Use of Blood Products on the Neonatal Unit

• Introduction
• Aims
• Broad recommendations/General principles
• Cross-matching
• Information about Blood Products 
• Consent
• Red Cell Transfusion
• Platelet Transfusion Fresh Frozen Plasma
• Cryoprecipitate
• 20% Human Albumin Solution HAS
• Requesting and Documentation

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 (revised 2016, 2020) (1). These guidelines aim to provide clarity on which blood products should be used when on the neonatal unit. 

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Aims

• 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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Broad recommendations/General principles

Whilst the administration of blood and blood components can be life-saving, it is not without risk. There are number of general principles which should always be followed when administering blood or blood components.

• Only use blood components when they are clearly indicated
• Whenever practicable, the planned use of blood products should be discussed with parents in advance.
• Avoid routine top ups out of hours and ensure the component is prescribed in millilitres.
• All efforts should be made to minimise donor exposure and unnecessary blood/blood products transfusion by
  • Delayed cord clamping for 1 minute (Delayed Cord Clamping Standard Operating Procedure (leedsth.nhs.uk)
  • Use of Cord blood for baseline investigations (blood group, FBC and DCT) in preterm < 32 weeks, VLBW & ELBW babies. This will require collaborative effort from the midwifery team and the neonatal team. Neonatal medical team should ensure that midwives will collect and send the cord blood samples (2 purple EDTA tubes). Reports have to be chased by the neonatal medical team. Please note, if the cord blood group is different from mother’s blood group, the blood bank will report it as baby's blood group. If the cord blood group result reveals a similar blood group to the mother’s , a repeat sample from the baby has to be sent to blood bank immediately for confirmation of new-born’s blood group. Blood components/products cannot be issued on a cord sample- Cord samples are for blood typing only.
    
    
  • Keeping blood sampling to the minimum required for safe practice.  Consider whether an investigation is required or whether trends can be monitored on blood gases.
    
    
  • Carefully returning discard or blood drawn to “clear” an arterial line to the patient after sampling, prior to flushing with saline.
    
    
  • Use of Paedipacks for preterm babies <28 weeks or babies who are likely to require more than one blood transfusion during their hospital stay.
    
    
• Take great care when checking blood/blood components prior to administration.
• Closely monitor the patient during and immediately following administration of Blood/blood components.

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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 to only be taken once during the first 4 months of life, provided there are no atypical maternal red cell antibodies and the baby's Anti-globulin (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.
• BloodTrack Tx has to be used to label all samples that are sent to Blood Bank to comply with the trust safer transfusion policy.
• If a handwritten label is used on the sample tube, it must be handwritten legibly by the person collecting the specimen. Minimum details are full name, DOB, NHS & PAS, date of collection and signature of collector.
• The form must contain full name, DOB, gender, unit number and ward, plus the name and signature of collector and their contact number. The request form CAN be completed using a correct addressograph label as long as it matches details on baby ID band and the tube exactly. The details on the form must be completed prior to the sample being taken and the signature of the person requesting and collecting the sample must be noted on the form- failure to complete the form correctly will result in the sample being rejected by the lab. Refer to the Sample acceptance policy for pathology samples.
• If Haemolytic disease of the new-born 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.
• Remember to take a pre-transfusion new-born screening bloodspot for a baby in NICU< day 5
• Additional cross-match specimens are required for 
  
  • Babies who had a complete name change on PAS. Please note, when babies change on PAS from BABY to forename (not a complete name change), no further cross matching sample is required, however, lab requires written ID that the forename has been changed - written confirmation such as albumin request form or pink transfusion request.
    
    
  • Transfusions of all infants >4 months

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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Information about Blood Products 

Babies less than 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 transfusions”.

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 new-borns
  • Obtain written consent for each individual blood or blood product transfusion episode.
• Emergency or life-threatening situations
  • A transfusion may be given if withholding 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 processed from regular donors.
• Blood is screened for hepatitis B & C, HIV, Syphilis and HTLV. The risk of infection is very low - about 0.79 per million for hep B, 0.035 per million for hep C and 0.14 per 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

1. Emergency transfusion for severe blood loss with hypovolemic shock.

• This situation requires urgent fluid volume resuscitation, usually with 10-20ml/kg crystalloid infusion initially, followed by blood resuscitation of (either type-specific cross matched or O Rh neg blood group).
• A blood grouping sample and new-born bloodspot should be taken from the baby prior to emergency transfusion.
• If immediate (threat to life) red cell transfusion is essential, use Emergency O D-negative blood (20ml/kg) from the Delivery Suite blood fridge (it has a Paedipack specifically for emergency cases), C floor theatres Clarendon Wing or Blood Bank. The Blood Bank must be informed if the emergency blood is removed from the Delivery Suite fridge to allow the lab staff to replace the blood stock. In all other situations use group specific or ideally cross matched blood.

