Blood Transfusion Therapy

Contents

28.1 Introduction . . . 414

28.2 Blood Screening Guidelines . . . 414

28.2.1 Blood Product Processing . . . 415

28.3 Transfusion Complications . . . 416

28.3.1 Hemolytic Reactions . . . 416

28.3.2 Nonhemolytic Reactions . . . 416

28.3.3 Allergic Reactions . . . 417

28.3.4 Graft Versus Host Disease (GvHD) . . . 417

28.3.5 Fluid Overload . . . 418

28.3.6 Transfusion-acquired Infections . . . 418

28.3.6.1 Bacterial Infections . . . 418

28.3.6.2 Cytomegalovirus (CMV) . . . 418

28.4 Erythrocyte Transfusion . . . 419

28.4.1 Erythrocyte Transfusion Options . . . 419

28.4.2 Special Transfusion Considerations . . . . 420

28.4.2.1 Partial Exchange Transfusion . . . 420

28.4.2.2 Specific Risks of Erythrocyte Transfusion . . . . 420

28.5 Platelet Transfusion Options . . . 420

28.5.1 Procurement and Storage . . . 421

28.5.2 Transfusion Guidelines . . . 421

28.5.3 Dosing Recommendations . . . 421

28.5.4 Infusion Guidelines . . . 421

28.5.5 Platelet-specific Transfusion Risks . . . 421

28.5.6 Platelet Alloimmunization . . . 421

28.5.7 Treatment Options . . . 421

Blood Transfusion Therapy Elizabeth Kassner 28.6 Granulocyte Transfusion . . . 421

28.6.1 Indications . . . 422

28.6.2 Dosing Guidelines . . . 422

28.6.3 Specific Risks . . . 422

28.7 Albumin . . . 422

28.7.1 Volume . . . 422

28.7.2 Transfusion . . . 422

28.8 Fresh Frozen Plasma (FFP) . . . 422

28.8.1 Indications . . . 422

28.8.2 Volume . . . 422

28.8.3 Transfusion . . . 422

28.9 Cryoprecipitate . . . 423

28.9.1 Indications . . . 423

28.9.2 Volume . . . 423

28.9.3 Transfusion . . . 423

28.10 Intravenous Immunoglobulin (IVIG) . . . 423

28.10.1 Indications . . . 423

28.10.2 Volume . . . 423

28.10.3 Side Effects . . . 423

28.11 Recombinant Human (rHu) Erythropoietin Alpha . . . 423

28.12 Palliative Care Issues for Transfusion Therapy . . 423

28.12.1 Erythrocyte Transfusion . . . 423

28.12.2 Platelet Transfusion . . . 423

References . . . 424

Bibliography . . . 424

28.1 Introduction

Blood transfusion is an essential part of modern health care. Used correctly, it can save life and im- prove health. However, as with any therapeutic inter- vention, it may result in acute or delayed complica- tions and carries the risk of transmission of infec- tious agents, such as human immunodeficiency virus (HIV), hepatitis viruses, syphilis, and Chagas disease.

It is also expensive and uses a scarce human resource.

The decision to transfuse blood or blood products must be based on a careful assessment of clinical and laboratory indications that a transfusion is necessary to save the individual’s life or prevent significant morbidity (Tables 28.1, 28.2, 28.3).

Children with malignancy or who are undergoing immunosuppressive treatment often experience myelosuppression that requires the necessary, and sometimes emergent, transfusion of blood products.

28.2 Blood Screening Guidelines

The differences in human blood are due to the pres- ence or absence of certain protein molecules called antigens and antibodies. The antigens are located on the surface of the red blood cells (RBCs), and the an- tibodies are in the blood plasma. Individuals have different types and combinations of these molecules.

There are more than 20 genetically-determined blood group systems known today, but the AB0 and Rh systems are the most important ones used for blood transfusions. Not all blood groups are compat- ible with each other. Mixing incompatible blood groups leads to blood clumping or agglutination, which is dangerous for blood recipients.

