A Walking Blood Donor Program for Seriously I11 Premature Infants P. G. HATTERSLEY, B. w . GOETZMAN, s. GROSS,AND w . J. BLANKENSHIP From thesacramento Medical Center of the Universityof California. Davis, and theSchoolof Medicine. Texas Tech University. Lubbock. Texas
Premature infants with hyaline membrane disease and related disorders are frequently hypovolemic. Furthermore, they frequently require repeated phlebotomies for laboratory evaluation of electrolytes, pH, oxygen tension, and other parameters. Adequate care of such infants is aided by small transfusions of heparinized blood. The walking donor program at the Sacramento Medical Center premature nursery furnishes these transfusions without exposing the infants to the hazards of receiving blood from many different donors. The program is described in detail, and the shortcomings of some of the alternative programs are pointed out.
ALTHOUGH NOT WI DELY discussed in the l i t e r a t ~ r e , ' . ~the * ~walking *~ donor transfusion of the seriously ill premature infant has found increasing use in recent years. An appropriately selected donor comes to the nursery where a physician draws 10 to 40 ml of blood into a syringe containing a small but measured amount of heparin. This heparinized blood is then infused into the infant. The most common indication for such minitransfusions is hyaline membrane disease. Because of the delicacy of their acid-base and electrolyte balance, infants with this disorder undergo repeated phlebotomies to obtain blood for laboratory studies, and iatrogenic volume depletion may result. The advantage of the walking donor for such patients is primarily availability, along with the belief that heparinized blood better meets the needs of the acidotic infant than does citrated bank blood. Such programs have recently come under severe c r i t i c i ~ m .The ~ . ~ chief criticism is that walking donor programs invariably remove Received for publication August 7, 1975, accepted October 3, 1975. Presented in part before t h e California Blood Bank Systems, Sacramento, California, June 15, 1973.
some measure of control of the blood transfusion from the transfusion service of the h ~ s p i t a l . ~I t. ~has been ~ t a t e d ~ t h.a~t administratively it is difficult to maintain proper documentation of the source of donor blood in such programs and, as a result, the following violations of proper blood transfusion practice occur: 1) blood is givln without compatibility or testing for HBsAg; 2) blood is overheparinized, causing bleeding in the baby; 3) the donor's arm is inadequately cleansed before venipuncture; and 4) donors consist of hospital staff members assigned to patient care, thus increasing t h e danger of transmitting dangerous viruses to the recipient. In so far as these dangers are ignored, and these errors made, walking donor programs are indeed undesirable. To assume that because the programs are not managed by the hospital blood transfusion section, their administration is difficult to maintain, and the above violations must occur is an assumption for which O b e ~ m a ngives ~ . ~ no evidence. We feel, from our experience, that a walking donor program set up by pediatricians, with the cooperation of the blood transfusion section, can avoid the errors described, and can render a service unavailable from the standard blood bank. We shall therefore describe the walking donor program as it presently exists at the Sacramento Medical Center of the University of California at Davis. Method Building up a Donor File Hospital personnel not directly related to patient care make up the bulk of the donors. In so far as possible, physicians, nurses, nurses' aides,
366 Transfusion July-Aug. 1976
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Volume 16 Number 4
361
WALKING DONOR PROGRAM
