Pedi-Pack Transfusion in a Newborn Intensive Care Unit R. M. KAKAIYA, F. S. MORRISON, J. E. RAWSON,L. L. LOTZ,A N D J. W. MARTIN From the University of Mississippi School of Medicine, University Hospital and the Mississippi Regional Blood Center, Jackson, Mississippi
reviewing donor source records as well as patient charts. Two instances of transfusion reaction were found in two babies. The disposition of the 236 Pedi-Packs which were thawed during this period was studied by reviewing the processing and distribution records. Hospital records of 18 patients who received 47 transfusions were evaluated carefully for transfusion response and clinical characteristics. The cost data were also analyzed. All donors were voluntary blood donors and were screened according to established blood banking standards. l 3 Serologic tests for syphilis were performed on all units prior to freezing and storage. Blood grouping and antibody screening were done before glycerolization. Only blood group 0 units were chosen for PediPack utilization. Direct antiglobulin testing and repeat blood grouping were performed after washing. All units were appropriately labeled. Blood was collected into citrate phosphate dextrose anticoagulant in the routine manner. The blood was centrifuged and the plasma transferred to a satellite bag for other use. The red blood cells were glycerolized and frozen within five days of collection by a modified Meryman technique,6 with high glycerol concentration and slow freezing in a mechanical freezer. The collection bag, containing approximately 250 ml red blood cells, was connected to a bottle containing 400 ml of 6.2 M glycerol (glycerolyte 57 solution)*. The collection bag was then attached to a shaker and 100 ml of glycerol was allowed to run into the collection bag at a rate of about 35 ml per minute while the bag was agitated. Five minutes were allowed for equilibration with the collection bag resting on a flat surface. After equilibration the remainder of the glycerol solution was added to the collection bag at a rate of approximately 35 ml per minute without agitation. The red blood cell-glycerol mixture was then mixed and equally divided into three integral freezing bags via an integral Y connector. t The contents of the freez-
Two hundred and ninety-one transfusions using 221 pediatric frozen red blood cell packs (Pedi-Packs) were given to 141 newborn babies and infants in the newborn intensive care unit. In 18 patients, 47 transfusions were studied for transfusion and clinical characteristics. Two possible hemolytic episodes are described in detail and remain unexplained. Blood loss for laboratory tests was found to average 3.1 mUkg per day spent in the newborn intensive care unit. The rise in hematwrit was found to be excellent. Overall, the transfusion of thawed pediatric red blood cell packs was found to be convenient, safe and effective. Because of pretesting possibilities with the use of this source of red blood cells, one of the problems associated with a walking donor program is eliminated.
PREMATURE NEWBORN BABIES in an intensive care unit require repeated phlebotomies for a variety of blood tests. Although micromethods are utilized for many laboratory tests in order to minimize blood loss, blood gas measurements are still being done with semi-microtechniques (one ml per sample) in our institution and others at the present time. The result is significant blood loss and anemia if frequent replacement with small volumes of red blood cells are not provided. Several methods for red blood cell transfusion for such purposes have been d e ~ e l o p e d * . ~ *and * - ~ ~are summarized in Table 1. Pediatric frozen red cell packs (Pedi-Packs) have been utilized in neonates and infants in our institution since May, 1976. Our experience with this technique is described herein. Materials and Methods Transfusion records of 291 transfusions to 141 recipients administered between May and December of 1976 were reviewed. Possible transfusion reactions were further analyzed by
* Fenwal Labs., Deerfield, IL.
Received for publication October 20, 1977; accepted March 5 . 1978.
t Union Carbide Corp., Chicago, IL.
0041-1132/79/0100/0019 $00.80 0 J. B. Lippincott Co. Transfusion January-February 1979
19
Volume 19 Number 1
20
Transfusion January-Febn~ary1979
KAKAIYA ET AL.
Table 1. Previous Methods: Transfusion of Neonates Method ~~
~~~
Advantages ~
Walking Donor Program
~~
Disadvantages
~~~~~
Ease of transfusion
Inordinate risk of exposure to hepatitis No labeling or blood bank control Does not provide packed red cells Allergic reactions to plasma proteins Risk of contemination through technique failure Risk of cytomegalovirus infection
Donor blood collected into quadruple packs
Retains blood bank control Minimal metabolic injury
Considerable wastage 2-3 DPG levels are not meintained if stored for more than five days
Donor blood collected into triple packs
The donor can be rebled in a shorter time if needed
Waste
Small amounts from a unit of red blood cells are aseptically removed and transfused
Easily available
The remaining unit may expire before a suitable recipient can be found Waste
Few metabolic changes in red blood cells Coagulation factors and platelets present Minimal wastage Mostly single donor source
ing bags were thoroughly mixed before freezing. Each freezing bag was placed, in an aluminum canister, in a mechanical freezer at -80 C for freezing and storage. Upon request for transfusion, a Pedi-Pack (one of the three partial units) was thawed by immersion into a 37 C water bath. Thawing required three to five minutes. The red blood cell-glycerol suspension in each bag after thawing measured about 200 ml. To this suspension was added 50 ml of 12 g/dl sodium chloride solution, buffered to pH 7.* Two minutes were allowed for equilibration while the suspension was manually agitated. Two hundred and fifty ml of 1.6 g/dl sodium chloride solution buffered to ph 7* was then added with continuous agitation and allowed to equilibrate for one minute. The diluted cell suspension was allowed to run into an IBM cell processor bag$ and washed once with the buffered 1.6 g/dl sodium chloride solution. Two more washings with buffered 0.2 g/dl dextrose in 0.8 g/dl sodium chloride solution* were performed by automatic cycle. The supernatant fluid was inspected for hemolysis after each wash. Upon completion of washing, the outlet tubing of the IBM cell processor bag was clamped to form two inch segments. The contents of the segments were used for repeat $
IBM Corp. Buffalo, NY.