For a blood transfusion to be successful, AB0 and Rh blood groups must be compatible between the donor blood and the patient blood (Table 28.4). If they are not, the RBCs from the donated blood will agglutinate. The agglutinated red cells can clog blood vessels and stop the circulation of the blood to vari- ous parts of the body. The agglutinated RBCs also he- molyze.

Table 28.1. Age-appropriate blood volumes (adapted from Lanzkowsky, 1999)

Age Total blood volume (ml/kg)

Newborn 82–86

1–3 years 74–81

4–6 years 80–85

7–9 years 86–88

10–15 years 83–88

16–18 years 90

Table 28.2. Disease and treatment transfusion guidelines based on hemoglobin (Rogers et al., 2002; Norville and Bryant, 2002)

Indication Hemoglobin

Prior to a course of chemotherapy

<8 g/l Receiving radiation therapy

<10 g/l Recovering from therapy-induced <7–8 g/l bone marrow suppression and low reticulo-

cyte count Signs and symptoms of anemia <10 g/l Active bleeding <8 g/l or acute

blood loss of

>10 % total blood volume

If child is asymptomatic, hold transfusion during known chemotherapy or radiation therapy-induced myelosuppres- sion

a

Unless child is beginning an intensive course of therapy with an existing low hemoglobin (8–10 g/dl), even if asymp- tomatic

b

During radiation therapy, hemoglobin should be main-

tained above 6–7 g/dl for optimal oxygen-carrying capacity

28.2.1 Blood Product Processing

Processing of blood products may include:

▬ Addition of:

1. Citrate-phosphate dextrose adenine (CPDA-1) Anticoagulant: binds to calcium, inhibiting co- agulation pathways

2. ADSOL (dextrose, adenine, mannitol, sodium chloride)

Enhances red cell survival

Each unit contains approximately 350–380 ml, with a hematocrit of 75–80% if preserved with CPDA-1 and 55–60% if preserved with ADSOL (Kulkarnis and

Gera, 1999; Norville and Bryant, 2002; Rogers et al., 2002)

▬ Washed cells: uses normal saline to remove white blood cells (WBCs), platelets, and plasma proteins

▬ Leukocyte depletion (leukopore filtration): allows for greater percentage of leukocyte removal than washed or frozen platelets (99.5% versus 90%, respectively). This will prevent alloimmunization to human leukocyte antigens (HLA), cytome- galovirus (CMV) transmission, immune suppres- sion, and nonhemolytic febrile reactions, and will possibly decrease the incidence of graft versus host (GvHD) disease. The recommended Food

Table 28.3. Disease/treatment specific transfusion guidelines (Norville and Bryant, 2002; Rogers et al., 2002)

Disease/treatment Platelet count

Leukemia 10,000–20,000/mm

Brain tumor <30,000/mm

Requiring lumbar puncture <20,000/mm

Requiring bone marrow aspirate/biopsy <5,000 /mm

Requiring surgery >50,000/mm

>100,00/mm

for surgery of eye or brain Requiring intramuscular injection >20,000/mm

Presence of bleeding 60,000/mm

(with normal prothrombin, partial thromboplastin, and fibrinogen level)

Child on therapy, with platelet recovery Platelet count <5,000/ul anticipated to be >1–2 days

Febrile patient with acute illness <20,000/mm

Table 28.4. Blood type compatibility

Blood group Antigens Antibodies Can give blood to Can receive blood from

AB A and B None AB AB, A, B, 0

A A B A and AB A and 0

B B A B and AB B and 0

0 None A and B AB, A, B, 0 0

Type and screen requested when likelihood of transfusion is low Type and crossmatch: Required for every PRBC transfusion Includes ABO, Rh crossmatching and antibody screen Includes ABO and Rh typing and antibody screen

Good for 72 hours; may use sample for type and crossmatch Antibody identification performed for positive antibody screen

and Drug Administration guidelines allow 5¥10

leukocytes per unit of blood or platelets (Rogers et al., 2002) Indications for leukocyte-reduced blood products include chronic transfusions, patients receiving chemotherapy, and bone marrow trans- plant candidates.

