Atlas of Procedures in Neonatology, 4th Edition



Transfusion of Blood and Blood Products

Naomi L.C. Luban


Blood Products Utilized in Neonates

  1. Packed red blood cells (PRBCs)
  2. Whole or reconstituted whole blood
  3. Platelet concentrates derived from whole blood or plateletpheresis
  4. Fresh frozen plasma (FFP) or frozen thawed plasma
  5. Cryoprecipitate
  6. Granulocyte concentrates derived from granulocytopheresis

Sources of Blood Products

  1. Banked donor blood
  2. Directed donor transfusions
  3. Autologous fetal blood transfusions

Indications, requirements, and transfusion techniques differ for each procedure and component. Simple transfusions are discussed in this chapter. Exchange transfusions are discussed in Chapter 42. Complications common to all blood products are listed later in this chapter.

  1. Precautions
  2. Whenever possible, obtain informed consent prior to transfusions, delineating risks, benefits, and alternatives to transfusion.
  3. Limit use of transfusions to justified indications.
  4. Select blood product appropriate for infant's condition.
  5. Confirm with proper identifiers at bedside that blood product is for correct patient. Maintain all records relevant to collection, preparation, transfusion, and clinical outcome.
  6. Avoid excessive transfusion volume or rate unless acute blood loss or shock dictates faster transfusion.
  7. Store blood and blood products appropriately. Freezing and lysis may occur if red blood cells (RBCs) are stored in unmonitored refrigerators.
  8. Use blood bank refrigerator for storage of RBCs, whole blood, thawed FFP, and thawed cryoprecipitate.
  9. Temperature should be controlled at 4 ± 2°C with constant temperature monitors and alarm systems.
  10. Refrigerator should be quality-controlled at least daily.
  11. Designated for blood products only
  12. Store platelets at 20 to 24°C with continuous agitation.
  13. PRBCs and whole blood should be out of refrigeration for <4 hours to minimize bacterial contamination and red blood cell hemolysis.
  14. Use approved blood warming services for PRBCs and whole blood. Syringes for aliquots must not be warmed in water baths because of the risk of contamination.
  15. Stop transfusion or slow rate if baby manifests any adverse side effects.
  16. Tachycardia, bradycardia, or arrhythmia
  17. Tachypnea
  18. Systolic blood pressure increases of >15 mm Hg, unless this is the desired effect
  19. Temperature above 38°C
  20. Hyperglycemia or hypoglycemia
  21. Cyanosis
  22. Skin rash, hives, or flushing
  23. Hematuria/hemoglobinemia
  24. Hyperkalemia
  25. Transfuse RBCs cautiously in incipient or existing cardiac failure.
  26. Monitor heart rate, blood pressure, and peripheral perfusion.
  27. Transfuse PRBCs, or
  28. Consider partial exchange transfusion:
  29. With hemoglobin level <5 to 7 g/dL
  30. With cord hemoglobin <10 g/dL
  31. Prevent fluctuations in glucose during RBC transfusion:
  32. In infants weighing <1,200 g or in other unstable infants, to prevent hypoglycemia
  33. Do not discontinue parenteral glucose administration.
  34. Establish separate intravenous line for blood administration.


