruction of blood
• Visual inspection of unit for Hemolysi
(thermal, drugs, solutions
added) treatment: Hydrate
Prevention:
• Proper administration of blood components
• Identify and eliminate cause

Allergic reaction Antibodies to plasma Mild Treatment:

protienes • Antihistamine: avil dose as above
Urticaria (administer1 h before transfusion for prevention of recurrent hives)
• Pruritis • May restart unit if symptoms are resolved

• Flushing

Moderate to sever Rule out other etiologies for respiratory distress, for example,
Respiratory distress transfusion associated circulatory overload (TACO), TRALI,
anaphylactic reaction
Transfusion therapy in pediatric DR/ Ehab Elsayed Abd Elhamied

• Wheezing • IgA levels

• Anti-IgA
• Laryngeal edema treatment: (for anaphylaxis)
• Nausea/vomiting • Epinephrine 0.01 ml/kg(1:1000) SC or IM (maximum 0.5 ml); can
repeat in 15 min
• Hypotension • (a) For management of anaphylaxis in children not responding to
initial epinephrine IM or subQ injections and volume resuscitation,
Symptoms usually begin shortly and where there is inadequate time for emergency transport or
after the start of transfusion prolonged transport is required,recommend intravenous epinephrine
0.01 mg/kg (0.1 ml/kg of a 1:10,000 solution up to 10 μg/min), with a
maximum dose of 0.3 mg
• (b) For cardiopulmonary arrest during anaphylaxis epinephrine 0.01
mg/kg (0.1 ml/kg of a 1:10,000 solution), up to 10 μg/min rate of
infusion, repeated every 35 min for continued cardiopulmonary
arrest. Higher subsequent doses (0.1- 0.2 mg/kg ( 0.1 ml/kg of
a 1:1000 solution) may be considered for unresponsive
asystole or pulseless electrical activity
• Diphenhydramine 1 mg/kg IV/IM/PO (maximum 50 mg); can repeat
in 15 min
• salbutamol nebulizer 0.05 - 0.15 mg/kg in 3 ml normal saline
(estimate 2.5 mg /30 kg - 5.0 mg /30 kg)
• Methylprednisolone 12 mg/ kg/dose IV
Prevention: (for moderate and recurrent reactions)
• Diphenhydramine 1 mg/kg/dose IV/PO 1 h before transfusion
• Corticosteroids 24 h before transfusion either one of the
following:
Methylprednisolone 1 mg/kg/dose IV
Hydrocortisone1 mg/kg/dose IV
Prednisone1 mg/kg/dose PO
• Washed RBCs/platelets
• IgA-deficient components if Appropriate
 Transfusion therapy in pediatric DR/ Ehab Elsayed Abd Elhamied

Febrile, non-haemolytic Immunological reactions 1. Flushing 1.Stop transfusion immediately, keep vein open and inform clinician
transfusion reaction between recipient HLA or for assessment
(FNHTR) (1:100 with 2. Fever temperature rise >1 c 2.Clerical check for compatibility between recipient and blood unit(s)
granulocyte specific
non-leukoreduced not explained by another given
antibodies with donor
blood components) condition 3.Antipyretic e.g .paracetamol can be given 10- 15 mg /kg
leukocytes
4.For mild febrile reaction and rapidly resolving symptoms,
3. Tachycardia
or reaction to the pyrogenic transfusion may be resumed slowly.
cytokines released from 4. sometimes rigors 5.For severe febrile reaction (e.g. rise in temperature > 1.5 °C), the
donor leukocytes during same unit should not be restarted.
storage Symptoms usually occur about 6. Haemolytic transfusion reaction and septic reaction should always
30min to 2 hr after starting a red be suspected and investigated and managed accordingly
cell transfusion. Even earlier
after a platelet transfusion