grouping and typing. A few drops of red blood cells from the outlet tubing section were suspended in normal saline, centrifuged and inspected for hemolysis. The supernatant fluid was cultured both aerobically and anaerobically in peptone broth. One tube was incubated at 37 C and the other at room temperature for 24 hours. The following day, both tubes were vented and incubated for another 24 hours. The entire procedure of deglycerolization took 30 minutes. Most Pedi-Pack transfusions were given to babies in the newborn intensive care unit of the University Hospital. The transfusions were given primarily for replacement of blood loss, but also for anemia from other causes when indicated. Hypovolemia' in patients with hematocrit of less than 40 per cent was treated with red blood cell transfusion. A crossmatch between donor and recipient, and when possible, between donor and recipient's mother was performed prior to transfusion. Crossmatch was repeated whenever a different donor source was used. If repeated transfusion was anticipated, the Pedi-Pack chosen was one which had all three packs from the same donor available. This was done to minimize antigenic exposure as well as to reduce cost and blood loss necessitated by repeated crossmatches. Small aliquots of crossmatch compatible red blood cells, as ordered,
Volume 19 Number I
21
PEDI-PACK TRANSFUSION
were transferred into I50 ml transfer packs and appropriately labeled. This aliquot was then delivered for transfusion. The time from placement of an order to the delivery of red blood cells for transfusion ranged from 45 minutes to two hours, depending upon the urgency of the clinical situation. The transfer packs containing the washed red blood cells were often kept warm by keeping them in the incubator next to the baby for 10 to 15 minutes. The blood administration set was connected to the red blood cell pack and the desired amount of red blood cells was drawn aseptically through a standard blood filter into a syringe and after proper identification, transfused into a peripheral or central vein through a 22-gauge needle, a 23-gauge catheter, or size three French catheter. Recipients were routinely followed very closely with hourly vital signs and strict input and output measurement. All blood removed for laboratory purposes was accurately recorded.
Results A total of 236 Pedi-Packs were thawed between May and December, 1976, from 85 units of red blood cells. Five Pedi-Packs had to be discarded because of a leak or rupture of the IBM cell processor bag. Two packs were contaminated with air during glycerolization because of sealing failure and were discarded. This represents a 2.9 per cent loss during processing. Eight Pedi-Packs (3.4%) were discarded because they were not used within 24 hours after thawing. .Overall loss, including the loss during processing, was 6.3 per cent. Bacterial cultures of the supernatant solutions from the deglycerolization process were all negative at 24 and 48 hours. Red blood cells from each deglycerolized washed Pedi-Pack were suspended in normal saline, centrifuged and inspected for hemolysis. Free hemoglobin was either absent or judged negligible.
Of the 221 Pedi-Packs used for 291 separate transfusions into 141newborn babies and infants, 172 were used as single transfusion. Thirty-one Pedi-Packs were used for two separate transfusions, 15 for three, and three for four transfusions each. The average number of transfusions from each Pedi-Pack was 1.3. There were two episodes of transfusion reaction encountered in 191 transfusions. Eighty-three patients received a single transfusion while 58 patients received more than one transfusion. The average number of transfusions per patient was 1.89. One hundred patients (71%) were provided single donor transfusions. Twenty-six patients (18%) received transfusions from two donors. Only 15 patients (11%) received transfusions from more than two donors. Forty-seven transfusions in 18 patients were reviewed in depth. Transfusion response and clinical characteristics in these patients are presented in Tables 2 and 3. Thirteen patients (76%) were admitted to the newborn intensive care unit on the first day of life. Only two patients were more than 12 days of age and the average weight was 1.8 kg. Most babies were receiving oxygen therapy. The average stay in the unit was seven days while 11 patients stayed longer than seven days. Since the mean total bilirubin level exceeded 7 mg/dl due to physiologic hyperbilirubinemia and since more than half were actually receiving phototherapy, posttransfusion bilirubin measurements could not be used as indicators of hemolysis of transfused red blood cells. Any amount of blood drawn was accurately recorded. In some instances, such blood losses were replaced with red blood cell transfusions before anemia actually developed. The average blood loss was 3. I mg/kg/day. The mean volume of red blood cells transfused was 12 ml. The mean rise in hematocrit was from 38 to 44 per cent. There were three deaths among these patients. One patient was an infant of 30 weeks
Table 2. Transfusion Response and Clinical Characteristics of 18 Patients Receiving 47 Transfusions Transfusion Response and Clinical Characteristics Weight in grams at transfusion Number of days' stay in Newborn Intensive Care Unit (NICU) Serum total bilirubin concentration at transfusion (mg/dl) Blood loss for laboratory tests in NICU (ml/kg/day) Amount per transfusion (ml) Pretransfusion hernatocrit (YO) Posttransfusion hematocrit (%)
Range 950-31 60
Mean 1822
1-19
7.5
0-16
7.4
1.4-7.9 6-24 22-58 24-64
3.1 11.9 38 44
22
KAKAIYA ET AL.