  1. When transfused blood has elevated glucose concentration, expect rebound hypoglycemia in infants with hyperinsulinism.
  2. Pretransfusion Testing and Processing (12)
  3. Blood group and Rh type
  4. Maternal ABO blood group and Rh type: Screen maternal serum for atypical antibodies.
  5. Baby's ABO blood group and Rh type: Screen baby's serum for atypical antibodies if maternal blood is unavailable.
  6. Cord blood may be used for initial testing.
  7. Baby's blood group is determined from the red cells alone, because the corresponding isoagglutinins anti-A and anti-B are usually weak or absent in the serum.
  8. Cross-matching
  9. Compatible blood may be low-anti-A, anti-B titer Group O Rh-negative blood or blood of the infant's ABO group and Rh type (except in alloimmune hemolytic disease of the newborn).
  10. Conventional cross-match is not required if infant <4 months old and no atypical antibodies are detected.
  11. Compatibility testing for repeated small-volume transfusions is usually unnecessary, because formation of alloantibodies is extremely rare in the first 4 months of life.
  12. If antibody screen is indirect antiglobulin test (IAT)-positive in mother or baby:
  13. Serologic investigation to identify antibody(ies) is necessary.
  14. Full compatibility testing is required.
  15. If anti-A or anti-B detected in infant, infant should receive RBC lacking A or B antigen until antibody screen is negative.
  16. If infant has received large volumes of plasma or platelets, passive acquisition of antibodies may occur; cross-matching is recommended.
  17. If directed donor blood from a parent is used, cross-matching is required.
  18. Specially processed products
  19. Blood donated in the United States is tested for human immunodeficiency virus (HIV), human T-lymphotropic virus I/II, hepatitis B and C viruses, West Nile virus, syphilis, and bacteria (in platelet products).
  20. Cytomegalovirus (CMV)-seronegative or third-generation leukodepleted (LD) blood is recommended for infants with birthweight 1,200 g born to seronegative mothers or those with unknown serostatus (1).
  21. Use of universal LD and/or CMV seronegative products is institution-specific (3).
  22. Irradiation to prevent transfusion-associated graft-versus-host disease (TAGVHD)
  23. Whole blood, PRBCs, previously frozen RBCs, granulocyte and platelet concentrates, and fresh plasma have been implicated in TAGVHD; LD products have also been implicated.
  24. Clinical indications for irradiated blood components are (1, 2, 4, 5 and 6)
  25. Intrauterine transfusion
  26. Premature infants, variably defined by weight and postgestational age
  27. Congenital immunodeficiency suspected or confirmed
  28. Undergoing exchange transfusion for erythroblastosis
  29. Hematologic/solid organ malignancy
  30. Recipient of familial blood donation
  31. Recipient of HLA-matched product
  32. Some institutions provide irradiated blood products to all neonates to avoid TAGVHD in patients with undiagnosed immunodeficiency.
  33. Equipment
  34. Blood product (see Appendix C)
  35. Cardiorespiratory monitor
  36. Blood: All blood and blood components must be filtered immediately prior to transfusion despite prestorage LD. Many transfusion services supply PRBCs and occasionally platelets and cryoprecipitate prefiltered to the neonatal intensive care unit (NICU).
  37. Administration set with in-line filter of 120- to 170-µm pore size to be used for all products
  38. Microaggregate filter, 20- to 40- µm pore size
  39. Must follow manufacturer's instructions
  40. Some function only if product is dripped
  41. Not advisable for syringe administration
  42. Usefulness questionable and unnecessary if LD and/or additive RBC's used
  43. Prestorage LD filtration (2, 3, 6)
  44. Removes 99.9% of white blood cells (WBCs) or 3 log leukodepletion
  45. Must follow manufacturer's instructions
  46. Attenuation/abrogation of CMV and other viruses (Epstein–Barr, HTLV I/II Human Thymphocyte Virus) harbored in WBCs
  47. LD performed by collecting facility preferred to bedside use



  1. Sterile syringe
  2. Blood administration set
  3. a May be manufactured with integral 120- to 170-µm filter
  4. May not be needed if prefiltered product is dispensed from transfusion service
  5. Blood warmer not needed
  6. Automated syringe pump with appropriate tubing and needle (7, 8, 9, 10, 11 and 12)
  7. Least hemolysis occurs with straight syringe pumps
  8. Vascular access: PRBCs may be transfused through 24-, 25-, or 27-gauge needles and short catheters but not through 27- or 28-gauge central venous catheters.
  9. The amount of hemolysis that results from infusion of RBCs is directly proportionate to the age of the blood and the rate of transfusion and inversely proportional to needle size.
  10. Hyperkalemia, hemoglobinuria, and renal dysfunction may result if hemolyzed blood is transfused.
  11. Normal saline flush (1 mL or more) to clear intravenous solution from line.