▬ Irradiation of blood products: This causes deple- tion of lymphocytes. Graft versus host disease (GVHD) occurs when donor lymphocytes engraft in a susceptible recipient. These donor lympho- cytes proliferate and damage target organs, espe- cially the bone marrow, skin, liver, and gastroin- testinal tract, which ultimately can be fatal. The disease initially was recognized as a complication of intrauterine transfusion and transfusion to re- cipients of allogeneic marrow transplant in pa- tients who had received total body irradiation.

If irradiated blood products are recommended, (Table 28.5), the irradiation dose is 1,500–2,500 cGy to the midplane with at least 1,500 cGy in the field without resultant cellular damage (Kulkarnis and Gera, 1999; Rogers et al., 2002; Wuest, 1996). Irra- diation of red blood cells decreases the storage time to 28 days.

28.3 Transfusion Complications 28.3.1 Hemolytic Reactions

Hemolytic transfusion reactions (HTR) typically oc- cur when immunologic incompatibility between transfused donor RBCs and recipient alloantibodies produces accelerated destruction of transfused cells.

Transfusion of ABO-incompatible RBCs to a recipi- ent with the corresponding preformed antibodies is the most common etiology. Complement-mediated intravascular hemolysis is associated with acute he- molytic transfusion reactions (AHTR) and extravas- cular RBC destruction with delayed hemolytic trans- fusion reactions (DHTR). AHTR are the most severe and are a medical emergency requiring rapid identi- fication of the event, discontinuation of the trans- fusion, hydration, and intensive patient monitoring.

The risk of hemolytic reactions from transfusions is approximately 1:25,000, with the risk of fatal he- molytic reactions approximately 1:160,000. AHTR are most often caused by ABO incompatibility be- tween patient and donor during red cell transfusion.

The signs and symptoms of ATHR will usually ap- pear within the first 5–15 minutes after the transfu- sion is started, but can happen at any time during the transfusion. They generally consist of

▬ Temperature increase >1 °C or 2 °F

▬ Hemoglobinuria

▬ Chills

▬ Hypotension

▬ Severe low back pain or chest pain

▬ Anuria

▬ Nausea and vomiting

▬ Dyspnea, wheezing

▬ Anxiety, impending sense of doom

▬ Diaphoresis

▬ Generalized bleeding

▬ Disseminated intravascular coagulation (DIC) Laboratory findings include hemoglobinemia, hemo- globinuria, and decreased haptoglobin.

Table 28.5. Indications for irradiated blood products in pedi- atric hematology/oncology patients

Generally accepted indications Bone marrow transplant recipients Patients with Hodgkin’s disease or non-Hodgkin’s lymphoma

Patients with certain solid tumors including neuroblastoma and glioblastoma

Patients receiving HLA-matched components or components from biological relatives Indications under review

Patients with certain hematologic malignancies such as acute leukemia

Patients receiving crossmatched compatible platelets No established indications

Most patients receiving chemotherapy

Patients with aplastic anemia not receiving

immunosuppressive therapy

Treatment consists of the following:

▬ Stop transfusion

▬ Administer diphenhydramine (1 mg/kg PO or IV;

maximum 50 mg/dose) and Paracetamol/acetamin- ophen (15 mg/kg PO; maximum 1,000 mg/dose) In contrast to RBC transfusion – in which ABO in- compatibility has potentially lethal implications – ABO matching has historically been considered less critical for platelet transfusion. Nonetheless, platelets bear ABO blood group antigens, and the plasma con- tained in platelet concentrates results in passive transfer of anti-A or anti-B antibodies (Heal et al., 1989)

28.3.2 Nonhemolytic Reactions

Nonhemolytic reactions are certainly more common than hemolytic reactions (30% rate of occurrence – 10% PRBC, 20% platelets) (Norville and Bryant, 2002) These reactions occur more often in children receiving frequent transfusions and begin shortly after the transfusion is started. They result from al- loantibodies in the patient’s plasma that react to HLA or other antigens on leukocytes or tumor necrosis factor, interleukin-1, -6, -8, and other cytokines.