• In babies with history of antepartum haemorrhage/acute blood loss, normal oxygen saturation can falsely reassure about haemoglobin levels (Oxygen saturation measures how much haemoglobin is currently bound to oxygen and if there is not much haemoglobin then saturation % will be high, even though oxygen delivery to the tissue will be poor). Serial Hb monitoring (blood gas/lab) is recommended to guide further transfusion.

• Massive Blood Loss is uncommon in neonatal practice but requires urgent attention to additional measures over and above red cell transfusion. Massive haemorrhage is defined as blood loss expected/ estimated to be:
  • Equivalent to a single circulating blood volume (80ml/kg) within a 24-hr period or,
  • 50% of the circulating blood volume (40ml/kg) within 3 hours or,
  • At a rate of 2 – 3ml / kg per minute or,
  • Signs of continuing shock following 40ml/kg crystalloid and/or colloid resuscitation for acute haemorrhage.
  • Details of Transfusion in massive haemorrhage in Neonates & Paediatrics (birth -16years) and how to put it into action are contained in the Trust Guideline (Transfusion in Massive Haemorrhage in Neonates & Paediatrics ( Birth - 16years ) (leedsth.nhs.uk)

2. Top up red cell transfusion

Red cell transfusions are largely given as small volume ‘top ups’ due to pre-term infants frequently becoming anaemic. Minimising phlebotomy losses where possible can help prevent anaemia and avoid red cell transfusion.

The following levels are given as a guide only for neonates <37 weeks gestational age at birth.

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

• In sick neonates with hypovolaemia, septic shock, peri-operatively etc.
• In those with symptoms which couldbe attributable to anaemia e.g. increased blood lactate, increasing respiratory distress and O2 requirement, tachycardia, increased desaturations, poor feeding, poor weight gain etc.
• Ex pre-term babies with CLD may tolerate a low Hb. Clinicians can be guided by clinical state and either transfuse as suggested or alter threshold limit based on judgement. In asymptomatic babies it is useful to check the reticulocyte count, as it is appropriate to withhold transfusion when the reticulocyte count >5-6 %.

• The blood must be administered within 4 hours of removal from the fridge. Ensure the patient has a working cannula available for transfusion before requesting blood to avoid unnecessary delays.
• The typical transfusion volume of 15ml/kg should be administered at 5ml/kg/hour (transfusion volumes can sometimes range from 10-20ml/kg as higher ends might be transfused for severe anaemia or bleeding).
• There is no indication for routine frusemide unless there is a risk of heart failure or volume overload

3. Irradiated Blood Products

These are required for the following groups:

• Babies who received an intra-uterine transfusion
• Babies with diagnosed or suspected T-cell immunodeficiency diseases which increases their susceptibility to transfusion associated graft versus host disease e.g., Di George syndrome
• Exchange transfusion

4. Exchange Transfusion see separate protocol Exchange Transfusion (leedsth.nhs.uk)

5. Feeding during blood transfusion in preterm babies

• At the moment the practice at the neonatal unit at Leeds Teaching Hospitals Trust does not advocate the cessation of enteral feeds for the duration of the transfusion as the evidence that is practice may reduce the incidence of Transfusion Associated Necrotising Enterocolitis TANEC is not robust.
• The neonatal unit will join the international WHEAT (WithHolding Enteral feeds Around packed red cell Transfusions) study which is a randomised control trial exploring whether withholding enteral feeds around the time of blood transfusions will reduce the rate of necrotising enterocolitis in preterm babies. This guideline will be updated in the light of any new recommendations from the WHEAT study.

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Platelet Transfusion Fresh Frozen Plasma

A separate guideline is available for investigation and management of thrombocytopaenia Thrombocytopenic Neonate (leedsth.nhs.uk)

Platelet transfusion is indicated 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:

• For infants with neonatal alloimmune thrombocytopenia (NAIT) see management of thrombocytopenia guideline Thrombocytopenic Neonate (leedsth.nhs.uk)