TRALI Passive infusion of donor 1- Hypotension Rule out hemolytic transfusion reaction (visual inspection plasma Hb,
1 in 50,000 – 200,000 HLA leukocyte antibody DAT, and other clinical and laboratory findings)
reported in the 2-Normal pulmonary capillary • Culture recipient
through plasma-containing
literature) • Culture blood component
components . neutrophil- wedge pressure
priming lipid mediator; • Rule out TACO by obtaining chest X-ray and/or brain
recipient antibody to donor 3- Acute respiratory distress natriuretic peptide level above)
occurring within 6 hour of • Test donor/recipient for white-cell-related antibody
white cells
starting transfusion • Diagnosis of exclusion
these mechanisms lead to 4. Severe bilateral pulmonary treatment: Withhold transfusion immediately and exclude other
microvascular injury in the edema causes of shortness of breath e.g. circulatory overload
lung 5. Severe hypoxia • Respiratory support may include oxygen, intubation/mechanical
6. Fever ventilation depending on severity of hypoxia
7. Chest X ray shows peri-hilar , • Blood pressure support
nodular shadowing in the mid 3. If properly treated, reversible and recovered without sequelae
and lower zone (pulmonary edema can clear usually within 72 hr)
• If leukocyte antibody is present in recipient, use leukocyte-reduced
blood components
• If donor antibody is implicated, no special measures are needed
• May want to prevent the use of plasma-containing components
from implicated donors in the future inform blood donor center
 Transfusion therapy in pediatric DR/ Ehab Elsayed Abd Elhamied

Blood component was 1. Rise in jugular venous pressure 1. Withhold transfusion immediately and exclude other causes
TACO administered at a rate or 2. Support treatment e.g. place patient upright with feet in
with distended neck veins dependent position; give diuretics , oxygen supplement, etc.
Circulatory overload volume more than the
(1 : 10,000) recipient circulatory system 2. Dyspnoea 3. May require intubation if severe dyspnoea
can accommodate. treatment:
3. Cough • Diuretics, i.e., furosemide
Neonates: 0.51.0 mg/kg/dose every 824 h (maximum IV
4. Crackles in bases of lung dose2mg/kg/dose )
Children: 0.52.0 mg/kg/dose every 6-12 h (maximum dose 6 mg/
kg/dose)
Prevention:
• Transfuse blood slowly
• Aliquot small volumes
Bacterial Contaminated blood 1. Rapid onset of chills and rigors 1. Stop transfusion immediately, keep vein open and inform clinician
Contamination Septic component (frequency is for assessment
reaction 2. High fever usually > 2 °C 2. Monitor patient closely for septicaemic shock
higher with platelet
(Red cell 1 : 500,000 components than red cells 3. Nausea, vomiting, diarrhoea 3. Clerical check for compatibility between recipient and blood unit(s)
Platelet 1 : 10,000)) given and exclude haemolytic transfusion reaction accordingly
4. Hypotension 4. Obtain patient’s blood for septic workup and send blood bags and
administration set for culture
5. DIC 5. Treat septicaemia with intravenous broad spectrum antibiotics
6. Intravascular haemolysis with adequate anti-pseudomonas coverage
6. Report to blood bank for further investigation
7. Renal failure treatment:
• Support blood pressure (see above)
• Administer appropriate broad spectrum antibiotics
Prevention:
• Attention to arm preparation for donor phlebotomy
• Prevention of contamination during blood collection and storage
• Screening of platelet components for bacterial Contamination

Infectious diseases e.g. Diseases that are Clinical manifestations of 1. Treatment for the infectious disease
• Hepatitis B transmitted symptoms related to the 2. Report to hospital blood bank
• Hepatitis C acquired diseases. Usually
through blood transfusion
• HIV incidental findings during follow-
e.g. window period
• HTLV up or investigation for liver
donation.
Parvovirus B19 derangement
 Transfusion therapy in pediatric DR/ Ehab Elsayed Abd Elhamied

Transfusion associated Engraftment and 1. Erythematous skin rash 1- 90%mortality rate

graft-versus-host proliferation of donor 2 - Unresponsive to medical intervention .
2. Diarrhoea Prevention
disease lymphocytes in the
(< 1 in 500,000 - recipient bone marrow 3. Abnormal liver function 1- Irradiation of blood products before transfusion in at-risk
resulting in setting up an recipients .
1,000,000)
immune response against 4. Pancytopenia resulting in 2- HLA-matched platelets .
3- Gamma irradiation (25 Gray) to prevent blast transformation of
the transfusion recipient. secondary infection and bleeding the donor lymphocytes .
Excellent candidates for irradiated blood products include bone
marrow or stem cell transplant patients, premature and term infants,
fetuses requiring intrauterine transfusions, and recipients with
hematologic malignancies or donor units from blood relatives.
Hypothermia Rapid infusion of cold blood Chills Treatment:
• Slow infusion rate
• Low temperature • Use blood warmer Prevention:
• Irregular heart rate • Transfusion with an approved blood warming device
• Keep patient warm
• Possible cardiac arrest