orderlies, and laboratory employees are not used. Definitely excluded are all persons working in the transplantation and dialysis services. Each donor m e e t s all s t a n d a r d s of t h e American Association of Blood Banks,IOand FDA regulations, as determined by a detailed history. Each donor is classified by ABO and Rh type (D, including D”), and tested for syphilis, HB,Ag and atypical antibodies, as well as a hematocrit and/or hemoglobin determination, and a direct antiglobulin test. T h e donor’s blood smear is examined for spherocytes and other congenital erythrocytic abnormalities. If the donor is of black origin, hemoglobin electrophoresis and G-6-PD determinations must prove normal. A file of acceptable donors is maintained in the premature nursery for quick reference. Any donor not called within two months is asked to return for repeat tests for syphilis and hepatitis. Choosing a Donor Walking donor transfusions a r e currently largely confined to infants which, in the physician’s opinion, will probably need three or more transfusions. When such a decision is made, a 3 ml clotted specimen of the infant’s blood, along with a specimen of maternal blood (requested when the infant is admitted) is sent to the laboratory. The blood of the infant and mother are tested for ABO and Rho(D) and a direct antiglobulin test is done on the infant’s erythrocytes. If the mother and infant are of incompatible ABO groups, but the direct antiglobulin test is negative, a donor of the infant’s type is called. If the direct antiglobulin test is positive, a donor of the mother’s group is chosen. On freshly drawn blood of the donor, the ABO and Rh type are rechecked, along with the standard compatibility test of infant’s (or mother’s) serum against the erythrocytes of the donor. Compatibility testing includes bovine albumin tests at room temperature and 37 C and the indirect antiglobulin test. Repeat tests for syphilis and HB,Ag are immediately initiated. Only at times of extreme emergency is blood given without waiting for the results of these latter tests, even though the donor has had negative tests within two months. Giving the Transfusion T h e nursery physician, upon receiving the report from the laboratory that the donor is satisfactory, thoroughly cleanses the skin of the donor’s arm with providone-iodine (Betadine), and rinses it with 70 per cent isopropyl alcohol, allowing a few moments for it to dry. (Alternate tech-
niques may be used as recommended by the blood transfusion section.) The desired volume of blood is obtained using a #20 scalp vein needle attached to a plastic syringe containing two units of heparin for each milliliter of donor blood to be drawn. Pass, et U I . , ~using this technique and three units of heparin per milliliter of donor blood, have demonstrated a normal partial thromboplastin time (PTT) one hour postinfusion. Measurement of the heparin poses no technical difficulty if one uses heparin sodium, 100 international units per ml. The heparinized blood is then administered to the infant through a platelet infusion set, which wastes approximately 1.0 ml. Two makes of inexpensive platelet infusion sets are available. Blood is given through a #5 French indwelling umbilical catheter, o r a peripheral intravenous line, over a 10- to 15-minute period. In certain instances, when red blood cell mass is critically low, sedimentation of the donor blood for 30 to 60 minutes, with the syringe in a vertical position, may be of help. The same donor can give subsequent minitransfusions without further compatibility testing, providing he has not developed signs of infection, and the patient has not shown signs of transfusion reaction.
Results O u r experience h a s been summarized by Blankenship, et al. Between September 1969 and December 1973, 791 walking donor transfusions were given to 376 infants. Most of the babies had very low birth weight, and three quarters (75.5%) had hyaline membrane disease. A few were diagnosed as respiratory distress type 11, and there was a scattering of other disorders. Transfusions varied in size up to 40 ml, with a mean of 19 ml. The infants received from one to 22 transfusions. Of the 376 infants, 325 received blood from single donors, and only a rare patient received from more than three donors. There were no recognizable transfusion reactions. Of the transfused infants, 245 (65%) survived. In our opinion, survival was unquestionably improved by these transfusions.
