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بنام خدا Transfusion in children Packed cell, platelet, FFP, cryoprecipitate, WBC Packed red cell Transfusion Packed red cells • Average hematocrit of a unit is 65-75% ( concentrated) • Estimated unit size : 250-350 cc • Stored at 2-6 C • Mixed with preservation ( shelf-life of 35 days) • Infusion should take maximum 4 hours General guidelines • Oncology: Hb,8gr/dl increased O2 requirement patient symptomatic • Bone marrow failure: Hb<7 gr/dl increased O2 requirement • Hemoglobinopathies: clinical situation(thalassemia major or intermediate, sickle cell Contraindication: • Anemia that can be corrected by nontransfusion therapy( iron, recombinants erythropoietin) • Hypovolemia Recommendation • CMV seronegative, irradiated, leukopoor preparation should be used per clinical guidelines Platelet transfusion Descriptions: • 1 random donor unit is concentrate of platelet separated from a unite of whole blood (5.5×1010 platelet in 40-70 cc plasma) • A single donor unit is a unit collected by apheresis that contain 4-8 time the number of platelet in 1 random donor unit (3 × 1011 platelet in 100-500 cc plasma) Platelet dosages • Dose of random donor unit platelet is one unit per 5-10kg, ( or 10cc/kg for small infant) • Dose of single donor platelet is 10cc/kg per infusion to maximum 1 unit apheresis(up to the adult dose) • Transfusion may proceed as quickly as tolerated: 10cc/ kg/hour General guideline • Hematology patients: Platelet<10,000 Actively bleeding ( and platelet < 50,000) Preparation for invasive procedure (IT , LP, liver biopsy….) • Oncology patients: Platelet<20,000 Actively bleeding ( and platelet < 50,000) Preparation for invasive procedure Contraindication: • Thrombocytopenia and platelet distraction in patient with autoimmune disorder(ITP) and no active bleeding • TTP : Platelet transfusions are contraindicated unless there is life-threatening haemorrhage, • Heparin-induced thrombocytopenia :HIT is frequently associated with severe thrombosis (acute arterial thrombosis !) Recommendation: • Infuse relatively quickly(10ccc/kg/hour) to reduce clumping and adherence in bag and tubing • If concern over platelet response, obtain posttransfusion platelet count at 15 minute to 1 hour Blood group and platelet transfusion • Identical ABO group as the patient are the components of choice and should be used as far as is possible (but not always available). • Administration of ABO non-identical platelets is acceptable transfusion practice (but may result in hemolysis) • In general, ABO-matched is best, but mismatched can be used when necessary Blood group and platelet transfusion • Group O platelets may be used for group A, B and AB patients if they have been tested and labelled as negative for high-titre anti-A and anti-B • RhD-negative platelet concentrates should be given, where possible, to RhD-negative patients, Blood group and platelet transfusion • If RhD-positive platelets are transfused to a RhD-negative woman: a dose of 250 i.u. antiD cover five adult therapeutic doses of RhDpositive platelets (it should be given subcutaneously in thrombocytopenic patients) • It is not necessary for men or women without childbearing potential Fresh Frozen Plasma Transfusion Fresh Frozen Plasma(FFP) • Contain coagulation factors in physiologically amounts( each ml contain I IU of each coagulation factor • Contain anticoagulation's such as protein C and S • Contain albumin, immunoglobulins, and complement proteins Indications for FFP • Patients who require replacement of multiple plasma coagulation factors( e.g. liver disease, DIC ..) • Massive transfusion ( have clinically significant coagulation deficiencies) • Patient taking warfarin who are bleeding or need to undergo an invasive procedure before Vit. K could reverse the warfarin effect • Transfusion or plasma exchange in patient with TTP • Management of patients with selected coagulation factor deficiencies , for which no specific coagulation concentrates are available Contraindications FFP • Don’t use when coagulopathy can be corrected with specific therapy( Vit.K, cryoprecipitate, coagulation factor concentrate) • Don’t use when blood volume can be safely and adequately replaced with other volume expander • Don’t use as a source of albumin Dosing FFP • Hemostasis can be achieved when the activity of coagulation factors is at least 25-30% of normal: Unless there is coagulation inhibitor( heparin, etc.), hyperfibrinogenemia • Plasma volume is approximately 40cc/kg • 10-15cc/kg of FFP will replace coagulation factors to 20-30% FFP storage • Frozen at -18 C for 1 year or at -65 for 7 years • Once thawed should be infused within 4 hours Cryoprecipitate Cryoprecipitate • Cold soluble remnant of FFE • Concentrated preparation that contain : Factor 8 (80-100 IU/bag), Fibrinogen(200mg/bag), Factor 13, von Willwberand factor Cryoprecipitate Indication: • First line therapy for control of bleeding with : fibrinogen deficiency, factor 13 deficiency • Second line therapy for : von Willebrand disease Factor 8 deficiency Cryoprecipitate Contraindications: • Don’t use unless result of