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Blood and blood products

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General points

  • Blood products should be used within 6 hours of opening.
  • Irradiate products if immunocompromised (newborn, transplant, oncology patients, cardiac with absent thymus) to prevent GVH disease/ viral infections
  • Use CMV negative products if immuno-compromised patients unless the patient is CMV positive
  • Blood products may contain high levels of citrate (which chelates calcium and causes acidosis) and potassium. Monitor electrolytes, renal function, coags and ECG.
  • Cross match is required for blood products unless life threatening emergency, where O negative blood may be requested.
  • Blood products should be warmed if possible.

Indications for transfusion

Indication Product
Hypovolaemia Albumin, FFP or red cells
Acute bleeding Red cells, FFP, Platelets
Coagulopathy FFP, platelets, cryoprecipitate
Anaemia Red cells
Immunological IVIG

Management of acute bleeding:

  1. Give blood to keep Hct > 0.3
  2. Fibrinogen >1.5, PR >1.5 or APTT >45, give FFP
  3. Give platelets
  4. Fibrinogen <1.5, give cryoppt
  5. Fibrinogen >1.5, PR <1.5, APTT < 45, give platelets
  6. If bleeding continues, give further platelets and cryoppt
  7. If post bypass, check ACT. If > 130, give protamine
  8. Notify surgeon for post-operative patients
  9. Sedate patient and warm blood products

Specific products

Product Give Indication
Packed rbc 10-15 ml/kg (4 ml/kg raises Hb by 10g/dL) Hypovolaemia and blood loss, anaemia
1. Hb <70g/dL and patient stable
2. Hb<100g/dL and:
- post operative cardiac surgery
- ventilated with FiO2>0.6,
- acute brain injury
- ongoing acute loss: bleeding, sepsis
Whole blood 10-15 ml/kg Acute blood loss, exchange transfusion
Platelets 10 ml/kg or 1u/5kg  (will raise  platelet count  by 50×109/L) 1. Pl <20×109/L
2. Pl <50×109/L if acute bleeding, severe  sepsis, post cardiac surgery, acute brain injury
4% albumin 10-15 ml/kg 1. Hypovolaemia
2. Plasma exchange
20% albumin  5 ml/kg  Severe symptomatic hypoalbuminaemia 
FFP 10 ml/kg  1. Coagulopathy (APTT >45 or PR > 1.5) and  active bleeding,
2. Massive transfusion
Cryoprecipitate  5 ml/kg  1. Fibrinogen < 1 and active bleeding (sepsis,  trauma, burns, liver failure)
2. Deficiency of factors VIII:c, XIII,vW factor
IVIG   400  mg/kg/dose Ig deficiency, GBS, ITP, Kawasaki's, toxic  shock. 
Prothrombinex    Deficiency of factor II, IX, X

Blood Orders for Bypass

Bypass 0-4 kg 1 WB, 1 RBC, paed packs equivalent to 1 donation +  1 unit plasma reduced
platelet concentrate + 100 ml 
albumin 20%
4-20kg 1 WB, 2 RBC + 100 ml 20% albumin
20-40kg 4 RBC
Non-bypass <5 kg 2 paed packs (O neg, CMV neg)
>5 kg 1 RBC

Transfusion reactions/problems

  1. Fever (common)
  2. Fluid overload: consider diuretics
  3. Metabolic : hypercalcaemia, hyperkalemia, acidosis, iron overload
  4. Transmission of disease(rare): HIV, CMV, EBV, bacterial sepsis
  5. Transfusion reactions: wheeze, urticaria, angioedema, shock, haemolysis, anaphylaxis, pain, hypotension,

Management of a transfusion reaction

  1. Stop the blood.
  2. Resuscitate patient: ABC
  3. Adrenaline 0.1 ml/kg 1: 10 000 if severe reaction
  4. Steroids (hydrocortisone 2 mg/kg), antihistamine
  5. Send the patient's blood for full blood count, transfusion antibodies screen, liver and renal function. Dipstick urine at the bedside for blood, and if positive send the urine for microscopy and cell count.  Notify blood bank and return the remainder of the unit of blood being transfused at the time of reaction to blood bank for further testing

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Document Control

  • Date last published: 18 January 2010
  • Document type: Clinical Guideline
  • Services responsible: Paediatric Intensive Care Unit
  • Owner: Fiona Miles
  • Editor: John Beca
  • Review frequency: 2 years