• Neonatal apnea

Hyperkalemia hemolysis of red cells • Nausea/diarrhea Serum potassium (K1) level

(elevated (immunologic/ • Monitor EKG for peaked T waves, loss of P wave,
• Muscle weakness widening QRS complex, ST depression, bradycardia/asystole
serum nonimmunologic); massive/
potassium) rapid infusion of blood with • Cardiac arrhythmias treatment:
high potassium level Depends on severity
• Cardiac arrest • Cardiac monitor
• Mild to moderate levels(5-6 mEq/l), try to enhance excretion;
Kayexalate resin 1 g/kg/dose every 26 h
• Severe (7 mEq/l), try to move K into cell acutely:
Regular insulin 0.1 unit/kg with glucose 0.5 g/kg over 30 min,
sodium bicarbonate 12 mEq/ kg IV given over 510 min
• If EKG changes are present then urgent reversal of membrane
effects is required: Calcium gluconate (10%) 100 mg/kg/dos
(1 ml/kg/dose) over 35 min
• If unsuccessful—dialysis recommended
Prevention:
Preventive measures for patients at risk for hyperkalemia:
• Fresher red cells
 Transfusion therapy in pediatric DR/ Ehab Elsayed Abd Elhamied

• Red cells with supernatant removed

• Washed red cells

Hypocalcemia massive transfusion of neonates: Ionized calcium level

(low ionized citrated blood particularly • Prolonged Q-T interval on
• Jitteriness • Poor feeding EKG
calcium) in clinical setting where
citrate metabolism is • Apnea • Seizures Prevention:
dysfunctional Monitor ionized calcium during
• Arrhythmia procedure and administer
calcium as necessary
• Increased irritability

Older children:

• Paresthesia • Tetany

• Arrhythmia • Increased

Irritability Vomiting

Hypoglycemia Discontinuing dextrose Jitteriness • Tremors Treatment:

infusion • If asymptomatic, maintenance glucose either PO (D5W) or IV 48
• Seizure • Apnea/cyanosis mg/kg/min as required
during transfusion; rebound • If seizure activity associated with hypoglycemia: 5-10 mg/kg IV
bolus (10% or 15% dextrose) followed by 8-10 mg/kg/min IV drip as
phenomena after exchange
required
transfusion Prevention:
Frequent glucose monitoring (30-60 min) during the transfusion;
point-of-care glucose

Post transfusion Caused by recipient sudden onset of severe

purpra antibody against the thrombocytopenia 7 – 10 days
platelet - specific antigen after the transfusion of platelet

Citrate toxicity The transfusion of large Excess citrate may be toxic to

quantities of citrated blood patients receiving large volumes
in a relatively short time in massive transfusion situations
or in patients with impaired liver
Transfusion therapy in pediatric DR/ Ehab Elsayed Abd Elhamied

