Blood Products on the Neonatal Unit - Use of

Publication: 01/10/2004  --
Last review: 09/01/2020  
Next review: 02/01/2023  
Clinical Guideline
CURRENT 
ID: 542 
Approved By:  
Copyright© Leeds Teaching Hospitals NHS Trust 2020  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Use of Blood Products on the Neonatal Unit

Introduction

Use of blood products in the neonatal unit is a frequent occurrence and not without risk. There is a huge variation in research findings, hence a difficulty in establishing an "evidence base". The British Committee for Standards in Haematology published its guidelines in 2004 (1).

An original audit of transfusion practice in the LGI Neonatal Unit identified  concerns with poor documentation, decisions about use of blood products, variable volumes and duration of infusions.

In order to improve our performance in all of these areas, guidelines based on available literature were put in place and these have now been updated. They are intended to serve as a reference to decrease unnecessary transfusions, rather than a rigid protocol. Modifications may be necessary depending on clinical circumstances.
Subsequent audit showed use of the red stamp in the medical notes was incomplete and reasons for deviations from the guidelines were not always clearly documented. Minor changes were put in place to improve these and follow-up audit is now required.

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Cross-matching

  • Samples from mother and infant should be obtained for grouping and screening for atypical antibodies, prior to cross-matching. These samples need only be taken once during the first 4 months of life, provided there are no atypical maternal red cell antibodies and the baby's Antiglobulin (Direct Coombs) test is negative. All samples must be labelled to the standards required by Trust Policy.
  • Babies where a maternal sample is not available, require testing for blood group, rhesus and atypical antibodies.
  • All patients must have their ID band checked at the time of sample collection.
  • The label on the sample tube should be handwritten legibly by the person collecting the specimen. Minimum details are full name, DOB, unit number, date of collection and signature of collector.
  • The request form CAN be completed using a correct addressograph label as long as it matches details on tube. The form must contain full name, DOB, gender, unit number and ward, plus the name and signature of collector and their contact number.
  • If Haemolytic disease of the newborn is suggested (clinical signs plus Direct Coombs Test or atypical antibody positive) special procedures are required to select appropriate blood for transfusion. Direct discussion with the lab is required for these babies.

It is the doctor's responsibility to ensure that any special requirements are communicated to blood bank (e.g. irradiated products etc). If in doubt, phone the laboratory for advice.

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Background - Information about Blood Products

Babies under 28 weeks or others likely to require several transfusions can be allocated to  "paedipack" system, in which one donation is divided into small volume packs which can be used for the same infant to reduce donor exposure. The request form must be labelled “Paediapck please, may need multiple transfusion”.

In the LTHT, all neonatal blood products are CMV-negative and leucocyte-depleted (to reduce the theoretical risk of vCJD). FFP is virus-inactivated.

Specialist products are provided as necessary (e.g. use irradiated red cells and platelets in cases of in-utero transfusion, exchange transfusion, proven or suspected T-cell immunodeficiency e.g. Di George).

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Consent

Consent must be gained for all transfusions.

Parents should be seen by the admitting doctor or a trained senior nurse and be given the leaflets “Children receiving a blood transfusion” and “Parents guide”. Pre-printed consent forms are available. These should be filled in completely and the pink copy given to parents/carers. The remainder should be filed in notes. A standard form may be used if necessary.

Full details of LTHT requirements can be found in the LTHT “Policy for use of written informed consent for transfusion of blood and blood components”.

Who can give consent?
Consent can be given by someone with parental responsibility. This is usually the mother or a married father. Advice on who has parental responsibility can be found on the reverse of consent form 2.

Where a person with parental responsibility is not available and where transfusion is necessary, inform the consultant on call.
If a parent refuses consent for transfusion, discuss with the on call consultant.

When to obtain consent?

  • All babies admitted to intensive care
    • Obtain written consent for transfusion of blood, platelets, fresh frozen plasma and cryoprecipitate on admission (individual products must be named separately). This will remain effective for the duration of the admission.
  • All other babies admitted to the Neonatal unit or surgical newborns
    • Obtain written consent for each individual blood or blood product transfusion episode.
  • Emergency or life threatening situations
    • A transfusion may be given if with holding it is life threatening. Attempt to contact a person with parental responsibility by telephone to obtain verbal consent BEFORE transfusion.
    • Document verbal consent fully in the medical notes.