Packed Red Blood Cell Transfusions

  1. Indications
  2. Guidelines and justifications for transfusions are controversial and vary among different authorities and institutions (13, 14). The transfusion guidelines followed by the U.S. Multicenter Recombinant Human Erythropoietin Trial established the safety, at least in the short term, of conservative transfusion practices for infants needing mild and moderate respiratory support (Table 41.1) (15). Transfusion guidelines continue to be liberal for infants with severe cardiorespiratory compromise (4). Limiting transfusion is now questioned as a cause of central nervous system complications and apnea (16).
  3. In general:
  4. Replace acute blood loss.
  5. Correct anemia that is compromising cardiovascular status or oxygen-carrying capacity.
  6. Contraindications
  7. None absolute
  8. Exert caution in patient with:
  9. Volume overload
  10. Congestive heart failure
  11. T-activation

TABLE 41.1 Guidelines for Transfusion of RBCs in Patients <4 Months of Age

1. Hematocrit <20% with low reticulocyte count and symptoms of anemiaa

2. Hematocrit <30% with an infant:

1. On >35% hood O2

2. On O2 by nasal cannula

3. On continuous positive airway pressure and/or intermittent mandatory ventilation with mechanical ventilation with mean airway pressure <6 cm H2O

4. With significant apnea or bradycardiab

5. With significant tachycardia or tachypneac

6. With low weight gaind

3. Hematocrit <35% with an infant:

1. On >35% hood O2

2. On continuous positive airway pressure/intermittent mandatory ventilation with mean airway pressure ≥6 cm H2O

4. Hematocrit <45% with an infant:

1. On extracorporeal membrane oxygenation

2. With congenital cyanotic heart disease

aTachycardia, tachypnea, poor feeding.
bMore than six episodes in 12 hours or two episodes in 24 hours requiring bagand-mask ventilation while receiving therapeutic doses of methylxanthines.
cHeart rate >180 beats/min for 24 hours, respiratory rate >80 breaths/min for 24 hours.
dGain of <10 g/day observed over 4 days while receiving ≥100 kcal/kg/day.
Source: Adapted from Roseff SD, Luban NL, Manno CS. Guidelines for assessing appropriateness of pediatric transfusion. Transfusion. 2002;42:1398–1413.

  1. Technique
  2. Determine total amount of blood needed.
  3. Calculate volume of blood for transfusion. Most infants are transfused 10 to 15 mL/kg of PRBCs, which will increase the hemoglobin by 3 g/dL.
  4. Calculate volume of PRBCs required:

[EBV × (Hct desired — Hct observed)] Hct of PRBC unit

where EBV is the estimated patient's blood volume, approximately 80 to 85 mL/kg in full-term infants and approximately 100 to 120 mL/kg in preterm infants, and Hct is hematocrit.

  1. Include volume of blood needed for dead space of tubing, filter, pump mechanism (varies from system to system; may be as much as 30 mL).
  2. Obtain blood product (see Appendix C).



  1. Several studies have documented the safety of using PRBCs stored in additive anticoagulant preservative solutions to outdate.
  2. Avoid use of RBCs stored in additive-containing solutions for massive transfusions, unless the additive is removed by inverted storage or centrifugation; risks of hyperosmolality, hyperglycemia, hypernatremia, hyperkalemia, hyperphosphatemia are postulated (17).
  3. In infants receiving 10 to 15 mL of PRBCs, the amount of K+delivered by the transfusion is estimated to be only 0.15 mEq/kg and does not pose a significant risk to most neonates.
  4. Donor exposures are reduced by repeatedly obtaining small aliquots of PRBCs from dedicated units until the outdate of 35 to 42 days (Figs. 41.1 and 41.2) (18, 19).

FIG. 41.1. Neonatal syringe set with filter. (Courtesy of Charter Medical Ltd., Winston-Salem, NC, USA). This system, when used with sterile connection technology, provides a closed delivery system that maintains primary unit outdate. Syringe blood aliquots (PRCBs, plasma) must be administered to the patient within 24 hours and syringe platelet aliquots within 4 hours.