Chronic complications
iron overload
Due to repeated red cell transfusions in β-thalassemia major. In patients not treated with
chelation therapy, cardiac disease from iron loading typically develops in late teens and early 20s. Iron
overload also develops in β-thalassemia intermedia due to increased absorption of dietary iron. Complications
of iron overload include:
a. Endocrine disturbances (e.g., growth retardation, pituitary failure with impaired gonadotropins,
hypogonadism, insulin-dependent diabetes mellitus, adrenal insufficiency, hypothyroidism,
hypoparathyroidism, osteopenia, and osteoporosis).
b. Cirrhosis of the liver and liver failure (exacerbated if concomitant hepatitis B or C infection).
c. Cardiac failure and arrhythmias due to myocardial iron overload.
d. Skin bronzing
immunomodulation
ransfusion-related immune modulation (TRIM) is a transient immunosuppression in recipients observed after
transfusion of allogeneic blood.
a – immunosuppression
inhibit neutrophil function
impair function of NK & cytotoxic cells
so the patient is susceptible to any infection not only blood born infection
b – alloimmunization
development of antibodies after exposure of non self human antigens
1st exposure → moderate production of IgM and IgG antibodies to the foreigen antigens
2nd exposure → rapid production of large amount of IgG
RBCs antigens ( ABO -Rh D C c E e – kill ) occur up to 37 % in thalassemia patient and 49% in SCD
Lead to DHTRs , AHTR , hyperhymolysis syndrome , HDFN ,difficulty in finding compatible blood
Platlet antigens HPA , HLA , ABH, lewis → refractoriness
Wbcs antigens HLA , neutrophil specific antigens → NHTRs , difficulty in finding compatible transplant donor
, humoral transplant rejection
c– microchimerism
survival of the donor cells in the recipient circulation for long time lead to supression of recipient
immune response
d- immuotolerance
inability to mount immune response when challenged with Ags
e- cytokine release
f- autoimmune
Transfusion therapy in pediatric DR/ Ehab Elsayed Abd Elhamied

Massive blood loss in children

• Massive blood loss has been defined as the loss of one blood volume over 24 hours 80 ml/kg
• or >30ml/kg or > 40% circulating blood volume within 3 hours in infants and children

Goal action Comment

Airway and breathing Provide 100%supplemental

oxygen with facemask and • Arrange intubation and ventilation.
non-rebreathe bag until Consider use of cuffed ET tube,
definitive airway is especially in trauma
obtained

• 2 wide bore cannula

1. Restore circulating
or intraosseous access
volume
• Send blood bank sample if not It is essential that samples are sent to the
done: 6ml in pink EDTA bottle. blood transfusion lab as soon as possible
• Also include CBC, APTT and INR
e.g. 10-20 ml kg -1 Use pressure bags Blood
• Give adequate (warm) crystalloid
loss is often under-estimated Shock,
or colloid
hypothermia and acidosis increase risk of
• Call for senior (on site) anaesthetist. DIC.
• Maintain BP
• Consider central venous line,
arterial line
• Measure urine output
Cell saver if available in theatre requires
Consider use of cell saver trained staff most suitable in trauma/vascular
bleeding

Maximum benefit from Tranexamic Acid if

given within first hour after injury. Do not
Consider early use of Tranexamic Acid
give more than 3 hours after injury

Dose is an initial bolus of 15mg/kg (max 1g)

Consider reversal if on
heparin/warfarin/other anticoagulants
Use a blood warmer and external patient
warming device.
Consider active warming to prevent
hypothermia

O Neg blood available immediately and will

continue to be supplied until group specific
Give 20ml/kg blood via fluid warmer blood is available
Transfusion therapy in pediatric DR/ Ehab Elsayed Abd Elhamied
Activate massive blood Uncrossmatched group specific blood available
loss protocol and initiate in 25 minutes Crossmatched blood available in
transfusion 45 minutes

MBL pack A FFP thawed in 20 – 30 min

Continue transfusion
20ml/kg blood and 20ml/kg FFP
with major blood loss
packs MBL pack B Anticipate PLTs < 50 X 109/L after 2 BV
If a second or subsequent Major Blood replacement
Loss Pack is required these will contain Platelets: Immediate if on site
• 20ml/kg blood The blood bank will issue compatible FFP and
PLTs which will not necessarily be the same
• 20ml/kg FFP
group as patient.
• 15ml/kg platelets Cryoprecipitate thawed in 20 – 30 minutes
• Cryoprecipitate 10ml/kg

Recombinant Factor VIIa

In life threatening haemorrhage refractive to

other treatments Recombinant Factor V11a
(Novo7) is available under restrictions within
the Trust formulary, and must be discussed
with a consultant haematologist. Please note
that there is only sufficient Novo 7 for one
bleeding episode in the Trust, and it must be
given after other clotting factors have
corrected any other coagulopathy.