Table 3. Major Clinical Diagnosis in 78 Patients Diagnosis Respiratory Distress Syndrome lntracranial Bleeding Pneumothorax Patent Ductus Arteriosus TransDosition of Great Vessels E. coli Bacteremia Hypothyroidism Total
Number of Patients 5 4
3 3 1 1 1 18
gestation weighing 1.4 kg. The delivery was complicated by breech presentation and abruptio placenta. Autopsy revealed a large intracerebral hemorrhage. Transfusions had not been used within ten days of death. A 28- to 30-week gestation infant weighing 990 g died on the third day after birth followingcardiorespiratory arrest. The patient had not received transfusion in the 12 hours preceding death. A 19-day-old infant underwent surgery for transposition of great vessels, developed acute renal failure postoperatively and died on the eighth postop day. Autopsy revealed transposition of great vessels, bilateral renal cortical necrosis, thrombosis of the abdominal aorta, and pulmonary hemorrhage. The infant had not received a transfusion for 48 hours prior to death. Case Reports Cue I
An eight-week-old black male infant weighing 2500 g was admitted for surgical repair of a large
asymptomatic right inguinal hernia. Physical examination revealed no abnormality except for the hernia. The hemoglobin was 11.8 ddl. hematocrit 33 per cent, and total WBC 78001p1 with a normal differential count. Routine urinalysis, chest x-ray and SMA-18 tests were normal. The hernia was repaired under nitrous oxide and halothane anesthesia. The surgery was uncomplicated and blood transfusion was not needed. Twelve hours after surgery, the baby developed sudden respiratory arrest while being fed formula by the mother. The child was promptly resuscitated with tracheal intubation. Controlled ventilation was required for eight hours, after which spontaneous respiration began. Because of poor respiratory effort, continued assisted ventilation was required with 40 per cent oxygen in inspired air. Chest x-ray immediately after the respiratory arrest revealed bilateral pulmonary edema which resolved within four hours after the administration of 5 mg furosemide intravenously. Postarrest hematocrit was 19 per cent and ten ml of group 0,
Transfusion
January-February 1979
Rh compatible, crossmatched red blood cells were transfused without incident. The hematocrit rose to 24 per cent in two hours. Forty-eight hours after surgery, because the hematocrit was only 21 per cent, a further transfusion of 24 ml of Pedi-Pack red blood cells from a different donor was given. No immediate reaction was noted, but about one hour after transfusion, pink urine appeared and transfusion reaction was suspected.' The urine showed 0 to 3 red blood cells per high power field. The patient's axillary temperature rose from 36.7 to 37.3 C while incubator temperature was 36.7 C. A blood sample was immediately sent to the blood bank. Plasma hemoglobin was 64 mg/dl and hematocrit was 27 per cent. Repeat crossmatch with before and after transfusion samples showed no incompatibility. Intravenous fluid at a rate of 25 muhour and 5 mg furosemide intravenously were administered, and the urine cleared within five hours. Urine output in six hours was 210 ml (1.4 rnukdhour). Posttransfusion total bilirubin was 0.9 mddl compared to the admission value of 0.4 mg/dl. The infant required ventilatory support until the ninth hospital day, was then extubated without respiratory difficulty and was discharged on the sixteenth hospital day. Case 2
A black male infant, weighing 2720 g, was delivered at term to a Gravida 2, para 1, 19-yearold. The pregnancy and delivery were uncomplicated. Apgar rating was nine and ten at one and five respectively. Upon physical examination at birth, the infant showed an abnormal respiratory rate of 95 per minute and mild retrosternal retraction. Arterial Po, on room air was 68 per cent, Pco, 41 per cent, and pH 7.34. The hematocrit was 44 per cent, glucose 45 mg/dl, Na 138 mEq/l and K 3.9 mEq/l. Chest x-ray suggested a diffuse bilateral pneumonitis. The infant was placed on 60per cent oxygen under oxyhood. Repeat blood gases were Po, 90 per cent, PCO, 41 per cent, and pH 7.40. Six hours after birth, the hematocrit was 32 per cent, but decreased to 29 per cent at nine hours. Eighteen rnl type 0, Rh compatible, frozen red blood cells were transfused. The crossmatch was compatible with the patient but incompatible with the patient's mother. Anti-P, antibodies were identified in the mother's serum. About five minutes after the transfusion, the baby suddenly became cyanotic and developed tachycardia. The systolic blood pressure was 70 mm of Hg after the onset of cyanosis while one hour prior to the transfusion it was 45 mm of Hg. The baby passed dark urine which was 3+ when tested for blood. Prior to the transfusion, a suprapubic tap had revealed clear urine. Blood smear
Volume 19 Number I
PEDI-PACK TRANSFUSION
showed a dual population of red blood cells with some burr cells and a few microspherocytes. White blood cells and platelets appeared normal. The prothrombin time was 17.5 seconds with a control of 13 seconds, partial thromboplastin time was 62.5 seconds with a control of 48 seconds. Platlets were 285,000/pl. Hemoglobin was 9.4 g/dl, hematocrit 32 per cent, reticulocytes 1.4 per cent, and WBC 14,OOO/pI. Recrossmatch with before and after transfusion samples showed no incompatibility. The infant remained cyanotic despite 100 per cent oxygen administration under oxyhood and was, therefore, intubated and ventilated with an FI,, of 1.0. Blood gases improved to Po, 179 per cent, Pco, 22 per cent, and pH 7.31. Chest x-ray one hour after transfusion showed no change. Hematocrit was 30 per cent at 17 hours after the first transfusion, and an additional 18 ml of frozen red blood cells from a different donor were given without reaction. The hematocrit rose to 35 per cent six hours after the second transfusion. The child was then extubated without deterioration of blood gases. On the third day, oral feedings were well tolerated. The hematocrit was 40 per cent and chest x-ray showed resolution of the pneumonitis. He was discharged on the twelfth hospital day. Discussion Although micromethods were used for most laboratory tests, significant blood loss presents a problem in this group of patients. The average blood loss due to testing was found to be 3.1 mYkg/day. Lanuza et ulS4reported that patients admitted for medical reasons to an adult intensive care unit lost an average of 27 ml of blood, for laboratory tests, during the first three days. Although our newborn babies lost only a fraction of that amount, the clinical implications are of far greater importance because the total blood volume in such infants is so small. The predicted blood volume in newborns and infants is 65 to 80 ml/kglJJ1 and the range, therefore, in our patients would be from 62 ml, in the smallest, to 253 ml in the largest. Since the average duration of stay III the newborn intensive care unit was seven days, blood loss during this period amounted to one third of the total blood volume in some babies. An effective, safe, and convenient means for replacing this blood loss is, therefore, an important consideration in this patient population.