Discussion
Recognizing the potential hazzards of improper programs, organized blood banks have attempted to render walking donor programs unnecessary. To meet the special problems of tiny infants, the following suggestions have been made: 1) the blood bank can provide heparinized blood; 2) Obermane*’
368
HATTERS L EY
and Watson-Williams" have suggested that a small volume of blood removed from CPD units intended for other patients could provide small transfusions for these infants. O b e ~ m a nhowever, ,~ has pointed out that this technique would not reduce the number of donors to which the infant is exposed, and 3) O b e r ~ n a n , ~and . ~ Fletcher, Kuhl, and Huestis3 have stated that blood drawn into citrate phosphate dextrose solution (CPD) shows a pH higher than that of blood drawn into acid citrate dextrose (ACD), being in the range of 7.2 on the day it is drawn. They have suggested that CPD blood drawn into quadruple packs, or half units into triple packs, might solve the problem of repeated transfusions from the same donor. Konugres and Donovan5 have further suggested that for maximum utilization, blood may be drawn from C P D quadruple packs into labeled and dated syringes which are stored in the refrigerator, and discarded if not used within 24 hours. The above suggestions, while they offer valuable help for the care of many tiny infants, fail to meet ideally the needs of certain severely ill premature infants. Blood drawn into CPD is clearly a great improvement over ACD, not only because of its higher pH, but also because of its better preservation of 2,3diphosphoglycerate (2,3-DPG). Our own recent studies, and those of PhibbsQ have demonstrated a pH in freshly drawn CPD blood of only 6.9 to 7. I , falling gradually on storage. Although such blood serves quite adequately the needs of most infants, such a pH is too low to be ideal for the acidotic infant. Furthermore, blood stored at refrigerator temperature rapidly loses platelets because of cold aggregation. It also gradually loses the labile clotting factors V and VIII, and becomes depleted of intracellular ATP. As usually drawn at the blood bank, heparinized blood contains 4.5 units of heparin per milliliter. If less heavily heparinized, the blood may begin to clot before it reaches the infant, unless used very soon. On the other hand, blood drawn into a measured minimum
Transfusion July-Aug. 1976
amount of heparin has a normal pH. When infused promptly, it has not lost platelets by cold aggregation, nor is it depleted of clotting factors o r ATP. Furthermore, the withdrawal from the donor of only that volume of blood which is to be infused into the infant prevents waste, and makes it possible to transfuse an infant repeatedly with the blood of a single donor, thereby decreasing exposure to infectious diseases. The work of Pass, et a1.,8analyzing the incidence of cytomegalovirus, demonstrated it in 24 per cent of the single-donor transfused babies, and in 13 per cent of nontransfused controls. What its incidence would have been in infants receiving multitransfusions from many donors is not known. The value of the walking donor program is illustrated in the handling of one such case. A 2 Ib, 9 oz infant arrived at the intensive care nursery appearing slightly pale, and with shallow respiration. He was both anemic and acidotic (Hgb: 11.8 g/dl; pH 7.12). X-ray studies of the chest showed a bilateral fine reticulogranular pattern suggestive of hyaline membrane disease. He was promptly crossmatched with a walking donor, and given 12 ml of type-specific blood. He had a stormy course, with four episodes of pneumothorax requiring a chest tube and assisted ventilation, and a period of atrio-ventricular block. During his first 14 days of life, while an umbilical catheter remained in place, 187 specimens of blood were drawn for testing, a volume of 155 ml, or approximately twice his total blood volume. During this period, he received 17 transfusions from a single walking donor. These transfusions varied in volume from 8 to 20 ml, and totaled 198 ml. His hemoglobin after the last one was 14.3 g/dl. He was discharged after 12 weeks, weighing 5 lbs, 8 oz, and appeared to be quite healthy. His subsequent development, through 12 months of age has been normal. Clearly, this infant's care would have been nearly impossible, his survival unlikely, without frequent small transfusions. Without the walking donor program: 1)
Volume 16 Number 4
WALKING DONOR PROGRAM
this infant probably would have received fewer but larger transfusions, with the attending danger of hypo- or hypervolemia; 2) he would have received blood and potential virus infections from a number of donors-possibly as many as 17, if volumes such as he received were given from separate minipacks; 3) the willingness of the pediatric staff to obtain blood samples at frequent intervals might have been lessened under any of the nonwalking donor systems described; 4) the cost in multiple crossmatches would obviously have exceeded that with a single donor; and 5) the danger of mislabeling or mixing up tiny packs or syringes of blood in the blood bank refrigerator obviously far exceeds that of mixing up donors. In our hands, the walking donor program has proven an essential adjunct for the intensive care nursery. The greatest need for such a system is for infants with hyaline membrane disease who require frequent sampling of blood for laboratory tests. Providing one adheres strictly to appropriate criteria for selection of patients, selection of donors, and handling of the blood, the danger to the infant is less than with bank blood. As organized at present, our blood bank has not demonstrated its ability to provide comparable service. References Blankenship, W., B. Goetzman, S. Gross, and P. Hattersley: A walking donor program for an intensive care nursery. J. Pediatr. 86:585, 1975. 2. -, B. Goetzman, P. Hattersley, and S. Gross: A walking donor program (WDP) for neonates. Clin. Res. 22:238A, 1974. 1.