Parents should be informed on the following

  • Blood is collected from screened volunteers and each unit is tested to look for certain infections. Blood given to babies is usually from regular donors.
  • Blood is screened for hepatitis B & C and HIV. The risk of infection is very low - about 1 in 900.000 for hep B, < 1 in 30 million for hep C and < 1 in several million for HIV. We do not yet know the risk of infection with variant Creutzfelt-Jakob Disease (vCJD).
  • The main risk from a transfusion is being given the wrong blood group (about 1 in 25 000). Each baby is tested to ensure that only compatible blood is given. Identification is checked before transfusion and regular monitoring occurs during the procedure.
  • Severe reactions are very rare and staff are trained to deal with them.
  • Temperatures or rashes may occur but are usually mild.
  • In addition, neonates are more at risk of hypoglycaemia, hypocalcaemia, thrombocytopenia, transfusion overload and graft versus host disease

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Red Cell Transfusion

The following levels are given as a guide only.

 

Threshold for transfusion

Frusemide
There is no indication for routine use of frusemide, except in those infants with heart failure or severe oedema.

1. Anaemia - first 24 hours

Hb<12g/dl

2. Ventilated

 

  • <28 days

 

i. in FiO2 > 30%

Hb<12g/dl

  • ii. in FiO2 <30

Hb<10g/dl

  • >28 days

Hb<10g/dl

3. Nasal CPAP/ High Flow

 

  • in FiO2 > 30%

Hb<10g/dl

  • in FiO2 < 30%

Hb<8g/dl

4. Stable + Chronic Lung Disease

 

  • in low-flow O2

Hb<8g/dl

  • in air

Hb<8g/dl

Red cell transfusion may be justified at higher thresholds than those mentioned:

  1. In sick neonates with hypovolaemia, septic shock, peri-operatively etc.
  2. In those with symptoms which could be attributable to anaemia e.g. increased blood lactate, increasing respiratory distress and O2 requirement, tachycardia, increased desaturations, poor feeding, poor weight gain etc.
  3. Older babies with CLD may tolerate a low Hb. There is no strong evidence to support the use of low or high thresholds for transfusion and clinicians must be guided by clinical state (2,3).  In asymptomatic babies it is useful to check the reticulocyte count, as it is appropriate to withhold transfusion when the reticulocyte count >5-6 %.

Irradiated Blood Products
These are required for the following groups:

  •  
    1. Babies who received an intra uterine transfusion
    2. Babies with a condition  which increases their susceptibility to transfusion associated graft versus host disease e.g. Di George syndrome
    3. Exchange transfusion

VOLUME OF RED CELL TRANSFUSION
15 ml/kg over 4 hours

Exchange Transfusion - see separate protocol

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Platelet Transfusion

Indications
A separate guideline is available for investigation and management of thrombocytopaenia.

To prevent or treat haemorrhage in patients with thrombocytopenia or abnormally functioning platelets.

Most infants who bleed do so in the first few days, however there is a subgroup of neonates who develop severe thrombocytopenia secondary to sepsis, NEC etc. These babies are unlikely to bleed even when profoundly thrombocytopenic. The following criteria have been agreed:

  • <25 x 109/l

transfuse all (same threshold for preterms as term)

  • 25-49 x 109/l

- if bleeding: transfuse
- if not bleeding: transfuse only if clinically unstable

AND

  • previous major bleed (pulm/intracranial) or
  • co-existing coagulopathy or
  • pre-op or
  • requires exchange transfusion, LP or surgical central line insertion
  • >50 x 109/l

transfuse only if

  • clinically bleeding or
  • platelets <100 x 109/l prior to major surgery

VOLUME OF PLATELET TRANSFUSION
15 ml/kg (up to volume of 1 unit) over 60 minutes

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Fresh Frozen Plasma

Indications

  • Treatment of disseminated intravascular coagulation (DIC)
  • Vitamin K-dependent bleeding
  • Inherited deficiencies of clotting factors
  • Pre-procedure in well babies with abnormal clotting - discuss individual cases with senior

There is NO evidence to support the use of FFP for

  1. volume replacement or correction of hypotension
  2. prevention of intraventricular haemorrhage or
  3. routine correction of clotting function if clinically well.