23
In our institution, the expiration rate due to outdating standard blood units is 2.9 per cent. This is similar to the 3.4 per cent waste related to expiration of Pedi-Packs. There are no figures in the literature with which to compare this experience. The average cost per Pedi-Pack was estimated to be $35. Since many Pedi-Packs were used for more than one transfusion in different patients, the average cost per transfusion was $26. The donor blood for the “Pedi-Pack” transfusion program was obtained entirely from voluntary blood donors, and each unit was tested for Hepatitis B antigen prior to the transfusion to further decrease the risk of hepatitis. This offers a distinct advantage over the walking donor program in which prior testing for Hepatitis B antigen is often not possible. Furthermore, it is likely that transfusion of deglycerolized red blood cells further reduces the risk of he pa ti ti^.^ Single donor sources were used in 71 per cent of our patients. This figure is similar to that obtained with a walking donor program. lo Since the process of deglycerolization removes most of the white blood cells and platelets, HLA antigenic stimulation is probably minimized. Theie were two episodes of transfusion reaction noted from a total of 191 transfusions. In both instances, the reactions could not be e>.plained on a serological basis. Bacterial cultwes of the supernatant solutions during washing in both instances were found to be sterile. Furthermore, the two remaining Pedi-Packs, obtained from the same two donors, were subsequently transfused to seven different patients and no reaction WLS observed in these cases. We have thus beea unable to explain the transfusion reactions and further experience will be needed in order to determine if these incidentt were related to the procedure itself or relaLed to a peculiarity of the transfused patient. Staples et ~ 1 . have ’ ~ shown that the quality of Pedi-Pack red blood cells is excellent and 2,3-DPG levels are well maintained. Deglycerolization, of
24
Transfusion January-February 1979
KAKAIYA ET AL.
course, removes most of extracellular potassium, white blood cells, anticoagulant and metabolic products. The Pedi-Pack transfusion program causes no difficulty to blood bank personnel in dealing with small amounts of red blood cells. Since aseptic precautions in the blood bank are not only mandatory but routine, contamination of blood during collection and handling is minimal. Current frozen red blood cell research, directed toward the development of sterile connectors,I2 may enable us to extend the dating of frozen red blood cells and thus further reduce outdating. Closed system processing will also further reduce any hazard of contamination. The Pedi-Pack transfusion program affords a ready and reliable source of red blood cells on demand. The posttransfusion rise in hematocrit in those patients studied was excellent. There is minimal delay related to processing and crossmatch. The difficulty of locating and recruiting donors at the time of need as in a walking donor program is eliminated and thus saves valuable time of physician and other personnel involved in the care of these patients. Based on our experience, we conclude that the Pedi-Pack transfusion program retains good blood bank control and greatly reduces risks inherent in exposure to multiple donors, as well as many of the problems of walking donor programs. Of the available means for supplying red blood cells to this patient population, we have found the use of frozen thawed Pedi-Packs efficient, effective, safe, convenient, and not prohibitively expensive. Acknowledgment The authors are indebted to the Blood Bank Staff of the University Hospital for invaluable support.
References 1. Ballard, R. A., J. A. Kitterman,, R. H. Phibbs,
H. Simpson, and W. H. Tooley: Observations on hypovolemia in the newborn. Clin. Res. 20: 278, 1972. 2. Blankenship. W. J., B. W. Goetzman, S . Gross, and P. G. Hattersley: A walking donor program
for an intensive care nursery. J. Pediatr. 86: 583, 1975. 3. Cam. J. B., A. M. DeQuesada. and D.
L. Shires: Decreased incidence of transfusion hepatitis after exclusive transfusion with reconstituted frozen erythrocytes. Ann. Intern. Med. 78:693,
1973. 4. Lanuza, D. M.,and J. A. Jennrich: The amount of
blood withdrawn for diagnostic tests in critically ill patients. Heart Lung 5933, 1976. 5. McCormick, R. A., M.Christman, and R. Boyles: Mini-transfusions for neonatal patients. Wis. Med. J. 71:248, 1972. 6. Meryman, H.T., and M. Hornblower: A method for freezing and washing red blood cells using a high glycerol concentration. Transfusion 12: 145, 1972. 7. Mollison, P. L.: Blood Transfusion in Clinical
Medicine, 5th ed.. Oxford, Blackwell Scientific Publications, 1972. p. 125. 8. Oberman, H. A.: Replacement transfusion in the newborn infant. A Commentary. J. Pediatr. 86: 586, 1975. 9.
-: Transfusion of the neonatal patient. Trans-
fusion 14: 183, 1974. D. Johnson, 1. A. Schulman, C. F. Grumet, E. B. Hafleigh. N. C. Malachowski, and P. Sunshine: Evaluation of a walkingdonor blood transfusion program in an intensive care nursery. J. Pediatr. 89646, 1976. 1. Russell, Sheenah, J. M.:Blood volume studies in healthy children. Arch. Dis. Child. 24:88,
10. Pass, M. A.. J.
1949. 2. Sherer, P. B.: Frozen Red Cell Outdating. Be-
thesda, U. S. Department of Health, Education and Welfare, Publication No. (NIH) 76-1004, 1975.
3. Standards for Blood Banks and Transfusion Services, 7 ed. American Association of Blood Banks, Washington. D. C.. 1974. 14. Staples, J. W.and G. E. Fritz: Development and use of pediatric frozen red cell packs. Transfusion 16566, 1976. __
R. M. Kakaiya, M.D.. Fellow in Hematology-Oncology, University of Mississippi School of Medicine, 2500 North State Street, Jackson, Mississippi 39216. F. S. Morrison, M.D.. Professor of Medicine, Chief Division of Hematology-Oncology, University of Mississippi School of Medicine: Director of the Blood Transfusion Service, University Hospital, and Executive Director, Mississippi Regional Blood Center (reprint requests). J. E. Rawson. M.D.. Assistant Professor of Pediatrics, and Chief, Division of Newborn Medicine, University of Mississippi School of Medicine. L. L. Lotz, MT (ASCP) SBB, Director of Laboratories, Mississippi Regional Blood Center, 2807 Old Canton Road, Jackson, Mississippi 39216. J. W. Martin, University of Mississippi School of Medicine.