  1. Verify whether cross-matched product is necessary or un–cross-matched product is adequate.
  2. Confirm that restrictions have been adhered to on blood product and transfusion tag.
  3. CMV: Tested/untested
  4. Irradiated: Yes/no
  5. Directed (familial) donation: Yes/no
  6. RBC antigen-negative: Yes/no
  7. Sickle tested-negative: Yes/no
  8. Other restrictions specified: Yes/no
  9. Verify appropriateness of blood selected for patient by comparing blood product and unit tag (integral to blood unit) information and patient identification. Bar-code reading devices are advisable.
  10. Blood unit tag and blood bag
  11. Patient hospital or medical record number
  12. Patient identification by armband or footband
  13. Blood group and type of both donor and recipient
  14. Expiration date and time and restrictions on unit and order
  15. Restrictions as ordered by physician or by institutional guidelines
  16. Warming PRBCs (2, 20, 21)
  17. There is no need to warm small-volume PRBC aliquots, particularly if the transfusion is given over 2 to 3 hours.
  18. PRBCs may be warmed by placing the syringe beside the infant in the warm-air incubator for 30 minutes prior to transfusion.
  19. Inappropriate warming by exposure of blood to heat lamps or phototherapy lights may produce hemolysis.
  20. Adhere to sterile technique throughout procedure.
  21. If prefiltered PRBCs are provided by the blood bank in a syringe, attach tubing directly to syringe.
  22. If PRBCs are provided in a bag, use large-bore needle (18-gauge or larger) to withdraw volume into syringe. Filter should be placed between bag and syringe (Fig. 41.1).
  23. Prime tubing with blood. Clear syringe and tubing of bubbles, and mount into infusion device.
  24. Verify patency of vascular access.
  25. Clear line into patient with normal saline.
  26. Record and monitor vital signs.
  27. Determine spot glucose test. Repeat hourly as needed.
  28. Begin transfusion at controlled rate: 5 mL/kg/hr.
  29. Gently invert container of blood every 15 to 30 minutes to minimize sedimentation.
  30. Stop transfusion if any adverse change in condition occurs.



  1. At end of infusion, clear blood from line with saline.
  2. Check recipient hemoglobin and hematocrit, if necessary, at least 2 hours after transfusion.
  3. If posttransfusion hematocrit/hemoglobin is not up to expected level, consider:

FIG. 41.2. Use of a sterile connecting device. A: An adult RBC unit is shown along with a set of pediatric transfer bags. The transfer bags can be attached by spiking the unit, causing it to expire in 24 hours; alternatively, the transfer bags can be connected using a sterile connection device. B, C: The separate tubings are loaded into the tubing holders of the device. The covers are closed. D: A welding wafer heated to about 500° F melts through the tubing. The tubing holders realign and the welding wafer retracts allowing the tubing ends to fuse together. E: The unit can now be aliquoted as needed. Because a functionally closed system has been maintained, the expiration date of the blood has not changed.

  1. Low hematocrit of PRBC unit
  2. Inappropriate calculation of transfusion requirement
  3. Ongoing blood loss
  4. Transfusion reaction
  5. Hemolysis due to ABO or other RBC incompatibility



  1. Infant has circulating anti-A, anti-B, and anti-AB, which is bound to A or B antigens on transfused RBCs.
  2. Direct antiglobulin test (DAT) negative initially but now positive
  3. Unexpected increase in bilirubin
  4. Infant has RBC antibody other than ABO.
  5. Hemolysis from extrinsic damage (mechanical) to RBCs or donor has hemolytic disorder.

Whole or Reconstituted Whole Blood

Reconstituted whole blood is prepared by adding a unit of RBCs to a compatible unit of FFP (1, 2).

Levels of coagulation factors V and VIII are low, platelet function is grossly abnormal, and concentration of K+ is high in stored whole blood. Transfusion of PRBCs and other blood components as required is preferable to the use of stored whole blood.

