GUIDELINES FOR PEDIATRIC TRANSFUSIONS AT HMC Theresa Nester, MD and Min Kang, MD March 2003 Q1.

What is the blood volume of a small child and how many units of red cells would be needed to replace one blood volume? Blood volume in infants Age Red cell vol mL/Kg Plasma vol mL/Kg Blood vol mL/Kg Body Wt Red cell vol mL Plasma vol mL Total blood vol mL >1 mo 34 41 75 10 Kg (1 yr) 340 410 750 15 Kg (3 yr) 510 615 1125 20 Kg (5 yr) 680 820 1500

5 Kg (2 mo) 170 205 375

If a child weighs 10 kg, 2.1 units of packed red cells will replace one total blood volume based on the following calculation: 750mL (total blood volume)/ 350 mL (volume of one unit of packed red cells) = 2.1 Red cell replacement calculation: Volume required = BV x desired Hct increase / Hct of red cell unit (60%) If the Hct of this child is 19% and you wish to increase the Hct to 24%, you will need 62 mL of red cell (750mL x 5/60 = 62 mL). Q2. What are the red cell products available at PSBC for the pediatric age groups most frequently treated at HMC ? What are the typical indications for each product ? What is the estimated turn around time if the component is ordered STAT ? Red cell: stored at 1-6 C 1. Pedi-pack unit: PSBC can create pedi-packs by dividing one adult unit into 4 smaller units. The volume of each unit is 50-80 mL. Considering that an average dose of red cells in a non-urgent situation is 10mL/kg, a pedi-pack is most appropriate for a child who weighs less than 7 kg. Because PSBC cannot guarantee that individual units will come from the same donor, if a child needs at least 2 pedi-packs, it is prudent to use part of a packed red cell unit so that the patient is exposed to only one donor. Age of pedi-pack units will be less than 7 day old. Pedi units are not returnable for credit. Turn around time: PSBC will try to have some pedi-pack units available at all times. If it is necessary to create 4 pedi-pack units from an adult unit STAT, the

quickest turn around time on average is 60 min plus transport time for the patient sample to go from HMC to PSBC and then units from PSBC to HMC. 2. Packed red cell unit: The average volume of a unit is 350 mL. Generally only a portion of the unit will be used for a small child. A packed red cell unit that has not been washed may be returned for credit, as long as it is kept at refrigerated conditions. Hint: If the chance of transfusion in the OR is low but not zero, ordering an adult unit will allow for return for credit if the unit is not used. Ordering a pedi unit will not allow return for credit if not used. Example: A 10 Kg child is the victim of a trauma and has a Hct of 10%. We decide to give a 20 mL/kg dose, which should increase the Hct to 26% (see above formula). The better (and faster) choice, rather than ordering 3 pediatric units, is to order one packed red cell unit and transfuse 200 mL. Turn around time (red cells needed faster than within 4 hours) for orders: 1. Emergency uncrossmatched: 30 minutes once sample received at PSBC. Tests performed: ABO and Rh typing, then release of the type-specific unit. Antibody screen and crossmatch are completed after the release; physician will be notified if incompatible units have been issued. 2. Emergency crossmatched: 45 minutes once sample received at PSBC if antibody screen is negative. Tests performed: ABO and Rh typing, antibody screen and crossmatch, then release of the unit. If the antibody screen is positive, antiglobulin crossmatch (instead of electronic crossmatch) plus antibody identification will be performed. HMC physician will be notified if the antibody screen is positive, so that physician may decide if the risk of giving uncrossmatched blood is lower or higher than the risk of waiting for fully crossmatched blood. 3. Pedi pack unit if none currently on the shelf at PSBC: Once sample received at PSBC, 30 minutes plus turn around time for either emergency crossmatched or uncrossmatched, above. Orders requiring more than one pedi-pack unit are often processed faster and result in less donor exposure by ordering one adult packed red cell unit instead. Q3. What is considered a usual dose and a large dose of red cells in pediatric transfusion ? What increment in Hct will be seen ? - Usual dose (low volume transfusion): 10 mL/kg; 6% Hct increase - Large dose (high volume transfusion): >20 mL/kg; >12% Hct increase Q4. What is the appropriate rate for transfusion of this dose ? - Nursing critical care guidelines suggest not to use a rapid infusion device if weight < 20 Kg - The safest recommended maximum red cell infusion rate due to potassium originating from the donated unit is 0.002 mEq/kg/min (personal communication with Dr. Ronald Strauss, pediatric transfusion specialist).