reviewing donor source records as well as patient charts. Two instances of transfusion reaction were found in two babies. The disposition of the 236 Pedi-Packs which were thawed during this period was studied by reviewing the processing and distribution records. Hospital records of 18 patients who received 47 transfusions were evaluated carefully for transfusion response and clinical characteristics. The cost data were also analyzed. All donors were voluntary blood donors and were screened according to established blood banking standards. l 3 Serologic tests for syphilis were performed on all units prior to freezing and storage. Blood grouping and antibody screening were done before glycerolization. Only blood group 0 units were chosen for PediPack utilization. Direct antiglobulin testing and repeat blood grouping were performed after washing. All units were appropriately labeled. Blood was collected into citrate phosphate dextrose anticoagulant in the routine manner. The blood was centrifuged and the plasma transferred to a satellite bag for other use. The red blood cells were glycerolized and frozen within five days of collection by a modified Meryman technique,6 with high glycerol concentration and slow freezing in a mechanical freezer. The collection bag, containing approximately 250 ml red blood cells, was connected to a bottle containing 400 ml of 6.2 M glycerol (glycerolyte 57 solution)*. The collection bag was then attached to a shaker and 100 ml of glycerol was allowed to run into the collection bag at a rate of about 35 ml per minute while the bag was agitated. Five minutes were allowed for equilibration with the collection bag resting on a flat surface. After equilibration the remainder of the glycerol solution was added to the collection bag at a rate of approximately 35 ml per minute without agitation. The red blood cell-glycerol mixture was then mixed and equally divided into three integral freezing bags via an integral Y connector. t The contents of the freez-
Two hundred and ninety-one transfusions using 221 pediatric frozen red blood cell packs (Pedi-Packs) were given to 141 newborn babies and infants in the newborn intensive care unit. In 18 patients, 47 transfusions were studied for transfusion and clinical characteristics. Two possible hemolytic episodes are described in detail and remain unexplained. Blood loss for laboratory tests was found to average 3.1 mUkg per day spent in the newborn intensive care unit. The rise in hematwrit was found to be excellent. Overall, the transfusion of thawed pediatric red blood cell packs was found to be convenient, safe and effective. Because of pretesting possibilities with the use of this source of red blood cells, one of the problems associated with a walking donor program is eliminated.
PREMATURE NEWBORN BABIES in an intensive care unit require repeated phlebotomies for a variety of blood tests. Although micromethods are utilized for many laboratory tests in order to minimize blood loss, blood gas measurements are still being done with semi-microtechniques (one ml per sample) in our institution and others at the present time. The result is significant blood loss and anemia if frequent replacement with small volumes of red blood cells are not provided. Several methods for red blood cell transfusion for such purposes have been d e ~ e l o p e d * . ~ *and * - ~ ~are summarized in Table 1. Pediatric frozen red cell packs (Pedi-Packs) have been utilized in neonates and infants in our institution since May, 1976. Our experience with this technique is described herein. Materials and Methods Transfusion records of 291 transfusions to 141 recipients administered between May and December of 1976 were reviewed. Possible transfusion reactions were further analyzed by
* Fenwal Labs., Deerfield, IL.
Received for publication October 20, 1977; accepted March 5 . 1978.
t Union Carbide Corp., Chicago, IL.
0041-1132/79/0100/0019 $00.80 0 J. B. Lippincott Co. Transfusion January-February 1979
19
Volume 19 Number 1
20
Transfusion January-Febn~ary1979
KAKAIYA ET AL.
Table 1. Previous Methods: Transfusion of Neonates Method ~~
~~~
Advantages ~
Walking Donor Program
~~
Disadvantages
~~~~~
Ease of transfusion
Inordinate risk of exposure to hepatitis No labeling or blood bank control Does not provide packed red cells Allergic reactions to plasma proteins Risk of contemination through technique failure Risk of cytomegalovirus infection
Donor blood collected into quadruple packs
Retains blood bank control Minimal metabolic injury
Considerable wastage 2-3 DPG levels are not meintained if stored for more than five days
Donor blood collected into triple packs
The donor can be rebled in a shorter time if needed
Waste
Small amounts from a unit of red blood cells are aseptically removed and transfused
Easily available
The remaining unit may expire before a suitable recipient can be found Waste
Few metabolic changes in red blood cells Coagulation factors and platelets present Minimal wastage Mostly single donor source
ing bags were thoroughly mixed before freezing. Each freezing bag was placed, in an aluminum canister, in a mechanical freezer at -80 C for freezing and storage. Upon request for transfusion, a Pedi-Pack (one of the three partial units) was thawed by immersion into a 37 C water bath. Thawing required three to five minutes. The red blood cell-glycerol suspension in each bag after thawing measured about 200 ml. To this suspension was added 50 ml of 12 g/dl sodium chloride solution, buffered to pH 7.* Two minutes were allowed for equilibration while the suspension was manually agitated. Two hundred and fifty ml of 1.6 g/dl sodium chloride solution buffered to ph 7* was then added with continuous agitation and allowed to equilibrate for one minute. The diluted cell suspension was allowed to run into an IBM cell processor bag$ and washed once with the buffered 1.6 g/dl sodium chloride solution. Two more washings with buffered 0.2 g/dl dextrose in 0.8 g/dl sodium chloride solution* were performed by automatic cycle. The supernatant fluid was inspected for hemolysis after each wash. Upon completion of washing, the outlet tubing of the IBM cell processor bag was clamped to form two inch segments. The contents of the segments were used for repeat $
IBM Corp. Buffalo, NY.