3.
4.
5.
6. 7.
8.
9. 10.
11.
369
Fletcher, J., M. Kuhl, and D. Huestis: One approach to minitransfusions in premature infants. Program of Annual meeting of the American Association of Blood Banks, 1974. Griffin, E., B. Meyer, M. Sedaghatian, M. Hart, and W. Daily: A walking donor program for regional neonatal intensive care nurseries (ICN’s). Pediatr. Res. 7:398, 1973. Konugres, A., and L. Donovan: Multiple neonatal replacement transfusions from a single unit of blood. Program of Annual meeting of American Association of Blood Banks, 1974. Oberman, H.: Special report. Transfusion of the neonatal patient. Transfusion 14:183, 1974. -: Replacement transfusion in the newborn infant: a commentary. J. Pediatr: 86:586, 1975. Pass, M., I. Schulman, N. Malachowski, J. Johnson, and P. Sunshine: Evaluation of a walking donor blood transfusion program in an intensivecare nursery. Clin. Res. 23:161A, 1975. Phibbs, R.: Personal communication. Technical methods and procedures, 6th ed. W. V. Miller, Ed. American Association of Blood Banks, 1974. Watson-Williams, E. J.: Personal communication.
Paul G. Hattersley, M.D., Professor of Medicine and Pathology, Sacramento Medical Center of the University of California, Davis, California Boyd W. Goetzman, M.D., Ph.D., Assistant Professor of Pediatrics, University of California at Davis School of Medicine. Sara Gross, M. T., Supervising Clinical Laboratory Technologist, Hematology and Blood Bank Sections, Sacramento Medical Center of the University of California, Davis. Willard J. Blankenship, M.D., Professor of Pediatrics and Obstetrics, Texas Tech University Health Sciences Centers, School of Medicine, Texas Tech University, Lubbock, Texas.
Premature infants with hyaline membrane disease and related disorders are frequently hypovolemic. Furthermore, they frequently require repeated phlebotomies for laboratory evaluation of electrolytes, pH, oxygen tension, and other parameters. Adequate care of such infants is aided by small transfusions of heparinized blood. The walking donor program at the Sacramento Medical Center premature nursery furnishes these transfusions without exposing the infants to the hazards of receiving blood from many different donors. The program is described in detail, and the shortcomings of some of the alternative programs are pointed out.
ALTHOUGH NOT WI DELY discussed in the l i t e r a t ~ r e , ' . ~the * ~walking *~ donor transfusion of the seriously ill premature infant has found increasing use in recent years. An appropriately selected donor comes to the nursery where a physician draws 10 to 40 ml of blood into a syringe containing a small but measured amount of heparin. This heparinized blood is then infused into the infant. The most common indication for such minitransfusions is hyaline membrane disease. Because of the delicacy of their acid-base and electrolyte balance, infants with this disorder undergo repeated phlebotomies to obtain blood for laboratory studies, and iatrogenic volume depletion may result. The advantage of the walking donor for such patients is primarily availability, along with the belief that heparinized blood better meets the needs of the acidotic infant than does citrated bank blood. Such programs have recently come under severe c r i t i c i ~ m .The ~ . ~ chief criticism is that walking donor programs invariably remove Received for publication August 7, 1975, accepted October 3, 1975. Presented in part before t h e California Blood Bank Systems, Sacramento, California, June 15, 1973.