  1. Indications
  2. Massive transfusion as in acute blood loss, when restoration of blood volume and oxygen-carrying capacity are needed simultaneously.
  3. Exchange transfusions
  4. Cardiopulmonary bypass
  5. Extracorporeal membrane oxygenation
  6. Continuous hemofiltration
  7. In children <2 years of age, transfusion of fresh (<48 hours old) whole blood has been associated with significantly less postoperative blood loss following bypass surgery for complex congenital heart disease (22). Recent studies now question use of whole blood (23).

TABLE 41.2 Guidelines for Platelet Transfusions (× 109/L)


Nonbleeding, Sick, Preterm

Nonbleeding Stable, Preterm

Nonbleeding, Term

Before Invasive Procedure

Actual Bleeding

Roberts (2006) Canada






Roseff (2002) USA




<50 if failure of products

<50 if stable
<50 if sick

Gibson (2004) UK




<100 if DIC Not specified


“Sick” infants in this context defined as those with a history of perinatal asphyxia, extremely low birthweight (<1,000g), need for ventilatory support with an inspired oxygen concentration >40%, clinically unstable, signs of sepsis, or those who require numerous invasive interventions.

  1. Precautions
  2. Not suitable for simple transfusion for anemia
  3. Not suitable for correction of coagulation factor deficiencies
  4. Hyperkalemia may result from rapid transfusion of large volumes (10, 11, 24).
  5. Anticoagulant effects must be considered (17).
  6. Equipment and Technique
  7. Same as for PRBCs
  8. The rate of transfusion may be increased to 10 to 20 mL/kg/hr to replace acute blood loss.
  9. When used for complex mechanical procedure, 120- to 150-µm filters often in line to device.

Platelet Transfusions

  1. Indications (Table 41.2)

The platelet count at which transfusion is recommended has to be individualized, because hemostatic competence is determined not only by the quantity of platelets but also by platelet function, vascular integrity, levels of coagulation factors, and underlying disorder/disease.

  1. Contraindications

Because the half-life of platelets is reduced in conditions of rapid consumption and/or immune destruction, platelet transfusions often do not produce a measurable platelet increment. Their use in these conditions is reserved for life-threatening situations in which other therapy is ineffective. In infants previously exposed to heparin, who develop thrombocytopenia, and platelet refractoriness, consider heparin-induced thrombocytopenia as cause (25). Poor


posttransfusion increment in infants with neonatal alloimmune thrombocytopenia (NAIT) can define diagnosis (26).