Symptoms include:

▬ Chills

▬ Fever (rise of 1 °C in 24-hour period)

▬ Urticaria

▬ Rigors

▬ Headache

▬ Nausea

Treatment consists of the following:

▬ Stop transfusion

▬ Administer diphenhydramine (1 mg/kg PO or IV;

maximum 50 mg/dose) and acetaminophen (15 mg/

kg PO; maximum 1,000 mg/dose)

▬ Consider premedicating future transfusion with diphenhydramine (0.5–1mg/kg; maximum 50 mg PO or IV) and acetaminophen (10–15 mg/kg PO);

Solu-Cortef 1–2 mg/kg IVP may also be given pri- or to transfusion in children with repeated trans- fusion reactions)

▬ Platelet transfusion may be restarted. However, if patient has a second reaction, the transfusion must be discontinued

28.3.3 Allergic Reactions

Allergens found in plasma may cause allergic trans- fusion reactions. If the recipient is sensitive to these, antibodies will be produced.

Clinical signs include:

▬ Skin erythema

▬ Pruritis

▬ Swollen lips

▬ Vomiting

▬ Hypotension

▬ Wheezing

▬ Laryngeal edema

▬ Anxiety

▬ Irritability

▬ Progression to anaphylaxis

Management aims to stop the allergic process. Anti- histamine can be administered. In the absence of fever the infusion can continue/restart. Recurrent al- lergic reactions indicate the routine use of antihista- mine with the possible addition of a steroid. Howev- er, if bronchospasm or life-threatening symptoms occur the infusion must be discontinued and the re- action treated.

28.3.4 Graft Versus Host Disease (GvHD) GvHD occurs when transfused lymphocytes are not recognized by the immunocompromised patient, re- sulting in engraftment of transfused cells that mount an attack against the host. Blood-relative donors with similar HLA haplotypes may increase the risk of oc- currence.

Symptoms may occur up to 30 days after transfu- sion and include

▬ Erythematous maculopapular dermatitis

▬ High fever

▬ Liver dysfunction

▬ Severe gastrointestinal symptoms (anorexia, diar- rhea, vomiting)

▬ Pancytopenia

Prevention should be attempted and includes the fol- lowing:

▬ Avoid donations from blood relatives

▬ Administer only irradiated blood components

28.3.5 Fluid Overload

Fluid overload may occur during blood product transfusion if the transfusion is administered too rapidly or the wrong volume is infused.

Symptoms include:

▬ Dyspnea

▬ Cough

▬ Tachycardia

▬ Hypertension

▬ Edema

▬ Headache

Treatment consists of the following:

▬ Stop transfusion

▬ Administer oxygen

▬ Diuretics (furosemide 1–2 mg/kg dose IV)

28.3.6 Transfusion-acquired Infections 28.3.6.1 Bacterial Infections

Transfusion-transmitted bacterial reaction has been identified as the most common and severe infectious complication associated with transfusion. Approxi- mately 57% of all transfusion-transmitted infections and 16% of transfusion-related deaths have been as- sociated with bacterial contamination. It has been es- timated that 1 in 38,500 units of red cells, 1 in 3,300 units of random donor platelets, and 1 in 2,000 units of apheresis platelets are contaminated with bacteria (Blajchman, 1999).

Blood components may be contaminated with bacteria throughout many stages of preparation, in- cluding blood collection, processing, pooling, and transfusion. Bacteria may enter into blood compo- nents through several sources: donors’ bacteremia, exposure to donor skin bacteria by venipuncture, and contaminated bags and environment in blood banks or hospitals.