some measure of control of the blood transfusion from the transfusion service of the h ~ s p i t a l . ~I t. ~has been ~ t a t e d ~ t h.a~t administratively it is difficult to maintain proper documentation of the source of donor blood in such programs and, as a result, the following violations of proper blood transfusion practice occur: 1) blood is givln without compatibility or testing for HBsAg; 2) blood is overheparinized, causing bleeding in the baby; 3) the donor's arm is inadequately cleansed before venipuncture; and 4) donors consist of hospital staff members assigned to patient care, thus increasing t h e danger of transmitting dangerous viruses to the recipient. In so far as these dangers are ignored, and these errors made, walking donor programs are indeed undesirable. To assume that because the programs are not managed by the hospital blood transfusion section, their administration is difficult to maintain, and the above violations must occur is an assumption for which O b e ~ m a ngives ~ . ~ no evidence. We feel, from our experience, that a walking donor program set up by pediatricians, with the cooperation of the blood transfusion section, can avoid the errors described, and can render a service unavailable from the standard blood bank. We shall therefore describe the walking donor program as it presently exists at the Sacramento Medical Center of the University of California at Davis. Method Building up a Donor File Hospital personnel not directly related to patient care make up the bulk of the donors. In so far as possible, physicians, nurses, nurses' aides,
366 Transfusion July-Aug. 1976
Volume 16 Number4
Volume 16 Number 4
361
WALKING DONOR PROGRAM
orderlies, and laboratory employees are not used. Definitely excluded are all persons working in the transplantation and dialysis services. Each donor m e e t s all s t a n d a r d s of t h e American Association of Blood Banks,IOand FDA regulations, as determined by a detailed history. Each donor is classified by ABO and Rh type (D, including D”), and tested for syphilis, HB,Ag and atypical antibodies, as well as a hematocrit and/or hemoglobin determination, and a direct antiglobulin test. T h e donor’s blood smear is examined for spherocytes and other congenital erythrocytic abnormalities. If the donor is of black origin, hemoglobin electrophoresis and G-6-PD determinations must prove normal. A file of acceptable donors is maintained in the premature nursery for quick reference. Any donor not called within two months is asked to return for repeat tests for syphilis and hepatitis. Choosing a Donor Walking donor transfusions a r e currently largely confined to infants which, in the physician’s opinion, will probably need three or more transfusions. When such a decision is made, a 3 ml clotted specimen of the infant’s blood, along with a specimen of maternal blood (requested when the infant is admitted) is sent to the laboratory. The blood of the infant and mother are tested for ABO and Rho(D) and a direct antiglobulin test is done on the infant’s erythrocytes. If the mother and infant are of incompatible ABO groups, but the direct antiglobulin test is negative, a donor of the infant’s type is called. If the direct antiglobulin test is positive, a donor of the mother’s group is chosen. On freshly drawn blood of the donor, the ABO and Rh type are rechecked, along with the standard compatibility test of infant’s (or mother’s) serum against the erythrocytes of the donor. Compatibility testing includes bovine albumin tests at room temperature and 37 C and the indirect antiglobulin test. Repeat tests for syphilis and HB,Ag are immediately initiated. Only at times of extreme emergency is blood given without waiting for the results of these latter tests, even though the donor has had negative tests within two months. Giving the Transfusion T h e nursery physician, upon receiving the report from the laboratory that the donor is satisfactory, thoroughly cleanses the skin of the donor’s arm with providone-iodine (Betadine), and rinses it with 70 per cent isopropyl alcohol, allowing a few moments for it to dry. (Alternate tech-
niques may be used as recommended by the blood transfusion section.) The desired volume of blood is obtained using a #20 scalp vein needle attached to a plastic syringe containing two units of heparin for each milliliter of donor blood to be drawn. Pass, et U I . , ~using this technique and three units of heparin per milliliter of donor blood, have demonstrated a normal partial thromboplastin time (PTT) one hour postinfusion. Measurement of the heparin poses no technical difficulty if one uses heparin sodium, 100 international units per ml. The heparinized blood is then administered to the infant through a platelet infusion set, which wastes approximately 1.0 ml. Two makes of inexpensive platelet infusion sets are available. Blood is given through a #5 French indwelling umbilical catheter, o r a peripheral intravenous line, over a 10- to 15-minute period. In certain instances, when red blood cell mass is critically low, sedimentation of the donor blood for 30 to 60 minutes, with the syringe in a vertical position, may be of help. The same donor can give subsequent minitransfusions without further compatibility testing, providing he has not developed signs of infection, and the patient has not shown signs of transfusion reaction.