It must be noted that "normal" values for clotting function in neonates are different to those in older children. In those infants with transiently "deranged" clotting who are well, without evidence of bleeding or DIC, it is frequently unnecessary to administer FFP. The decision must be made on the basis of the general clinical condition of the child - discuss with senior.

VOLUME OF FFP TRANSFUSION
15 ml/kg over 60 mins

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Cryoprecipitate

Indications
Cryoprecipitate provides fibrinogen, factor VIII & Von-Willebrand factor. It is used in sick infants with severely deranged clotting and fibrinogen level <1g/l. Early use of fresh frozen plasma may avoid the need for cryoprecipitate.

VOLUME OF CRYOPRECIPITATE
5 ml/kg over 30 mins or
as per discussion with Paediatric Haematologist

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20% Human Albumin Solution

Indications
Concentrated albumin may be used in the scenario of VLBW infants with hypoproteinaemia and oedema. There is no firm evidence that it confers any benefit re outcome. Optimising nutrition and fluid intake remains crucial. If albumin is to be used, it should only be administered to those with serum albumin <20g/l and significant clinical oedema.

VOLUME OF 20% ALBUMIN TRANSFUSION
5mls/kg over 2 hours

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Documentation

The following documents strongly advocate good documentation. It is essential that all blood products must be traceable to the patient receiving them - failure to complete documentation can have severe medico-legal consequences in the event of viral transmission or other adverse reactions. Clear links must be established between each stage in the procedure from collection of the sample to infusion of the blood product:

  1. Department of Health (HSC "Better Blood Transfusion 2")
  2. Handbook of Transfusion Medicine
  3. Leeds Teaching Hospitals Guidelines to Safer Blood Transfusion Procedures

The administration of any type of blood product must be documented in the medical notes using a rubber stamp and red standard inkpad.

  1. The minimum dataset required to be completed comprises and is available as a stamp to be put in the medical notes:


1. Date ...........................................................................

2. Indication ....................................................................

3.Type of product .........................................................

4. Volume of product .....................................................

5. Name of Administrator ................................................

6. Complications ...........................................................

  1. Once the decision has been made to transfuse, the SHO/SPR who actually prescribes the transfusion stamps the medical notes and completes fields 1 and 2; Fields 3 to 6 must be completed by the nurse giving the transfusion;
  2. Documentation is compulsory for every newborn receiving one of the following blood products: Red Cells, Platelets, FFP, HAS (4.5 or 20%), Cryoprecipitate. The peel off part of the product compatibility label containing the donation number should also be added to the fluid chart.

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Provenance

Record: 542
Objective:
  • To ensure Positive Patient Identification takes place for every transfusion, in line with Trust Policy
  • To improve the decision-making process regarding use of neonatal blood products and thus to avoid unnecessary transfusions.
  • To improve the documentation of blood product administration in the medical notes.
  • To reaffirm the importance of taking informed consent.

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Clinical condition:

Neonates potentially requiring blood products

Target patient group: Newborn Infants
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

  • British Committee for Standards in Haematology (2016).  Guidelines on transfusion for fetuses,neonates and older children.  http://www.bcshguidelines.com/4_HAEMATOLOGY_GUIDELINES.html
  • Randomized trial of platelet transfusion thresholds  in neonates (PLANET study): N Engl J Med 2019; 380:242-251 https://www.nejm.org/doi/full/10.1056/NEJMoa1807320
  • British Committee for Standards in haematology Transfusion Task Force: Writing Group. Transfusion Guidelines for neonates and older children. British Journal of Haematology, 124, 433-453
  • Kirpalani H et al. The Premature Infants in Need of Transfusion (PINT) Study. J Pediatr 2006 Sep;149(3):301-307.
  • Bell EF et al. Randomised trial of liberal versus restrictive guidelines for red blood cell transfusion in preterm infants. Pediatrics 2005 Jun;115(6):1685-91

A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. Leeds consensus. (where no national guidance exists or there is wide disagreement with a level C recommendation or where national guidance documents contradict each other)

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Document history

LHP version 2.0

Related information

Not supplied

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