grouping and typing. A few drops of red blood cells from the outlet tubing section were suspended in normal saline, centrifuged and inspected for hemolysis. The supernatant fluid was cultured both aerobically and anaerobically in peptone broth. One tube was incubated at 37 C and the other at room temperature for 24 hours. The following day, both tubes were vented and incubated for another 24 hours. The entire procedure of deglycerolization took 30 minutes. Most Pedi-Pack transfusions were given to babies in the newborn intensive care unit of the University Hospital. The transfusions were given primarily for replacement of blood loss, but also for anemia from other causes when indicated. Hypovolemia' in patients with hematocrit of less than 40 per cent was treated with red blood cell transfusion. A crossmatch between donor and recipient, and when possible, between donor and recipient's mother was performed prior to transfusion. Crossmatch was repeated whenever a different donor source was used. If repeated transfusion was anticipated, the Pedi-Pack chosen was one which had all three packs from the same donor available. This was done to minimize antigenic exposure as well as to reduce cost and blood loss necessitated by repeated crossmatches. Small aliquots of crossmatch compatible red blood cells, as ordered,
Volume 19 Number I
21
PEDI-PACK TRANSFUSION
were transferred into I50 ml transfer packs and appropriately labeled. This aliquot was then delivered for transfusion. The time from placement of an order to the delivery of red blood cells for transfusion ranged from 45 minutes to two hours, depending upon the urgency of the clinical situation. The transfer packs containing the washed red blood cells were often kept warm by keeping them in the incubator next to the baby for 10 to 15 minutes. The blood administration set was connected to the red blood cell pack and the desired amount of red blood cells was drawn aseptically through a standard blood filter into a syringe and after proper identification, transfused into a peripheral or central vein through a 22-gauge needle, a 23-gauge catheter, or size three French catheter. Recipients were routinely followed very closely with hourly vital signs and strict input and output measurement. All blood removed for laboratory purposes was accurately recorded.
Results A total of 236 Pedi-Packs were thawed between May and December, 1976, from 85 units of red blood cells. Five Pedi-Packs had to be discarded because of a leak or rupture of the IBM cell processor bag. Two packs were contaminated with air during glycerolization because of sealing failure and were discarded. This represents a 2.9 per cent loss during processing. Eight Pedi-Packs (3.4%) were discarded because they were not used within 24 hours after thawing. .Overall loss, including the loss during processing, was 6.3 per cent. Bacterial cultures of the supernatant solutions from the deglycerolization process were all negative at 24 and 48 hours. Red blood cells from each deglycerolized washed Pedi-Pack were suspended in normal saline, centrifuged and inspected for hemolysis. Free hemoglobin was either absent or judged negligible.
Of the 221 Pedi-Packs used for 291 separate transfusions into 141newborn babies and infants, 172 were used as single transfusion. Thirty-one Pedi-Packs were used for two separate transfusions, 15 for three, and three for four transfusions each. The average number of transfusions from each Pedi-Pack was 1.3. There were two episodes of transfusion reaction encountered in 191 transfusions. Eighty-three patients received a single transfusion while 58 patients received more than one transfusion. The average number of transfusions per patient was 1.89. One hundred patients (71%) were provided single donor transfusions. Twenty-six patients (18%) received transfusions from two donors. Only 15 patients (11%) received transfusions from more than two donors. Forty-seven transfusions in 18 patients were reviewed in depth. Transfusion response and clinical characteristics in these patients are presented in Tables 2 and 3. Thirteen patients (76%) were admitted to the newborn intensive care unit on the first day of life. Only two patients were more than 12 days of age and the average weight was 1.8 kg. Most babies were receiving oxygen therapy. The average stay in the unit was seven days while 11 patients stayed longer than seven days. Since the mean total bilirubin level exceeded 7 mg/dl due to physiologic hyperbilirubinemia and since more than half were actually receiving phototherapy, posttransfusion bilirubin measurements could not be used as indicators of hemolysis of transfused red blood cells. Any amount of blood drawn was accurately recorded. In some instances, such blood losses were replaced with red blood cell transfusions before anemia actually developed. The average blood loss was 3. I mg/kg/day. The mean volume of red blood cells transfused was 12 ml. The mean rise in hematocrit was from 38 to 44 per cent. There were three deaths among these patients. One patient was an infant of 30 weeks
Table 2. Transfusion Response and Clinical Characteristics of 18 Patients Receiving 47 Transfusions Transfusion Response and Clinical Characteristics Weight in grams at transfusion Number of days' stay in Newborn Intensive Care Unit (NICU) Serum total bilirubin concentration at transfusion (mg/dl) Blood loss for laboratory tests in NICU (ml/kg/day) Amount per transfusion (ml) Pretransfusion hernatocrit (YO) Posttransfusion hematocrit (%)
Range 950-31 60
Mean 1822
1-19
7.5
0-16
7.4
1.4-7.9 6-24 22-58 24-64
3.1 11.9 38 44
22
KAKAIYA ET AL.