Results O u r experience h a s been summarized by Blankenship, et al. Between September 1969 and December 1973, 791 walking donor transfusions were given to 376 infants. Most of the babies had very low birth weight, and three quarters (75.5%) had hyaline membrane disease. A few were diagnosed as respiratory distress type 11, and there was a scattering of other disorders. Transfusions varied in size up to 40 ml, with a mean of 19 ml. The infants received from one to 22 transfusions. Of the 376 infants, 325 received blood from single donors, and only a rare patient received from more than three donors. There were no recognizable transfusion reactions. Of the transfused infants, 245 (65%) survived. In our opinion, survival was unquestionably improved by these transfusions.
Discussion
Recognizing the potential hazzards of improper programs, organized blood banks have attempted to render walking donor programs unnecessary. To meet the special problems of tiny infants, the following suggestions have been made: 1) the blood bank can provide heparinized blood; 2) Obermane*’
368
HATTERS L EY
and Watson-Williams" have suggested that a small volume of blood removed from CPD units intended for other patients could provide small transfusions for these infants. O b e ~ m a nhowever, ,~ has pointed out that this technique would not reduce the number of donors to which the infant is exposed, and 3) O b e r ~ n a n , ~and . ~ Fletcher, Kuhl, and Huestis3 have stated that blood drawn into citrate phosphate dextrose solution (CPD) shows a pH higher than that of blood drawn into acid citrate dextrose (ACD), being in the range of 7.2 on the day it is drawn. They have suggested that CPD blood drawn into quadruple packs, or half units into triple packs, might solve the problem of repeated transfusions from the same donor. Konugres and Donovan5 have further suggested that for maximum utilization, blood may be drawn from C P D quadruple packs into labeled and dated syringes which are stored in the refrigerator, and discarded if not used within 24 hours. The above suggestions, while they offer valuable help for the care of many tiny infants, fail to meet ideally the needs of certain severely ill premature infants. Blood drawn into CPD is clearly a great improvement over ACD, not only because of its higher pH, but also because of its better preservation of 2,3diphosphoglycerate (2,3-DPG). Our own recent studies, and those of PhibbsQ have demonstrated a pH in freshly drawn CPD blood of only 6.9 to 7. I , falling gradually on storage. Although such blood serves quite adequately the needs of most infants, such a pH is too low to be ideal for the acidotic infant. Furthermore, blood stored at refrigerator temperature rapidly loses platelets because of cold aggregation. It also gradually loses the labile clotting factors V and VIII, and becomes depleted of intracellular ATP. As usually drawn at the blood bank, heparinized blood contains 4.5 units of heparin per milliliter. If less heavily heparinized, the blood may begin to clot before it reaches the infant, unless used very soon. On the other hand, blood drawn into a measured minimum
Transfusion July-Aug. 1976
amount of heparin has a normal pH. When infused promptly, it has not lost platelets by cold aggregation, nor is it depleted of clotting factors o r ATP. Furthermore, the withdrawal from the donor of only that volume of blood which is to be infused into the infant prevents waste, and makes it possible to transfuse an infant repeatedly with the blood of a single donor, thereby decreasing exposure to infectious diseases. The work of Pass, et a1.,8analyzing the incidence of cytomegalovirus, demonstrated it in 24 per cent of the single-donor transfused babies, and in 13 per cent of nontransfused controls. What its incidence would have been in infants receiving multitransfusions from many donors is not known. The value of the walking donor program is illustrated in the handling of one such case. A 2 Ib, 9 oz infant arrived at the intensive care nursery appearing slightly pale, and with shallow respiration. He was both anemic and acidotic (Hgb: 11.8 g/dl; pH 7.12). X-ray studies of the chest showed a bilateral fine reticulogranular pattern suggestive