The bacteria implicated in bacterial reactions as- sociated with red cells are typically Gram-negative bacilli such as Yersinia enterocolitica and Pseudo- monas fluorescens. In contrast, bacteria implicated in reactions associated with platelets are mostly Gram- positive species such as Staphylococcus and Strepto- coccus. The clinical severity of transfusion-transmit- ted bacterial reactions depends largely on the type and load of bacteria involved as well as the recipient’s condition. Gram-negative agents usually produce en- dotoxins and cause severe reactions, whereas Gram- positive agents often cause minor reactions. The load of bacteria is determined by the storage time. Platelet units that are stored over 3 days and red cell units that are stored over 21 days are strongly associated with an increased risk of bacterial reactions. In addi- tion, age and underlying diseases in recipients may also play an important role in determining the sever- ity of a bacterial reaction.

Symptoms include:

▬ Fever

▬ Chills, rigors

▬ Hypotension

Treatment consists of the following:

▬ Obtain cultures and treat with antibiotics as ap- propriate

▬ Treat with acetaminophen (15 mg/kg PO; maxi- mum dose 1,000 mg) and meperidine (0.5–1 mg/

kg) for rigors

▬ Consider pre-medicating future transfusion with diphenhydramine (0.5–1mg/kg, maximum 50 mg, PO or IV) and acetaminophen (10–15 mg/kg PO)

▬ Prestorage filtration may decrease febrile reac- tions

28.3.6.2 Cytomegalovirus (CMV) (See section 16.4.3 in chapter 16)

Infection with cytomegalovirus (CMV) is common

and often lasts for a lifetime. The prevalence of CMV

antibodies increases with age, and approximately

50–80% of the adult population are infected with the

virus. The acute infection is usually asymptomatic,

particularly in immunocompetent individuals. How-

ever, CMV infection may result in severe outcomes in immunocompromised or immunodeficient individu- als, including those receiving bone marrow or solid organ transplants.

The prevalence of CMV antibodies among blood donors is 35–50%. Prevention of transfusion-trans- mitted CMV infection in high-risk recipients is criti- cal.

▬ Use CMV-seronegative blood products for CMV- negative patients

▬ Use leukocyte-depleting filters capable of >3 log removal of white blood cells if only CMV-positive blood products are available

28.4 Erythrocyte Transfusion

Erythrocytes originate from pluripotent stem cells, which undergo proliferation, differentiation, and maturation. Iron and chemical growth factors stimu- late the process of erythropoiesis. Erythrocyte values vary with age until 12 years,, and thereafter according to gender (Table 28.6). Iron, ferritin, and bilirubin values vary until age 15 years, and thereafter accord- ing to gender (Table 28.7). The lifespan of erythro- cytes in serum is approximately 90–120 days; there- fore, signs or symptoms of treatment-associated ane- mia may not be observed for 4–6 weeks after the myelosuppressive therapy has been administered.

Table 28.6. Normal hematocrit, hemoglobin, and reticulocyte values for age (Lankowsky, 1999; Schwartz, 2000)

Age Hematocrit (%)

Hemoglobin (g/dl) Reticulocyte

Cord blood 51–55 13.5–20 3.2–5

2 weeks 50–51 12.5–20 0.5–1

3 months 35–36 9.5–14.5 0.7–1

6 months–6 years 36–37 10.5–14 1

7–12 years 38–40 11–16 1

Adult male 43–47 13–18 1

Adult female 41–42 12–16 1

a

Hematocrit is defined as the percentage of blood volume that is specifically comprised of RBCs; can be influenced by hydra- tion status

Table 28.7. Age-appropriate iron, ferritin, bilirubin values (adapted from Choukair, 2000)

