Blood Components Transfusion

Over the past two decades, transfusion practices have evolved significantly, especially in terms of enhanced safety protocols to minimize the risk of transfusion-transmitted infections, such as variant Creutzfeldt-Jakob disease (vCJD). Specific safety improvements have also been implemented for neonatal and pediatric blood components. However, it remains crucial to transfuse blood components only when necessary and to select the most suitable component for each patient’s unique circumstances.

Irradiated blood components

All cellular blood components should be leucocyte depleted. However, residual lymphocytes can cause fatal transfusion-associated graft versus host disease (TA-GvHD) in patients who are severely immunocompromised. Irradiation of blood components at 25Gy effectively inactivates these lymphocytes, thus preventing this complication from occurring.

Indications for irradiated red cells and platelets

• All patients with Hodgkin lymphoma
  • continue indefinitely.
• All patients treated with regimens containing purine analogue drugs
  • fludarabine, cladribine (2-cda), deoxycoformycin, clofarabine, nelarabine & Bendamustine
  • continue indefinitely.
• All patients treated with anti-thymocyte globulin (ATG)
  • continue indefinitely
• All patients treated with alemtuzumab (Campath)
  • continue indefinitely
• All recipients of allogeneic bone marrow (BMT) or peripheral blood stem cell transplant (PBSCT)
  • start from the initiation of conditioning chemo/radiotherapy.
  • continue for the duration of GvHD prophylaxis or until lymphocytes >1×10⁹/l.
  • continue indefinitely if chronic GvHD present or on-going immunosuppression is required.
• All donors of bone marrow (BM) or peripheral blood stem cells (PBSC)
  • from 7 days prior to / during the harvest
• All patients undergoing BM or PBSC harvesting for future autologous re-infusion.
  • from 7 days prior to / during the harvest
• All patients undergoing autologous BMT or PBSCT
  • start from the initiation of conditioning chemo/radiotherapy.
  • continue until 3 months post-transplant.
  • or 6 months post-transplant if total body irradiation (TBI) was used in conditioning.
• All cases where there may be a shared haplotype between the donor and the recipient
  • donations from first or second-degree relatives
  • HLA-matched platelets
• Neonates who have previously received blood components in utero (IUT)
  • continue until 6 months after the expected date of delivery.
• Children with severe T lymphocyte immunodeficiency syndromes, such as
  • combined Immunodeficiency (CID).
  • severe Combined Immunodeficiency (SCID).
  • 22q11 Deletion Syndrome (DiGeorge Syndrome / Velo-Cardio-Facial Syndrome).
  • Wiskott-Aldrich Syndrome.

Packed red blood cells transfusion

In pediatric oncology, the transfusion of packed red blood cells (PRBCs) is the primary treatment for anaemia, offering a quick and relatively safe way to correct anaemia and related symptoms. The use of hematopoietic growth factors, such as recombinant erythropoietin (rhEPO), is still debated. The risk-benefit ratio of PRBC transfusions must be evaluated for each patient, taking into account discussions with the patient and their family; thus, transfusions are not recommended for clinically stable children recovering from chemotherapy-induced aplasia. The pediatric oncology field lacks evidence-based guidelines for PRBC transfusion thresholds, emphasizing the need for individualized transfusion decisions.

Considerations include the impact of anaemia on quality of life, such as fatigue and patient preference, cardiovascular stability, procedure and sedation safety, the patient’s clinical condition, bleeding risks, comorbidities like infection, and the expected duration of reduced erythropoiesis. Typically, severe anaemia (haemoglobin <7 g/dL) is the threshold for PRBC transfusion in pediatric oncology patients, though it may not be necessary for patients who are well-compensated and recovering from chemotherapy-induced aplasia.

Certain clinical scenarios may modify the threshold for PRBC transfusion: (1) a patient undergoing planned surgery may need PRBC transfusion to reduce the risks associated with induction anaesthesia or blood loss; (2) a critically ill patient; (3) a patient experiencing bleeding; (4) a patient who has recently suffered from severe haemorrhage; and (5) a febrile patient at risk of sepsis with elevated RBC and coagulation factor consumption.

Red blood cell transfusion guidelines

Amount

Calculate the desired rise in hemoglobin (Hb):

3 ml/kg will raise the Hb by 1g/dl (or 10g/l)

Therefore, dose in ml = 3 x weight (in kg) x desired rise in Hb (in g/dl)

Transfusion Reactions

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