Table 3. Major Clinical Diagnosis in 78 Patients Diagnosis Respiratory Distress Syndrome lntracranial Bleeding Pneumothorax Patent Ductus Arteriosus TransDosition of Great Vessels E. coli Bacteremia Hypothyroidism Total
Number of Patients 5 4
3 3 1 1 1 18
gestation weighing 1.4 kg. The delivery was complicated by breech presentation and abruptio placenta. Autopsy revealed a large intracerebral hemorrhage. Transfusions had not been used within ten days of death. A 28- to 30-week gestation infant weighing 990 g died on the third day after birth followingcardiorespiratory arrest. The patient had not received transfusion in the 12 hours preceding death. A 19-day-old infant underwent surgery for transposition of great vessels, developed acute renal failure postoperatively and died on the eighth postop day. Autopsy revealed transposition of great vessels, bilateral renal cortical necrosis, thrombosis of the abdominal aorta, and pulmonary hemorrhage. The infant had not received a transfusion for 48 hours prior to death. Case Reports Cue I
An eight-week-old black male infant weighing 2500 g was admitted for surgical repair of a large
asymptomatic right inguinal hernia. Physical examination revealed no abnormality except for the hernia. The hemoglobin was 11.8 ddl. hematocrit 33 per cent, and total WBC 78001p1 with a normal differential count. Routine urinalysis, chest x-ray and SMA-18 tests were normal. The hernia was repaired under nitrous oxide and halothane anesthesia. The surgery was uncomplicated and blood transfusion was not needed. Twelve hours after surgery, the baby developed sudden respiratory arrest while being fed formula by the mother. The child was promptly resuscitated with tracheal intubation. Controlled ventilation was required for eight hours, after which spontaneous respiration began. Because of poor respiratory effort, continued assisted ventilation was required with 40 per cent oxygen in inspired air. Chest x-ray immediately after the respiratory arrest revealed bilateral pulmonary edema which resolved within four hours after the administration of 5 mg furosemide intravenously. Postarrest hematocrit was 19 per cent and ten ml of group 0,
Transfusion
January-February 1979
Rh compatible, crossmatched red blood cells were transfused without incident. The hematocrit rose to 24 per cent in two hours. Forty-eight hours after surgery, because the hematocrit was only 21 per cent, a further transfusion of 24 ml of Pedi-Pack red blood cells from a different donor was given. No immediate reaction was noted, but about one hour after transfusion, pink urine appeared and transfusion reaction was suspected.' The urine showed 0 to 3 red blood cells per high power field. The patient's axillary temperature rose from 36.7 to 37.3 C while incubator temperature was 36.7 C. A blood sample was immediately sent to the blood bank. Plasma hemoglobin was 64 mg/dl and hematocrit was 27 per cent. Repeat crossmatch with before and after transfusion samples showed no incompatibility. Intravenous fluid at a rate of 25 muhour and 5 mg furosemide intravenously were administered, and the urine cleared within five hours. Urine output in six hours was 210 ml (1.4 rnukdhour). Posttransfusion total bilirubin was 0.9 mddl compared to the admission value of 0.4 mg/dl. The infant required ventilatory support until the ninth hospital day, was then extubated without respiratory difficulty and was discharged on the sixteenth hospital day. Case 2
A black male infant, weighing 2720 g, was delivered at term to a Gravida 2, para 1, 19-yearold. The pregnancy and delivery were uncomplicated. Apgar rating was nine and ten at one and five respectively. Upon physical examination at birth, the infant showed an abnormal respiratory rate of 95 per minute and mild retrosternal retraction. Arterial Po, on room air was 68 per cent, Pco, 41 per cent, and pH 7.34. The hematocrit was 44 per cent, glucose 45 mg/dl, Na 138 mEq/l and K 3.9 mEq/l. Chest x-ray suggested a diffuse bilateral pneumonitis. The infant was placed on 60per cent oxygen under oxyhood. Repeat blood gases were Po, 90 per cent, PCO, 41 per cent, and pH 7.40. Six hours after birth, the hematocrit was 32 per cent, but decreased to 29 per cent at nine hours. Eighteen rnl type 0, Rh compatible, frozen red blood cells were transfused. The crossmatch was compatible with the patient but incompatible with the patient's mother. Anti-P, antibodies were identified in the mother's serum. About five minutes after the transfusion, the baby suddenly became cyanotic and developed tachycardia. The systolic blood pressure was 70 mm of Hg after the onset of cyanosis while one hour prior to the transfusion it was 45 mm of Hg. The baby passed dark urine which was 3+ when tested for blood. Prior to the transfusion, a suprapubic tap had revealed clear urine. Blood smear
Volume 19 Number I
PEDI-PACK TRANSFUSION
showed a dual population of red blood cells with some burr cells and a few microspherocytes. White blood cells and platelets appeared normal. The prothrombin time was 17.5 seconds with a control of 13 seconds, partial thromboplastin time was 62.5 seconds with a control of 48 seconds. Platlets were 285,000/pl. Hemoglobin was 9.4 g/dl, hematocrit 32 per cent, reticulocytes 1.4 per cent, and WBC 14,OOO/pI. Recrossmatch with before and after transfusion samples showed no incompatibility. The infant remained cyanotic despite 100 per cent oxygen administration under oxyhood and was, therefore, intubated and ventilated with an FI,, of 1.0. Blood gases improved to Po, 179 per cent, Pco, 22 per cent, and pH 7.31. Chest x-ray one hour after transfusion showed no change. Hematocrit was 30 per cent at 17 hours after the first transfusion, and an additional 18 ml of frozen red blood cells from a different donor were given without reaction. The hematocrit rose to 35 per cent six hours after the second transfusion. The child was then extubated without deterioration of blood gases. On the third day, oral feedings were well tolerated. The hematocrit was 40 per cent and chest x-ray showed resolution of the pneumonitis. He was discharged on the twelfth hospital day. Discussion Although micromethods were used for most laboratory tests, significant blood loss presents a problem in this group of patients. The average blood loss due to testing was found to be 3.1 mYkg/day. Lanuza et ulS4reported that patients admitted for medical reasons to an adult intensive care unit lost an average of 27 ml of blood, for laboratory tests, during the first three days. Although our newborn babies lost only a fraction of that amount, the clinical implications are of far greater importance because the total blood volume in such infants is so small. The predicted blood volume in newborns and infants is 65 to 80 ml/kglJJ1 and the range, therefore, in our patients would be from 62 ml, in the smallest, to 253 ml in the largest. Since the average duration of stay III the newborn intensive care unit was seven days, blood loss during this period amounted to one third of the total blood volume in some babies. An effective, safe, and convenient means for replacing this blood loss is, therefore, an important consideration in this patient population.