Age Iron Ferritin Total bilirubin

Newborn infant 100–250 mcg/dl 25–200 ng/ml <1 mg/dl

1 month 40–100 mcg/dl 200–600 ng/ml <1 mg/dl

2–5 months 40–100 mcg/dl 50–200 ng/ml <1 mg/dl

6 months–15 years 50–120 mcg/dl 7–140 ng/ml <1 mg/dl

Adult male 65–170 mcg/dl 15–200 ng/ml 0.1–0.2 mg/dl

Adult female 50–170 mcg/dl 12–150 ng/ml 0.1–0.2 mg/dl

28.4.1 Erythrocyte Transfusion Options

▬ Whole blood

– Used when massive blood loss has occurred – Contains RBCs, WBCs, platelets, and plasma – Requires crossmatching within 72 hours; must

be ABO-identical and Rh-compatible – 8 cc/kg increases hemoglobin (Hgb) 1 g/dl

▬ PRBCs (Packed red blood cells) – Treatment choice (Table 28.8)

– Does not significantly increase volume

– Preparation includes removing plasma from whole blood; sediment and erythrocytes are centrifuged from 1 unit of whole blood

– Shelf life 42 days; lifespan after transfusion 30 days

– Requires crossmatching within 72 hours; must be ABO-identical and Rh compatible

– Transfuse over 3–4 hours (must be completed in 4 hours)

– Filter with 40-micron microaggregate (leuko- pore) filter

▬ Directed donor

– Donation and screening takes approximately 2 days

– Donate whole blood every 8 weeks

– Check local blood bank specific guidelines re- garding use of expiring products

28.4.2 Special Transfusion Considerations 28.4.2.1 Partial Exchange Transfusion

▬ Preferred to single or frequent PRBC transfusions

▬ Requires two large IV catheters

▬ Process involves withdrawing patient’s blood and administering PRBCs in small increments of 10–50 ml, determined by the patient’s weight

▬ Allows for rapid correction of severe anemia with less risk of pulmonary congestion. Recommended for newly diagnosed children with hyperleuko- cytosis (>100,000/mm

) with associated hyper- uricemia or tumor lysis syndrome

28.4.2.2 Specific Risks of Erythrocyte Transfusion

▬ Electrolyte imbalances (potassium and calcium), hypothermia, arrhythmias, post-transfusion pur- pura, hemolytic transfusion reactions, pulmonary edema with rapid or repeated transfusions

28.5 Platelet Transfusion Options

▬ Single donor (apheresis)

– 6–8 units equivalent to random donor unit – Collected by apheresis

– Volume ~200–300 ml; adjust per child’s weight in kg

– Reduces patient risk of alloimmunization be- cause of limited donor exposures

– Standard apheresis unit

– 3.5¥10

platelet content and <50¥10

WBCs – Standard apheresis unit leukocyte-reduced – 3.5¥10

platelet content and <5¥10

WBCs – Facilitates matched or type-specific platelets – Can obtain partially or fully HLA-matched

platelets from family members

▬ Random donor

– Obtained from whole blood

– 6 units typically considered pooled concentrate – 6 units = 4.8¥10

platelet content and 600¥

10

WBCs

– 6 units leukocyte-reduced = 3.8¥10

platelet content and <5¥10

WBCs

Table 28.8. Hemoglobin-specific dosing recommendations (Kulkarnis and Gera, 1999; Norville and Bryant, 2002; Rogers et al., 2002)

Hemoglobin value Transfusion dose

<8 g/l 10–15 ml/kg over 3–4 hours

<5 g/l PRBC volume =

(ml/kg = Hgb value) over 4 hours; e.g.,10 kg child with Hgb of 5 would receive 50 ml PRBC safely over 4 hours

10 ml/kg yields increase in hemoglobin of 2–4/dl

28.5.1 Procurement and Storage

▬ Single units of whole blood are processed and platelet-rich plasma is removed; platelets are then separated from plasma by centrifugation

▬ May be stored for up to 5 days when processed in 50–60 ml anticoagulant and gently agitated to pre- vent clumping

