Paediatric blood transfusion

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Paediatric blood transfusion

• Dr. Chitra Rajeswari T
• Dr. Lokesh Kashyap

www.anaesthesia.co.in anaesthesia.co.in_at_gmail.c
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Why to transfuse blood

• Basic physiological function is to ensure
  adequate oxygenation of the tissues
• Physiology of oxygen transport

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Hypoxic hypoxia
Anaemic hypoxia
Histotoxic hypoxia
Stagnant hypoxia
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Anaemic hypoxia
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Oxygen delivery

• DaO2
• Cardiac output X CaO2 oxygen content
• Oxygen content
• Hb saturation X 1.34 X Hb conc 0.003 X
  PO2
• Amount of oxygen carried by 100 ml of blood

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Fetal hemoglobin
Cardiac reserve
Increased metabolism
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Fetal hemoglobin

• HbF 70-80 of full term and 97 of premature
  infants total hemoglobin at birth

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Fetal hemoglobin

• Shorter life span of 90 days (HbA- 120 days)
• HbF interacts poorly with 2,3,DPG
• P50 with HbF is 19 mmHg
• P50 with HbA is 27 mmHg
• Leftward shift of ODC

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ODC
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Hemoglobin for equivalent oxygen delivery
P 50 Hb
Adult 27 10
Infants gt3 month 30 8.2
Infants lt3 month 24 14.7
Motoyama et al. 1990
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6 months- 6 years
12 7- 13 years
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Preoperative hemoglobin

• At the time of nadir
• Term infant with Hb lt 9 g/dl
• Preterm infant lt7 g/dl
• Haemoglobin levels that are adequate for the
  older patients may be suboptimal in the younger
  infant

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Fetal hemoglobin
Cardiac reserve
Increased metabolism
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Adult vs children - cardiac reserve

• Children have a higher cardiac output to blood
  volume ratio than adults

Estimated circulating blood volume Estimated circulating blood volume
Age Blood volume (ml/kg)
Premature infant 90-100
Term infant 3 months 80-90
Children older than 3 months 70
Very obese children 65
Sandra et al. Pediatric anesthesia 2005
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Adult vs children - cardiac reserve

• The neonatal myocardium operates at near maximum
  level of performance as a baseline
• The newborns heart may be unable to compensate
  for a decreased oxygen carrying capacity by
  increasing cardiac output
• The neonatal myocardium will also suffer a
  greater degree of decompensation when exposed to
  decreased oxygen delivery

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Metabolism

• Oxygen consumption

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When to transfuse blood?
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MABL

• MABL Starting Target hematocrit
• Blood loss more than this target value then RBC
  cell transfusion should be initiated
• 65 ml of packed RBC Hct 70 150 ml of whole
  blood Hct 30
• 0.5 ml of PRBC for each ml of blood loss beyond
  the MABL
• 1 ml/kg PRBC raises the hematocrit by 1.5

X EBV
Starting hematocrit
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• May benefit from higher hematocrit
• Preterm and term infants
• Cyanotic congenital heart disease
• Large ventilation/ perfusion mismatch
• High metabolic demand
• Respiratory failure

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Guidelines for perioperative management of anemia
Minimum acceptable hemoglobin
Infants gt 3 months 8 g/dl
Infants lt 2 months Ex-premie lt52 weeks PCA 10g/dl
Infants in first week of life Weight lt 1500 g With cardiopulmonary disease 12g/dl
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Guidelines contd

• In an elective setting, anemia should be
  evaluated and treated,surgery may be postponed
  for a month or longer
• Cumulative record of blood loss should be kept
  for critically ill infants and loss replaced when
  it exceeds 10 of blood volume

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Guidelines contd

• In an emergency setting, anesthesia administered
  with extreme caution
• Maintain high PaO2
• Adequate cardiac output
• Adequate intravascular volume
• Avoid factors increasing oxygen consumption
• Avoid leftward shift of ODC

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Guidelines contd

• Oxygen extraction ratio
• as hematocrit drops to 15, OER increases from
  38 to 60
• Central venous Po2
• Decline of pVo2 is the most sensitive indicator
  of anemia
• Normal gt 38 mm Hg

Holland et al. 1987
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Pediatric transfusions guidelines

• Platelet transfusions
• platelet count less than 50000 in acute bleeding
• Less than 1 lakh for intracranial and
  Subarachnoid or extra corporeal circulation
  procedures
• 5 mL/kg - 10 mL/kg causes a rise of platelets of
  50 to 100 109/L
• Fresh frozen plasma
• aPTT or PT gt 1.5 times normal
• 10-15 ml/kg
• Cryoprecipitate
• Fibrinogen 100 mg/dl
• 1 unit /10 kg BW raises plasma fibrinogen by 50
  mg/dl

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Transfusion reactions

• Acute transfusion reactions ( lt 24 hours)
• Febrile nonhemolytic reaction
• Urticarial/allergic reaction
• Acute hemolytic reaction
• Bacterial contamination and sepsis
• Fluid overload
• Anaphylaxis
• TRALI
• Delayed transfusion reaction
• Infection
• Delayed hemolytic reaction
• Post transfusion purpura
• Graft Vs host disease
• Iron overload

