Blood transfusion in Pediatrics

A blood transfusion is the introduction of whole blood or blood components into the venous circulation.

Indications

Infants:

• Asymptomatic infant with hematocrit <20%
• Infant with hematocrit <30% and requiring oxygen <35% or requiring CPAP or mechanical ventilation; of having significant apnea or bradycardia; or having heart rate > 180/min or respiratory rate >80/min persisting for > 24 hours; or having a weight gain <10 g/ day observed over 4 days while on >100 cal/kg/day or undergoing surgery
• Infant with hematocrit <35% if receiving oxygen >35% or getting mechanical ventilation

Children:

• Hb 4 g/dL or less (hematocrit 12%) irrespective of the clinical condition
• Hb 4-6 g/dL (hematocrit 13-18%) with features of hypoxia acidotic breathing, dyspnea, or impaired consciousness.
• Hyper parasitemia in malaria (>20%).
• Features of cardiac decompensation such as cardiomegaly or CCF.

Equipment Needed

A tray containing:

• Unit of blood or blood components, whichever is ordered
• Blood transfusion set
• IV pole
• Venipuncture set containing a pediatric size gauge needles if one is not already in place
• Antiseptic wipes
• Plaster gloves

Correct Storage Conditions

• Whole blood/RBCs: Transfusion should be started within 30 minutes of removing the pack from storage temperature (+2 to 6°C). It should be completed within 4 hours of starting infusion if the hospital temperature is between 22°C and 25°C. In case of high ambient temperature, shorter out of refrigeration times should be used.
• Platelets: Transfuse as soon as they have been received and should be completed in about 20 minutes.
• FFP: In adult, FFP 1 U 200-300 mL in 20 minutes (start within 30 minutes) and in children depending on the clinical Condition. These products should be infused through a new, sterile blood administration set containing an integral filter and should be changed 12 hourly if multiple transfusions are needed. For platelet transfusion, a fresh set primed with saline should be used. The child should be monitored frequently during infusion of blood or blood products.

Preparation

• Obtain a written consent from the parents (institutional policy).
  Assess vital signs for baseline data.
  Determine any known allergy or previous adverse reactions to blood.
  Note specific signs related to child’s pathology and the reason for transfusion.
• Explain the procedure and its purpose to parents as well as child as appropriate.
  If the child has an IV solution infusing, check whether the needle and solution are appropriate to administer blood.
• Obtain the correct blood component for the child.
• Check the physician’s order with the requisition.
• Check the requisition form with the blood bag label. Specifically check the client’s name, identification no., blood grouping and typing, and the expiry date of blood.
• Observe the blood for abnormal color, gas bubbles, etc.

Procedure

• Perform hand hygiene.
• Set up the equipment.
• Ensure the blood filter inside the drip chamber is suitable.
• Attach the blood tubing to the blood filter.
• Put on gloves.
• Close all the clamps on Y set.
• Using a twisting motion, insert the spike into a container on NS.
• Hang the container on the IV pole about 1 m above the planned venipuncture site.
• Prime the tubing.
• Allow a small amount of NS to infuse to make sure there are no problems with the flow or venipuncture site.
• Invert the blood bag gently several times to mix the cells with the plasma.
• Expose the port on the blood bag by pulling back the tabs.
• Insert the remaining Y set spike into the blood bag.
• Suspend the blood bag.
• Open the upper clamp on the Y set arm to the blood, and prime tubing.
• Establish blood transfusion. Adjust the flow rate as prescribed.
• Observe the child closely for the first 5-10 minutes.
• Monitor the vital signs.
• Remove gloves and perform hand hygiene.

Post procedure Care

• Document the relevant data.
• Monitor the vital signs after blood trans-fusion.
• If no infusion is to follow, clamp the blood tubing and remove the needle.
• If the primary IV is to be continued, flush the maintenance line with the saline solution.
• Discard the administration set according to recommendations.