• Because of their short shelf-life, platelets are not routinely stored in the hospital but ordered from the National Health Service Blood and Transplant (NHSBT) in Barnsley as required.
• Request for platelets should be made at the earliest possible opportunity by telephoning the hospital Blood Transfusion Laboratory (Ext: 23398 (LGI) & ext: 65559 (SJUH)), followed by the relevant blood sample if the patient’s blood group is unknown to the Lab. Once the request is received the Transfusion Laboratory will order platelets to be delivered from the National Blood Service Centre.
• N.B. Requests may take up to 2 hours before delivery to the clinical area depending on availability, type of request (e.g., irradiated) and level of traffic between NHSBT and the hospital.
• In emergency situations such as major haemorrhage, plan ahead and communicate early with the Blood Transfusion Laboratory. SJUH 65559, LGI 23398.
• 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
• Clinically significant bleeding (including massive blood loss) or prior to invasive procedures with a risk of significant bleeding in neonates with an abnormal coagulation profile, defined as a PT or APTT significantly above the normal gestational and postnatal age-related reference range.
• volume replacement or correction of hypotension
• prevention of intra-ventricular haemorrhage or
• Routine correction of clotting function if clinically well.
• Requests for FFP must be made via a telephone call to the Transfusion Laboratory LGI – 23398, SJUH - 65559).
• The Transfusion Laboratory requires a confirmed ABO group and Rh D blood group on the Blood Bank system to order to issue FFP. Please send a correctly labelled sample for Group and Save to the lab as soon as possible to prevent any delays- please liaise with the Blood Bank laboratory. Be aware that FFP needs to be thawed before being issued to a patient and this process can take up to 30 minutes plus transport time to the clinical area.
• Requests for Cryoprecipitate must be made via a telephone call to the Transfusion Laboratory LGI – 23398, SJUH - 65559).
• The Transfusion Laboratory requires a confirmed ABO group and Rh D blood group on the Blood Bank system to order to issue Cryoprecipitate. Please send a correctly labelled sample for Group and Save to the lab as soon as possible to prevent any delays- please liaise with the Blood Bank laboratory. Be aware that Cryoprecipitate needs to be thawed before being issued to a patient and this process can take up to 30 minutes plus transport time to the clinical area.
• 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 regarding 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.
• Please discuss with a consultant if it is felt that a baby needs more than one 10ml/kg 5% HAS bolus.
• 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 regarding 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.
• Please discuss with a consultant if it is felt that a baby needs more than one 10ml/kg 5% HAS bolus.

Fresh Frozen Plasma

Indications

There is NO evidence to support the use of FFP for

It must be noted that "normal" values for clotting function in neonates are different to those in older children. In 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 after discussion with a senior.

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Cryoprecipitate

Cryoprecipitate provides higher concentrations of fibrinogen, factor VIII & Von-Willebrand factor than fresh frozen plasma and is indicated for use in infants with severe coagulopathy and fibrinogen levels <1g/l. Early use of fresh frozen plasma may avoid the need for cryoprecipitate.

• Requests for Cryoprecipitate must be made via a telephone call to the Transfusion Laboratory LGI – 23398, SJUH - 65559).
• The Transfusion Laboratory requires a confirmed ABO group and Rh D blood group on the Blood Bank system to order to issue Cryoprecipitate. Please send a correctly labelled sample for Group and Save to the lab as soon as possible to prevent any delays- please liaise with the Blood Bank laboratory. Be aware that Cryoprecipitate needs to be thawed before being issued to a patient and this process can take up to 30 minutes plus transport time to the clinical area.

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20% Human Albumin Solution HAS

• 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 regarding 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

• Please discuss with a consultant if it is felt that a baby needs more than one 10ml/kg 5% HAS bolus.

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Requesting and 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
• Documentation is compulsory for every new-born receiving one of the following blood products: Red Cells, Platelets, FFP, HAS (5% or 20%), Cryoprecipitate. The administration of any type of blood product must be precisely documented on PPM. The minimal dataset required comprises of date, indication, and type of product, volume of product, name of administrator, outcome and any complications.
• The pink LTHT blood product prescription chart (order code: WPG 602) must be used by prescribers and administrators of blood products. The peel off part of the product compatibility label containing the donation number should be added to the blood product chart by the two administrating practitioners.
• Requesting/ordering any blood component from the transfusion laboratory is the responsibility of the medical team. Once telephone communication with the lab is completed and order is documented in the transfusion prescription chart, the order has to be CARPS (ed) via CARPS system by a medics or a nurse. The patient full details, ward location and what product/component they require must be placed on carps for the porter to collect the blood component/product from blood bank. Alternatively, a competent member of the clinical team can collect the blood product/component from the blood bank laboratory. The individual collecting the blood component/product must be competent and must have written documentation of the patient’s identifiers.
• To ensure traceability (a legal requirement), the act of transfusing a unit to a particular patient must be recorded using the electronic Autofate system or by signing the attached manila tag and sending it to the Transfusion Laboratory within 24 hours. The component is autofated prior to and at the end of transfusion
• Transfusion observations (Heart rate, Temperature, Respiratory rate) must be recorded at the start, 15 minutes after the start and at the end for each unit transfused.

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