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TRALI

• TRALI
• Acute hypoxemia
• Non-cardiogenic pulmonary edema
• During or after transfusion
• Leading cause of transfusion-related mortality in
  2003 FDA, TRALI conference
• Underdiagnosis underreporting

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Incidence

• All plasma-containing blood blood components
• 1/5,000 blood blood component
• 1/2,000 plasma-containing component
• 1/7,900 units of FFP
• 1/432 units of whole blood derived platelets

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Pathophysiology

• Leukocyte antibodies
• Biologically active substance
• Lipids cytokines
• Neutrophil priming activity
• Leukocyte Antibodies
• Neutrophil in pulmonary capillary ? pulmonary
  damage capillary leak
• Antibody to donor leukocyte
• Ab to HLA I, II, granulocyte, monocyte, IgA

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Management

• Supportive
• Stop transfusion if timely recognition
• Oxygen and ventilatory support as employed in
  ARDS
• Avoid blood from multiparous female donors

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Immunologic

• Transfusion related graft vs host disease
• Lymphocytes in transfused blood component
  proliferate and cause host tissue destruction
• Immunocompromised patient
• Premature infants
• Children with cancer or severe systemic illness
• Acute blood loss
• Cardiopulmonary bypass

Prevented by irradiated blood
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Pediatric transfusions - neonates

• Neonates have some specific considerations with
  respect to anesthesia and blood products.
• Major hemolytic reaction (ABO) occurs less
  frequently in neonates compared with older
  children and adults.
• For the first 34 months of life, infants are
  unable to form alloantibodies to RBC antigens.
• After 4 months of age, hemolytic reactions become
  a potential factor

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Massive blood transfusion
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Definition

• Loss of one or more circulating blood volume in
  24 hour
• 50 blood volume in 3 hours
• Loss occurring at the rate of 2-3 ml/kg/min

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Problems of massive transfusion

• Hypocalcemia
• Hyperkalemia
• Hypomagnesemia
• Hypothermia
• Volume overload
• Dilutional coagulopathy
• Acid base changes
• Shift of ODC curve
• Microaggregate delivery
• TRALI

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Hypocalcemia

• Degree of ionized hypocalcemia depends upon
• Blood product transfused
• Rate
• Hepatic blood flow
• Hepatic function

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Hypocalcemia

• Degree of ionized hypocalcemia depends upon
• Blood product transfused
• Rate
• Hepatic blood flow
• Hepatic function

FFP
gt 1 ml / kg / min
Decreased ability to metabolise by neonate
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Hypocalcemia
Myocardial depression
Inhalational agents
Decreased ability to metabolise by neonate
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Prevention of hypocalcemia

• Rate should be lt 1 ml / kg / min
• If more than gt 1 ml / kg / min calcium should
  also be transfused
• Calcium infusion
• Calcium chloride 5-10 mg/kg
• Calcium gluconate 15-30 mg/kg
• Frequent measurement of ionised calcium

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Hyperkalemia

• Blood components with high potassium
• Whole blood
• Irradiated blood
• Near the expiry date

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Prevention of hyperkalemia

• Washing of erythrocytes
• Newer blood (lt 7 days)
• Avoiding whole blood and prefer packed RBC

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Treatment

• CaCl2 15-20 mg/kg
• Calcium gluconate 45-60 mg/kg
• 1-2 min intervals until the arrhythmia is
  resolved
• Glucose and insulin
• Hyperventilation
• Albuterol
• kayexalate

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Hypomagnesemia

• Result of citrate toxicity
• Stabilizes the resting membrane potential
• Life threatening arrhythmia that dose not respond
  to exogenous calcium therapy needs magnesium
  sulphate
• 25-50 mg/kg followed by 30-60 mg/kg/24 hours

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Acid-base changes

• RBC metabloism can elevate the dissolved CO2 to
  180-210 mmHg
• Anaerobic metabolism increases the lactic acid
  content
• Initial transient combined respiratory and
  metabolic acidosis
• Citrate metabolism leads to metabolic alkalosis

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Hypothermia

• Shift to left of ODC curve decreased oxygen
  delivery
• Apnea
• Hypoglycemia
• Decreased drug metabolism
• Increased oxygen consumption
• Coagulopathy

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Coagulopathy

• Massive blood transfusion leads to
  thrombocytopenia
• 40, 20 and 10 of starting platelet count is
  seen after 1st, 2nd and 3rd blood volume loss
• Dilution and loss of clotting factors
• Clotting factor deficiency should be anticipated
  after one blood volume loss

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Recombinant factor VIIa

• Retrospective review of use of factor 7a in
  children undergoing major neurosurgical
  procedures experiencing massive uncontrollable
  hemorrhage
• Useful adjunct to control life threatening
  bleeding,but more extensive research is needed
• Uhring et al Ped crit care med, 2007

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Mechanism of action
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Blood Conservation

• Preoperative Autologous Donation
• Acute Normovolemic Hemodilution
• Intraoperative Blood Salvage
• Preoperative Erythropoietin
• Positioning
• Hypotensive anaesthesia
• Pharmacological enhancement of hemostasis
• Artificial blood

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