Consultant anaesthetist

Consultant surgeon, gastroenterologist,

Contact senior personnel obstetrician as appropriate

Blood bank

Remember simple measures

(pressure/elevation) can be useful
Transfusion therapy in pediatric DR/ Ehab Elsayed Abd Elhamied
Arrest bleeding Early surgical intervention Hypocalcaemia and hyperkalaemia can occur
especially with hypothermia and acidosis. More
Consider interventional radiology
common in neonates.
• If continued oozing repeat CBC and Acidosis
Coag. screen every 4 hours or after
Repeat blood tests every 30ml/kg of blood given • Use 1-2 ml/kg sodium bicarbonate

• It is recommended to perform at • Lactate > 2 mmol/L predictor of mortality

least one set of tests after major
Hypocalcaemia
transfusion

Serum Calcium and Potassium • Use 0.5 ml/kg 10% calcium gluconate
[0.11 mmol/kg] (max 20 ml) slow
intravenous injection over 5-10 minutes

Hyperkalaemia

• Use 10 ml/kg 10% dextrose with 0.1

units/kg insulin Monitor ECG

Aim of treatment

• Aim core temperature > 36°C

• Aim PLTs > 75 X 109/L, UNLESS multiple or

CNS trauma or if known PLTs dysfunction,
in which case aim PLTs > 100 X 109

• Aim for fibrinogen >1.5g/ L Fibrinogen <

0.5g/ L strongly associated with
microvascular bleeding

• Aim for INR / APPT ratio < 1.5

• Aim Hb 80 – 100 g/L

• Keep base deficit < 6 mmol/L

• Keep ionised Ca > 1 mmol/L

• Keep K < 6.0 mmol/L

‫هذه الورقات صدقة جارية لحمايا العزيز الشيخ ممدوح خلف وزوجته رحمهما الله نسألكم الدعاء‬
Transfusion therapy in pediatric DR/ Ehab Elsayed Abd Elhamied

Pediatric massive blood check list

Action point Completed? Time

Plan for haemorrhage control

2 x vascular access IV or IO
First blood sample taken
Second blood sample taken
Tranexamic acid, 15mg/kg
Warmed Packed Red Cells 20 ml/kg 1.
2.
Warmed Cryoprecipitate 10 ml/kg 1.
Warmed Fresh Frozen Plasma 10 ml/kg 1.
2.

1. There should be a written order from physician.

2. There must be a request form for blood transfusion, should be filled up by the physician assigned.
2.1 The complete four names of the patient.
2.2 Age
2.3 Medical Record number
2.4 Room and bed number
2.5 The indication of transfusion (complete diagnosis filled up by the Physician with signature).
2.6 Type of blood (PRBC, FFP or FWB or cryoprecipitate)
2.7 The number of units of blood
2.8 Blood group of the patient
2.9 The date and time of transfusion
2.10 Transfusion history (whether any blood transfusion was given before or not)
2.11 Last hemoglobin
2.12 Write the name of the person who has taken and labeled the sample
2.13 Separate request form for each component
2.14 Inadequately filled request forms are not to be accepted except in the emergency.
3. Infection Control policy manual must be strictly followed.
4. How to collect the sample.
4.1 Blood extraction for blood typing and cross matching must be drawn by two nurses and the request
must be signed by both.
4.2 Two nurses who have drawn the blood sample should sign the request form
and specimen tube should be signed by the doctor.
4.3 Make entry on the patient chart that blood was drawn for cross matching and
Transfusion therapy in pediatric DR/ Ehab Elsayed Abd Elhamied

the tube to be labeled at the patient bedside.