23
In our institution, the expiration rate due to outdating standard blood units is 2.9 per cent. This is similar to the 3.4 per cent waste related to expiration of Pedi-Packs. There are no figures in the literature with which to compare this experience. The average cost per Pedi-Pack was estimated to be $35. Since many Pedi-Packs were used for more than one transfusion in different patients, the average cost per transfusion was $26. The donor blood for the “Pedi-Pack” transfusion program was obtained entirely from voluntary blood donors, and each unit was tested for Hepatitis B antigen prior to the transfusion to further decrease the risk of hepatitis. This offers a distinct advantage over the walking donor program in which prior testing for Hepatitis B antigen is often not possible. Furthermore, it is likely that transfusion of deglycerolized red blood cells further reduces the risk of he pa ti ti^.^ Single donor sources were used in 71 per cent of our patients. This figure is similar to that obtained with a walking donor program. lo Since the process of deglycerolization removes most of the white blood cells and platelets, HLA antigenic stimulation is probably minimized. Theie were two episodes of transfusion reaction noted from a total of 191 transfusions. In both instances, the reactions could not be e>.plained on a serological basis. Bacterial cultwes of the supernatant solutions during washing in both instances were found to be sterile. Furthermore, the two remaining Pedi-Packs, obtained from the same two donors, were subsequently transfused to seven different patients and no reaction WLS observed in these cases. We have thus beea unable to explain the transfusion reactions and further experience will be needed in order to determine if these incidentt were related to the procedure itself or relaLed to a peculiarity of the transfused patient. Staples et ~ 1 . have ’ ~ shown that the quality of Pedi-Pack red blood cells is excellent and 2,3-DPG levels are well maintained. Deglycerolization, of
24
Transfusion January-February 1979
KAKAIYA ET AL.
course, removes most of extracellular potassium, white blood cells, anticoagulant and metabolic products. The Pedi-Pack transfusion program causes no difficulty to blood bank personnel in dealing with small amounts of red blood cells. Since aseptic precautions in the blood bank are not only mandatory but routine, contamination of blood during collection and handling is minimal. Current frozen red blood cell research, directed toward the development of sterile connectors,I2 may enable us to extend the dating of frozen red blood cells and thus further reduce outdating. Closed system processing will also further reduce any hazard of contamination. The Pedi-Pack transfusion program affords a ready and reliable source of red blood cells on demand. The posttransfusion rise in hematocrit in those patients studied was excellent. There is minimal delay related to processing and crossmatch. The difficulty of locating and recruiting donors at the time of need as in a walking donor program is eliminated and thus saves valuable time of physician and other personnel involved in the care of these patients. Based on our experience, we conclude that the Pedi-Pack transfusion program retains good blood bank control and greatly reduces risks inherent in exposure to multiple donors, as well as many of the problems of walking donor programs. Of the available means for supplying red blood cells to this patient population, we have found the use of frozen thawed Pedi-Packs efficient, effective, safe, convenient, and not prohibitively expensive. Acknowledgment The authors are indebted to the Blood Bank Staff of the University Hospital for invaluable support.
References 1. Ballard, R. A., J. A. Kitterman,, R. H. Phibbs,
H. Simpson, and W. H. Tooley: Observations on hypovolemia in the newborn. Clin. Res. 20: 278, 1972. 2. Blankenship. W. J., B. W. Goetzman, S . Gross, and P. G. Hattersley: A walking donor program
for an intensive care nursery. J. Pediatr. 86: 583, 1975. 3. Cam. J. B., A. M. DeQuesada. and D.
L. Shires: Decreased incidence of transfusion hepatitis after exclusive transfusion with reconstituted frozen erythrocytes. Ann. Intern. Med. 78:693,
1973. 4. Lanuza, D. M.,and J. A. Jennrich: The amount of
blood withdrawn for diagnostic tests in critically ill patients. Heart Lung 5933, 1976. 5. McCormick, R. A., M.Christman, and R. Boyles: Mini-transfusions for neonatal patients. Wis. Med. J. 71:248, 1972. 6. Meryman, H.T., and M. Hornblower: A method for freezing and washing red blood cells using a high glycerol concentration. Transfusion 12: 145, 1972. 7. Mollison, P. L.: Blood Transfusion in Clinical
Medicine, 5th ed.. Oxford, Blackwell Scientific Publications, 1972. p. 125. 8. Oberman, H. A.: Replacement transfusion in the newborn infant. A Commentary. J. Pediatr. 86: 586, 1975. 9.
-: Transfusion of the neonatal patient. Trans-
fusion 14: 183, 1974. D. Johnson, 1. A. Schulman, C. F. Grumet, E. B. Hafleigh. N. C. Malachowski, and P. Sunshine: Evaluation of a walkingdonor blood transfusion program in an intensive care nursery. J. Pediatr. 89646, 1976. 1. Russell, Sheenah, J. M.:Blood volume studies in healthy children. Arch. Dis. Child. 24:88,
10. Pass, M. A.. J.
1949. 2. Sherer, P. B.: Frozen Red Cell Outdating. Be-
thesda, U. S. Department of Health, Education and Welfare, Publication No. (NIH) 76-1004, 1975.
3. Standards for Blood Banks and Transfusion Services, 7 ed. American Association of Blood Banks, Washington. D. C.. 1974. 14. Staples, J. W.and G. E. Fritz: Development and use of pediatric frozen red cell packs. Transfusion 16566, 1976. __
R. M. Kakaiya, M.D.. Fellow in Hematology-Oncology, University of Mississippi School of Medicine, 2500 North State Street, Jackson, Mississippi 39216. F. S. Morrison, M.D.. Professor of Medicine, Chief Division of Hematology-Oncology, University of Mississippi School of Medicine: Director of the Blood Transfusion Service, University Hospital, and Executive Director, Mississippi Regional Blood Center (reprint requests). J. E. Rawson. M.D.. Assistant Professor of Pediatrics, and Chief, Division of Newborn Medicine, University of Mississippi School of Medicine. L. L. Lotz, MT (ASCP) SBB, Director of Laboratories, Mississippi Regional Blood Center, 2807 Old Canton Road, Jackson, Mississippi 39216. J. W. Martin, University of Mississippi School of Medicine.