Safest maximum red cell infusion rate depending on age of red cell unit Body Wt 5 Kg (2 mo) 10 Kg (1 yr) 15 Kg (3 yr) 20 Kg (5 yr) 40-42 d storage 0.55 mL/min 1.1 mL/min 1.65 mL/min 2.2 mL/min 33mL/hr 66mL/hr 99mL/hr 132mL/hr 20-21 d storage 0.9 mL/min 1.8 mL/min 2.7 mL/min 3.6 mL/min 54 mL/hr 108 mL/hr 162 mL/hr 216 mL/hr 5-7 d storage 2.1 mL/min 4.2 mL/min 6.3 mL/min 8.4 mL/min 126 mL/hr 252 mL/hr 378 mL/hr 504 mL/hr The above table is based on the assumption that the safest maximum red cell infusion rate for potassium is 0.002 mEq/kg/min. 5-7 day old red cells are typically reserved for neonates requiring high volume transfusions. Pediatric Trauma: Note that the above recommendations may be too slow for practical purposes in a trauma situation. Red cell factors that may contribute to hyperkalemia include age and irradiation of the red cell unit. For children beyond neonatal age (>4 mo), the age of the red cell unit alone should not greatly impact the serum potassium. Massive transfusion situations in which the childs total blood volume is replaced with red cells may significantly alter the patients serum potassium. Patient factors that may increase their sensitivity to potassium include shock, renal failure, and hypothermia. If time allows, washing the cells in a cell saver prior to infusion will alleviate the potassium load from the unit. Rapid infusion of red cells or plasma should be performed using a blood warmer. A syringe can be used with a blood warmer to rapidly infuse blood: In a 10 Kg child, rapid infusion of red cells can be achieved by using a syringe (20 mL) and Alton Dean pressure device to obtain an infusion speed of 100 mL/min. In a 20 kg child, a rate of 200mL/min may be possible. The syringe can be any size, depending on the amount needed to transfuse and the size of the patient. Because this infusion rate is faster than the recommended maximum red cell infusion rate due to potassium load, it is strongly advised that the serum potassium be measured frequently with rapid red cell infusions for small children. Having glucose and insulin readily available is recommended. Calcium may be useful should signs of hypocalcemia develop with massive transfusion of plasma. Treatment of Hyperkalemia in Children: 10% calcium gluconate 1 mg/kg IV over 5-10 minutes

0.25-0.50 grams glucose per kg plus 0.3 units insulin per gram glucose IV over 30-60 minutes consider furosemide 1-2 mg/kg IV

Q5. In transfusion medicine, what age group is considered to be a neonate ? Do these patients require modifications to the components that older pediatric patients do not require ? Neonates are defined in transfusion medicine to be younger than 4 month of age. The red cell units for neonates require special modifications such as irradiation. Notify PSBC if a patient at HMC is less than 4 month old. The lab procedures at PSBC will ensure that the appropriate product is prepared for the neonate. If possible, waiting for a fresh (<7 day old) irradiated unit of red cells to arrive from PSBC would be ideal. If not possible, transfuse a unit from the stock supply of type O red cells kept at HMC; controlling the rate of infusion will help adjust for the potassium load in the older unit of red cells. Q6. For platelets, plasma, and cryoprecipitate, what products are available at PSBC ? What dose is appropriate for a small child ? Other blood components available from PSBC and the volume of each component Platelet: stored at 20-24 C, all platelet components released to HMC have a 4 h expiration time after release from PSBC 1. Single whole blood platelet: 50 mL 2. Pooled whole blood platelets: 50 mL x number of pooled single units 3. Apheresis platelet: 250-300 mL, FFP: thawed FFP has a 24 h shelf life if maintained at 1-6 C 1. Standard FFP: 250 mL 2. Divided FFP: 65 mL Cryoprecipitate: thawed cryoprecipitate has a 4 h expiration time at 20-24 C 1. Single unit cryoprecipitate: 15 mL 2. Pooled cryoprecipitate: 120 mL (equivalent to 6 units of cryoprecipitate) Q7: What is the usual dose of the blood components for pediatric populations ? Dosage- general Component Red cell FFP WB platelet Apheresis platelet Cryoprecipitate Dosage 10-15 mL/Kg 10-15 mL/Kg 5-10 mL/Kg or 0.1 unit/ Kg 5-10 mL/Kg 1.5-3 mL/Kg or 0.1 0.2 units/Kg Expected Increment Hct 6-9% 15-20% coag factor 50,000/L 50,000/L 60- 100 mg/dL

Dosage for 10 Kg and 20 Kg child Weight of patient 10 Kg Red cell 100 150 mL (1 unit) FFP 100 150 mL (1 unit) WB platelet 50 100 mL (1-2 units) Apheresis platelet 50 100 mL (1 unit) Cryoprecipitate 15 30 mL (1 2 units)

20 Kg 200 300 mL (1 unit) 200 300 mL (1 unit) 100 200 mL (2-4 units) 100 200 mL (1 unit) 30 60 mL ( 2 4 units)

Example: Given the above table, an appropriate order for a 10 kg child with a platelet count of 50,000/L and a fibrinogen level of 40 mg/dL would be: One unit of whole blood platelets and 1 to 2 individual units of cryoprecipitate. If plasma is to be ordered, the appropriate order would be for one adult unit of FFP. Note: The tech taking the order at PSBC will not understand a request for 150 cc of FFP; it is necessary to order components in increments such as one unit of FFP. Once received, infuse the appropriate dose and discard the remainder of the unit. Q8: What sample is required for the order of red cells ? Samples Patient Age Sample size for RBC units (tube size) <1 year old 2 full EDTA microtubes 1-5 years old 1 full 3 mL EDTA tube > 5 years old 1 full 5 mL EDTA tube As a general guideline, a minimum 2 ml sample is required for ABO/Rh typing and antibody screen. However, if an antibody is detected and an electronic crossmatch can not be performed, consider adding 1 mL for each additional red cell unit in excess of 2. When a child's blood volume is adequate to tolerate collection of a 7 ml sample, it is best to collect the full 7 ml sample to avoid re-draws if an antibody is identified or more blood is needed. Note: For the order of blood components other than red cells (platelet, FFP and cryoprecipitate), only ABO/Rh typing is required. Therefore, 2 mL in an EDTA tube will suffice.