4.4 The blood should be drawn using an approved aseptic techniques and should be drawn carefully to
avoid hemolysis of the red cells.
4.5 The sample from the recipient should include small red top vacutainer, for adult, 3 ml for pediatric
patients and 1.5 ml for neonate.
4.6 The labeled tube and blood transfusion request form should be carried to the blood bank
technologist on duty and sign in the nurse logbook that he has received it having checked all the details,
etc. Name, amount of blood in the correct bottle etc.
5. Recipient samples are valid for only 48 hours.
6. Cross matched blood will be kept in the blood bank up to the time of transfusion and will be issued to
the wards unit one at a time within 48 hours. Except for surgical cases when blood is taken and stored in
the blood fridge in the theater during the operation day.
7. The ward Staff Nurse must sign for each unit of blood product in the Blood Bank sign out book.
8. The Nurse and Blood Bank Technologist must carefully compare the patient’s number in the
registered book with the data on the request form and blood unit label. These must agree before the
blood is taken out at blood bank.
9. If blood is issued but not used within 30 minutes it should be returned to the blood bank
immediately.
10. Transfusion must start within 30 minutes of release from blood bank.
11. Do not store any blood in the ward. Unused units must be returned immediately to the blood bank.
12. Blood should not be collected from blood bank until the IV access has been established on the
patient.
13. If any discrepancy is noted between the information on the blood tag, compatibility tag, patient’s
chart and blood transfusion request from do not hang blood, incident report should be made
immediately and blood bank must be informed.
14. If the cellular blood products (PRBC, Whole Blood, and Platelets) are not being filtered in the blood
bank, then it should be leukofiltered at the bed side during the transfusion.
BEFORE BLOOD TRANSFUSION
1. Blood component should be checked and signed by the doctor.
2. Blood must be checked by 2 nurses (The assigned Nurse and Shift Coordinator).
3. Previous IV fluid must be Normal Saline.
4. IV set is hemoset.
5. IV cannula is good and patent.
6. IV cannula is proper size (18 or 20) for adult (24 or 26 for neonate.
7. Blood transfusion must be started within 30 minutes of collection from blood bank.
8. Reassure the patient at the start and during blood transfusion.

EQUIPMENT
1. Blood administration set
2. Clinical thermometer and watch
3. Sphygmomanometer and Stethoscope
4. Observation Chart (T,P, R and BP)
Transfusion therapy in pediatric DR/ Ehab Elsayed Abd Elhamied

5. Fluid Balance Chart

6. IV Hydrocortisone and Chlorpheniramine .
7. Gloves
8. Blood warmer (if rapid transfusion is needed)
PROCEDURE
1. Wash hands, wear gloves.
2. Take baseline vital signs.
3. Blood transfusion assessment form must be filled and signed by assigned Nurse.
4. Transfusion must be started slowly for 15-30 minutes.
o Blood must be checked by a doctor before transfusion.
o Using blood warmer when rapid transfusion or transfusion via a CVP line.
o Blood must never be warmed by heating the bag in hot water, on a radiator or in microwave it can
cause blood to hemolyse.
o Blood transfusion may not be started if patient temperature is elevated. Unless approved by the doctor
o Transfusion must be given within 2-3 hours.
o Patients temperature and blood pressure must be taken hourly and recorded and PRN.
o Pulse and respiration checked half hourly and PRN and recorded.
o Correct prescribed amount transfused.
o Observe the urine output for volume and color throughout the transfusion.
o Observe and encourage the patient to report any of the following:
• Facial flushin • Itching • Rash on the chest or abdomen • Pain or inflammation at the cannula site
• Circulatory overload (rising pulse and respiratory rate) • Headaches
• Feeling hot and flushed or shivering • Chest or abdominal pain or pain in the extremities
• Lumbar pain • Edema of the eyes or face • Oliguri • Laryngeal swelling and dyspnea
The transfusion should be stopped and medical staff must be informed.
o Each unit of blood should normally be transfused within 4 hours.
o All blood bags must be returned to blood bank if there is transfusion reaction.
o Use blood transfusion set and prime line with 0.9% normal saline absolutely no other solution should
be used for blood transfusion.
o No medication is administered in the same tubing of blood.
o Inspect blood for clots, discoloration and excessive bubbling.
o All blood transfusion reaction should be reported to doctor in-charge, the doctor’s name, signature
and action take during transfusion should be documented on the blood transfusion reaction form.
POST PROCEDURE
1. Ensure the patient is comfortable
2. Instruct the patient for and report any reaction or complication.
3. Replace the equipment and discard waste appropriately.
4. Patient must be observed for 4 hours after blood transfusion/PRN.
DOCUMENTATION
1. Document the completion of procedure in nurse’s note.
2. Record intake and output chart.
3. Write date and time of starting and finishing of blood.
4. Signature with ID number