Complications

Immediate reactions:

• Serious hemolytic transfusion reaction
• Febrile reactions
• Circulatory overload
• Air emboli
• Hypothermia
• Electrolyte disturbances

Delayed reactions:

Transmission of infections agents, including HIV, HBV, HCV, syphilis, and malaria, and CMV

• Alloimmunization: Antibody formation, occurs in patient receiving multiple trans-
• fusions
• Delayed hemolytic reaction

Nurse’s Responsibility

PRBCs and whole blood:

• Regulate infusion rate using microaggregate filter via infusion pump into 5 mL/kg/h over 2-4 hours (usual rate).
  Do not use the tubing to infuse > 1 U of blood.
• Monitor vital signs before transfusion, 15 minutes after initiation, hourly during transfusion, and upon completion of transfusion.
• Do not refrigerate the blood in the nursing unit. Only the blood bank refrigerator may be used.
• Ensure that each unit is infused in 4 hours or less. If a longer infusion time is needed, the unit must be divided in the blood bank.
• Do not infuse solutions other than NS in the line with RBCs.

FFP:

• Regulate infusion rate using microaggregate filter to 20 mL/min over 1-2 hours every 12-24 hours until hemorrhage stops.
• Monitor PT and PPT before and after
  FFP infusion.
• Monitor levels of other coagulation factors (e.g., fibrinogen, fibrin split product, D-dimer, ATIII, and proteins
  C and S).

Platelets:

• Regulate infusion rate to 10 mL/kg/h, IV push over an hour or as patient can tolerate.
• Monitor vital signs before transfusion, 15 minutes after initiation, and at the end of transfusion.
• Obtain platelet count 60 minutes to 24 hours after infusion.

Granulocytes:

• Monitor vital signs before transfusion, 15 minutes after initiation and at the end of transfusion.
• Premedicate 1 hour before transfusion, usually with antihistamines, acetaminophen, or steroids infuse at slow rate (2-4 hours) within a 24-hour period.
• A minimum of 4-6 hours between amphotericin B and granulocyte infusion recommended.

Factor VIII:

• Use reconstituted factor within 3 hours of mixing.
• Inject reconstituted factor intravenously over 2-5 minutes.
• Assess for signs of an adverse reaction such as hives, itchy wheals with redness, and tightness in chest wheezing, low blood pressure (BP), or trouble breathing.
  Notify healthcare provider immediately if symptoms are present.

Cryoprecipitate:

• Monitor closely PT/PPT and levels of fibrinogen; fibrinogen split products, D-dimer.
• Use a filter needle to draw up and administer within 15-30 minutes.

General Instructions

These are applied to all types of transfusions.

• Take vital signs, including BP, before administering blood to establish baseline data for intratransfusion and post-trans-fusion comparison; 15 minutes after initiation; hourly while blood is infusing; and upon completion of the transfusion.
• Check the blood type and group of the recipient against the donors, regardless of the blood products used.
• Administer the first 50 mL of blood or initial 20% of volume (whichever is smaller) slowly and stay with the child.
• Administer with NS in a piggyback setup or have NS available.
• Administer blood through an appropriate filter to eliminate the particle in the blood and to prevent the precipitation of formed elements by gently shaking the container frequently.
• Use blood within 30 minutes of its arrival from the blood bank; if it is not used, return it to the blood bank-do not store it in a regular unit refrigerator.
• Infuse a unit of blood (or the specified amount) within 4 hours. If the infusion exceeds this time, the blood should be divided into appropriate-size quantities by the blood bank, with the unused portion refrigerated under the controlled conditions.
• If a reaction of any type is suspected, take vital signs, stop the transfusion, maintain a patent IV line with NS and new tubing, notify the practitioner, and do not restart the transfusion until the child’s condition has been medically evaluated.
• Blood is usually administered to children by infusion pump; therefore, the usual precautions and management related to pumps apply. When the blood infusion is started with a standard transfusion set, the filter chamber is filled to allow the total filter to be used.
• The drip chamber is partially filled with blood to permit counting of the drops.
• When the flowrate is adjusted, it is important to remember that blood administration sets do not use micro drops (60 drops/mL) but regular drops (usually 10-15 drops/mL). Therefore, it must be considered when calculating the flow rate.
• Oxygen may be administered to provide optimum environmental conditions for hemoglobin saturations.
• Oxygen administration is of limited value, however, because each gram of hemoglobin is able to carry a limited amount of the gas. In addition, prolonged use of supplemental oxygen can decrease erythropoiesis. Therefore, the child is monitored closely for evidence of decreasing benefit from oxygen. One of the first signs of hypoxia is restlessness.

REFERENCES

1. Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
2. Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
3. Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwer’s, ISBN-13:978-9388313285
4. Marcia London, Ruth Bindler, Principles of Paediatric Nursing: Caring for Children, 8th Edition, 2023, Pearson Publications, ISBN-13: 9780136859840
5. Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/

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