of hyaline membrane disease. He was promptly crossmatched with a walking donor, and given 12 ml of type-specific blood. He had a stormy course, with four episodes of pneumothorax requiring a chest tube and assisted ventilation, and a period of atrio-ventricular block. During his first 14 days of life, while an umbilical catheter remained in place, 187 specimens of blood were drawn for testing, a volume of 155 ml, or approximately twice his total blood volume. During this period, he received 17 transfusions from a single walking donor. These transfusions varied in volume from 8 to 20 ml, and totaled 198 ml. His hemoglobin after the last one was 14.3 g/dl. He was discharged after 12 weeks, weighing 5 lbs, 8 oz, and appeared to be quite healthy. His subsequent development, through 12 months of age has been normal. Clearly, this infant's care would have been nearly impossible, his survival unlikely, without frequent small transfusions. Without the walking donor program: 1)
Volume 16 Number 4
WALKING DONOR PROGRAM
this infant probably would have received fewer but larger transfusions, with the attending danger of hypo- or hypervolemia; 2) he would have received blood and potential virus infections from a number of donors-possibly as many as 17, if volumes such as he received were given from separate minipacks; 3) the willingness of the pediatric staff to obtain blood samples at frequent intervals might have been lessened under any of the nonwalking donor systems described; 4) the cost in multiple crossmatches would obviously have exceeded that with a single donor; and 5) the danger of mislabeling or mixing up tiny packs or syringes of blood in the blood bank refrigerator obviously far exceeds that of mixing up donors. In our hands, the walking donor program has proven an essential adjunct for the intensive care nursery. The greatest need for such a system is for infants with hyaline membrane disease who require frequent sampling of blood for laboratory tests. Providing one adheres strictly to appropriate criteria for selection of patients, selection of donors, and handling of the blood, the danger to the infant is less than with bank blood. As organized at present, our blood bank has not demonstrated its ability to provide comparable service. References Blankenship, W., B. Goetzman, S. Gross, and P. Hattersley: A walking donor program for an intensive care nursery. J. Pediatr. 86:585, 1975. 2. -, B. Goetzman, P. Hattersley, and S. Gross: A walking donor program (WDP) for neonates. Clin. Res. 22:238A, 1974. 1.
3.
4.
5.
6. 7.
8.
9. 10.
11.
369
Fletcher, J., M. Kuhl, and D. Huestis: One approach to minitransfusions in premature infants. Program of Annual meeting of the American Association of Blood Banks, 1974. Griffin, E., B. Meyer, M. Sedaghatian, M. Hart, and W. Daily: A walking donor program for regional neonatal intensive care nurseries (ICN’s). Pediatr. Res. 7:398, 1973. Konugres, A., and L. Donovan: Multiple neonatal replacement transfusions from a single unit of blood. Program of Annual meeting of American Association of Blood Banks, 1974. Oberman, H.: Special report. Transfusion of the neonatal patient. Transfusion 14:183, 1974. -: Replacement transfusion in the newborn infant: a commentary. J. Pediatr: 86:586, 1975. Pass, M., I. Schulman, N. Malachowski, J. Johnson, and P. Sunshine: Evaluation of a walking donor blood transfusion program in an intensivecare nursery. Clin. Res. 23:161A, 1975. Phibbs, R.: Personal communication. Technical methods and procedures, 6th ed. W. V. Miller, Ed. American Association of Blood Banks, 1974. Watson-Williams, E. J.: Personal communication.
Paul G. Hattersley, M.D., Professor of Medicine and Pathology, Sacramento Medical Center of the University of California, Davis, California Boyd W. Goetzman, M.D., Ph.D., Assistant Professor of Pediatrics, University of California at Davis School of Medicine. Sara Gross, M. T., Supervising Clinical Laboratory Technologist, Hematology and Blood Bank Sections, Sacramento Medical Center of the University of California, Davis. Willard J. Blankenship, M.D., Professor of Pediatrics and Obstetrics, Texas Tech University Health Sciences Centers, School of Medicine, Texas Tech University, Lubbock, Texas.