laboratory studies indicate a specific hemostasis defect for which this product indicated • Don’t use if virus inactivated factor 8 concentrates or recombinants factor preparation are available for patient with v.W. disease or hemophilia A • Don’t use for DIC( dose not contain all necessary factors(factor 5) Cryoprecipitate dose • Hyperfibrinogenemia: 0.2 bag /kg( increase fibrinogen approximately 50-100 mg/dl) • Factor 13 deficiency: 1 bag/10 kg once • Bleeding in vWD : 1 bag/10kg every 6-12 hours WBC transfusion WBCs • Administered as soon after collection as possible • If stored, maintain at room temperature(20-24 C) without agitation, for no more than 24 hours • Donor preparation with G-CSF increased harvest yield WBCs : need to • Be cross-matched with the recipient's serum • Irradiated because of the large number of lymphocytes present. • Considered for patients with an absolute neutrophil count <0.5 x 109/L and a good chance of marrow recovery. Indication : • Documented sever bacterial of fungal infections with an ANC<500 , • Functional granulocyte defect and unresponsiveness to antimicrobial therapy Contraindication: • Irreversible BM failure • Prophylaxis's in non infected patients Pediatric dosage • 1-2×109 cell/kg • Once initiated, WBC therapy should continue on daily basis until infection is cured, patient defervesce, or ANC is>500 Processing Leukodepletion, Gamma irradiation, washing, CMV negative Processing: Leukodepletion Processing: Leukodepletion • Leukodepletion is a technical term for the removal of leucocytes (white blood cells) from blood components using special filters. • Leukodepletion of blood components removes ≥ 99% of contaminating leucocytes • Prestorage or bedside filter? Processing: Leukodepletion • Reduced risk of platelet refractoriness(HLA alloimmunization) • Reduced risk of febrile non-haemolytic transfusion reactions • Reduced risk of CMV transmission • Possible reduced risk of transfusion-associated GVHD (reduce risk but not prevent) Processing: Gamma irradiation Processing: Gamma irradiation • Gamma irradiation of blood product to stop donor lymphocyte proliferation • Prevent transfusion induced GVHD (100% fatal) Gamma irradiation: indication • Intrauterine transfusion • Neonates with a birth weight of ≤ 1,200 g and/or gestational age ≤ 30 weeks. • Congenital cellular immunodeficiency. • Aplastic anaemia receiving ATG Gamma irradiation: indication Autologous BMT • Bone marrow or peripheral blood stem cell autologous transplantation (in the 7 days before collection of bone marrow or PBSC and up to 3 months after BMT, or 6 months for patients undergoing TBI). Gamma irradiation: indication Allogeneic BMT • All recipients of allogeneic haemopoietic stem cell transplantation (SCT) must receive irradiated blood components from the time of initiation of conditioning chemoradiotherapy • Irradiated components should be continued while the patient continues to receive GVHD prophylaxis (until the end of GVHD prophylaxis) • Allogeneic blood transfused to bone marrow and peripheral blood stem cell donors 7 days prior to or during the harvest should also be irradiated. Gamma irradiation: indication chemotherapy • Hodgkin’s lymphoma • chemotherapy (should be decided on an individual basis) • It is not necessary to irradiate red cells or platelets for adults or children with acute leukaemia, except for HLA-selected platelets or donations from first- or second-degree relatives Gamma irradiation: indication other indications • All transfusions from first- or second-degree relatives should be irradiated, even if the patient is immunocompetent • All HLA-selected platelets should be irradiated, even if the patient is immunocompetent. • All granulocytes should be irradiated before issue and transfused with minimum delay Gamma irradiation: not necessary When none of the above conditions are present, it is not necessary to irradiate blood components transfused to: • HIV infection, • Aplastic anaemia • Solid organ transplantation, • Chemotherapy for NHL, acute leukaemia and solid tumours • It is not necessary to irradiate red cells for routine 'top-up' transfusions of premature or term infants unless either there has been a previous IUT, or the donation has come from a first- or second-degree relative Processing: washing Processing: washing • Help to remove extra K from red cell • Remove IgA form plasma • Extra plasma containing antigens and cytokine • Should be used within 24 hr. Processing: washing Indication : • Patients with IgA deficiency • Prevention of allergic reactions • Post-transfusion febrile reactions, present even when leukodepleted RBCs are used Processing: CMV negative components CMV negative components: Are recommended for the following recipients to reduce the risk of CMV transmission : CMV negative recipients of allogeneic stem cell and bone marrow transplants CMV negative pregnant women Intrauterine transfusions Infants weighing less than 1200 g at birth CMV negative components : May be recommended for CMV negative individuals: HIV infection Conditions likely to require an BMT or Solid organ transplant recipients Severe neutropenia