▬ Require plastic bags that permit entry of oxygen, which enhances aerobic metabolism and prevents accumulation of lactic acid

28.5.2 Transfusion Guidelines

▬ Specific guidelines for platelet transfusion contin- ue to vary and be disputed widely

▬ Platelet counts between 5,000–10,000/mm

are con- sidered safe in a stable pediatric oncology patient

▬ Platelet count, clinical manifestations, and the child’s diagnosis and therapy schedule should guide the decision to transfuse for treatment and/or prophylaxis

28.5.3 Dosing Recommendations

▬ 1 unit/m

or 1 unit/7.5 kg (each unit = 5.5–10

platelets)

▬ Transfusion response may be assessed in 1 and 24 hours

▬ 60 minutes post-transfusion standard dose in- creases platelet count 10,000–12,000/mm

(Rogers et al., 2002). Note: Platelet increase/recovery also depends on variables such as infection, prior al- loimmunization, and injury of platelets during procurement, storage, or transfusion

28.5.4 Infusion Guidelines

▬ ABO compatibility is recommended

▬ ABO incompatibility may contribute to a poor post-transfusion increase and a shorter survival time of transfused platelets

▬ Rh antigens are not expressed on platelets

▬ Females who are Rh-negative should ideally not receive Rh-positive transfusions

▬ Infuse rapidly (20–60 minutes) through 170-mm- diameter filter

28.5.5 Platelet-specific Transfusion Risks

▬ Nonhemolytic reactions

– 20–30% occurrence (Norville and Bryant, 2002)

28.5.6 Platelet Alloimmunization

▬ Children receiving multiple transfusions may de- velop antibodies against HLA-A and B antigens, which destroy platelets expressing the HLA-A or B antigens

▬ Platelet refractoriness is defined as post-transfu- sion increment of <5,000/ul measured 60 minutes post-transfusion and recurring on two sequential occasions

28.5.7 Treatment Options

▬ Platelets stored <24 hours

▬ Antibody testing

▬ If antibodies are not detected, consider nonim- mune causes

▬ HLA-matched single-donor platelets

▬ Crossmatching compatible platelets

▬ Intravenous immunoglobulin 400 mg/kg/day be- fore the platelet transfusion for up to 9 days

▬ Massive transfusion with random-donor platelets

▬ Vinblastine-loaded platelets

28.6 Granulocyte Transfusion

▬ Granulocytopenia: absolute granulocyte count

<200/l

▬ Obtained by leukopheresis, which is labor-inten- sive and expensive

▬ Granulocytes have a half-life of 6–10 hours, serum survival 12–14 hours, tissue survival 5 days

▬ ABO/Rh-compatible, HLA-matched preferred

28.6.1 Indications

▬ Absolute neutrophil count (ANC) <100 with sys- temic bacterial or fungal infection, culture-posi- tive and unresponsive to antibiotic or antifungal coverage for 24–48 hour-period

▬ ANC <500 with expected recovery more than sev- eral days and prolonged survival is anticipated if the infection is controlled

▬ Agranulocytosis or granulocyte dysfunction

28.6.2 Dosing Guidelines

▬ 1–2¥10

WBC/kg infused over 2–4 hours daily un- til infection clears or ANC increases to 500 (Kulka- rnis and Gera, 1999; Norville and Bryant, 2002)

▬ Maintain at room temperature until transfusion

▬ Administer through a standard blood set 170-mi- cron filter

▬ Do not administer with a leukocyte-depleting fil- ter

▬ Irradiation is questionable – possible compromise of cell integrity

28.6.3 Specific Risks

▬ CMV infection

▬ GvHD

▬ Granulocyte preparations contain viable lympho- cytes

▬ Alloimmunization

▬ Hemolytic reactions

▬ Respiratory distress with pulmonary infiltration

28.7 Albumin

▬ Protein component of plasma; requires separation from blood plasma by centrifuge

▬ Crossmatching not required

▬ Indications include hypovolemia, hypoproteine- mia, ascites, pleural effusion

28.7.1 Volume

▬ 1 g/kg=20 ml/kg of 5%

▬ 1 g/kg=4 ml/kg of 25%

28.7.2 Transfusion

▬ 5% solution: 1–10 ml/minute; increase rate for pa- tients in shock

▬ 25% solution: 0.2–0.4 ml/minute

28.8 Fresh Frozen Plasma (FFP)

▬ FFP contains plasma proteins, fibrinogen (1–2 mg/

ml), factor IX, factor V, and factor VIII (approxi- mately 1 unit/ml of each coagulation factor)

▬ Plasma portion remaining after RBCs are removed from whole blood

▬ Frozen at 18 °C within 8 hours of processing

28.8.1 Indications

▬ Replace coagulation factors

▬ Massive blood loss

▬ Active bleeding and abnormal PT/PTT

▬ Antithrombin III (AT-III) deficiency, protein C or S deficiency requiring surgery

▬ Thrombocytic thrombocytopenia purpura (TTP)

▬ Crossmatching not required, but donor and recip- ient must be ABO-identical and Rh-compatible

28.8.2 Volume

▬ 10–15 ml/kg

28.8.3 Transfusion

▬ Over 2–4 hours, infused within 6 hours of thaw

time

28.9 Cryoprecipitate

▬ Precipitated product when FFP is thawed; rich in clotting factors

▬ Not virally inactivated

▬ 10–15 ml (1 unit) contains – 80–100 units factor VIII

– 150–250 mg fibrinogen/10–15 ml – 40–70% vWF activity

– 20–30% factor XIII activity

▬ Crossmatching not required

28.9.1 Indications

▬ Replace fibrinogen deficiencies

28.9.2 Volume

Varies related to diagnosis and condition

28.9.3 Transfusion

1–2 hours, within 4 hours of thaw time

Repeat every 8–12 hours until bleeding is stopped or factor VIII level is normalized

28.10 Intravenous Immunoglobulin (IVIG) 28.10.1 Indications

▬ Antibiotic deficiency, immunoregulatory disorder

▬ Crossmatching not required

28.10.2 Volume

▬ 200–400 mg/kg every 3–4 weeks, infuse over 2–4 hours

28.10.3 Side Effects

▬ Fever, chills, tachycardia, headache, flushing

28.11 Recombinant Human (rHu) Erythropoietin Alpha

▬ Erythropoietin (EPO) is a glycoprotein that in- creases the number of stem cells committed to the red cell line

▬ 90% produced in kidneys, 10% in liver

▬ Production and maturation of RBCs may be expe- dited with administration of EPO

▬ Therapeutic experience in children is limited

▬ May be indicated in specific patient populations;

e.g., Jehovah Witnesses

▬ Agents expensive, require additional injections, and side-effect profile unknown for children

28.12 Palliative Care Issues for Transfusion Therapy

In general, blood component therapy is deferred un- less it is clear that the child would receive immediate and direct benefit from transfusion therapy

28.12.1 Erythrocyte Transfusion

▬ Temporarily improve physical and psychological functioning and respiratory status

28.12.2 Platelet Transfusion

▬ Decrease active bleeding

▬ Prevent spontaneous intracranial hemorrhaging

References

Blajchman MA (1999). Reducing the risk of bacterial contami- nation of cellular blood components. Advances in Transfu- sion Safety, 102: 183–193

Choukair, MK (2000). Blood chemistries/body fluids. In Siber- ry, Iannone (eds) The Harriet Lane Handbook, 15th edn, pp 199–130. Mosby, St Louis

Heal JM, Mullin A, Blumberg N (1989). The importance of ABH antigens in platelet crossmatching. Transfusion, 29: 514–20 Kulkarnis, R, Gera, R (1999). Pediatric transfusion therapy:

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