  1. Equipment and Technique
  2. Platelets
  3. Random donor platelet concentrate (5.5 3 × 1010platelets in 40 to 70 mL of plasma)
  4. Separated from whole blood by centrifugation within 8 hours of blood draw
  5. Resuspended in plasma
  6. Shelf life of 5 days
  7. Volume-reduced platelets
  8. Standard platelet concentrate concentrated to a volume of 15 to 20 mL by centrifugation (27)
  9. Associated with loss of platelets and possible decrease in platelet function
  10. Shelf life reduced to 4 hours
  11. Use only if infant has oliguria, severe volume load sensitivity
  12. Plateletpheresis (3 × 1011platelets in volume of 250 mL plasma)
  13. Removes only platelets, returns RBCs and plasma to donor
  14. Usually leukodepleted before storage
  15. Permits repeated donations from same donor every 48 hours under select circumstances
  16. High yield of platelets
  17. More expensive product
  18. Useful when multiple platelet transfusions of a particular antigen specificity are required, as in neonatal albimmune thrombocytopenia (NAIT) or for infants on extracorporeal membrane oxygenation (ECMO) needing multiple platelet transfusions.
  19. May be HLA-typed or typed for PLA1 or other specific platelet antigen in case of NAIT.
  20. Maternal plateletpheresis product is preferred for NAIT. Use maternal antigen-negative platelets, washed, irradiated, and resuspended in group-compatible ABO plasma or saline.
  21. Calculate volume of platelets to transfuse based on type of product.
  22. 10-15 mL/kg of random platelet provides 10 × 109platelets/kg and should increase platelet count to >50 × 109/L in the absence of ongoing consumption.
  23. Can use same calculations for apheresis platelets, but studies do not confirm posttransfusion increments. Advise use of equivalent unit calculations and not mL/kg.
  24. Other products (HLA-typed, cross-matched platelets) used for platelet (PLT) refractoriness; washed PLTs if using PLT antigen-matched maternal PLTs.
  25. Blood administration set with 120- to 170-µm in-line filter, unless platelets have been prefiltered while drawing into a syringe. Specific sets designed for plasma/ platelets have in-line filters with reduced surface area to increase platelet transfusion efficacy.
  26. Sterile syringe for automated pump infusion. Use of syringe technique will increase damage to platelets. Administer by drip if clinically feasible.
  27. Automated syringe pump
  28. Connecting intravenous tubing
  29. Intravenous access, preferably through 23-gauge or larger needle or through umbilical venous catheter
  30. Normal saline flush solution
  31. Precautions
  32. Use type-specific (Rh-negative) platelets when potential for sensitization is present (i.e., in Rh-negative female). Although platelets do not have Rh antigens, all products have some red blood cell contamination (less in plateletpheresis), which may cause Rh sensitization (28).
  33. Use platelets from donor with ABO-compatible plasma (Table 41.3). Isohemagglutinins in ABO-incompatible plasma may result in hemolysis, a positive DAT, and poorer in vivo platelet survival than anticipated.
  34. Transfuse platelets as soon after preparation as possible. Platelets should never be refrigerator-stored or warmed.
  35. Platelets should not be infused through arterial lines.
  36. Technique for Platelet Administration by Automated Syringe
  37. Estimate by weight the volume of platelets in a single bag to determine fluid load to infant.
  38. Confirm correct platelet product.
  39. Infant and unit identification

TABLE 41.3 Choice of Platelets











  1. P.324
  2. Infant and donor blood group, and Rh type
  3. Check other restrictions: CMV negative, irradiated, etc.
  4. Attach, aseptically, in sequence:
  5. Platelet concentrate or bag aliquot
  6. Platelet administration set, including filter
  7. Three-way stopcock
  8. Transfusion syringe
  9. Draw into syringe volume of platelets for transfusion and tubing dead space. Clear air bubbles.
  10. Remove syringe from three-way stopcock and attach to connecting tubing.
  11. Establish IV access. If infant is at risk for hypoglycemia with interruption of continuous glucose source, start new IV or monitor closely throughout infusion.
  12. Clear IV of glucose solution with 1 mL or more of normal saline.
  13. Attach connecting tubing and syringe to IV line.
  14. Monitor patient's vital signs.
  15. Infuse platelets over 1- to 2-hour period, faster if tolerated by infant.
  16. After infusion is complete, flush IV line with 1 mL of normal saline before restarting glucose solution.
  17. Determine survival time of transfused platelets by obtaining platelet counts at 1, 2, or 24 hours.
  18. Complications

See list of complications for all blood products (1, 2, 29).

  1. Accentuated hemolysis in sensitized but IAT-negative ABO setup
  2. Rh sensitization in Rh-negative recipient (28)
  3. Volume overload
  4. Allergic reactions, including hypotension
  5. Transfusion-related lung injury (TRALI) (30, 31)
  6. Increased morbidity in necrotizing enterocolitis (NEC) (32)

Granulocyte Transfusions

  1. Indications
  2. Granulocyte transfusions are used infrequently, displaced by improved cidal antibiotics, supportive care, and, in rare circumstances, use of granulocyte- and granulocyte/macrophage-stimulating factors (33).
  3. Historical indications not confirmedin randomized trials to be relevant:
  4. Neonates <14 days old, with bacterial sepsis and neutropenia (neutrophil plus band count <3 × 109/L)
  5. Older neonates with bacterial sepsis, unresponsive to antibiotics with neutrophil and band counts <0.5 × 109/L
  6. Equipment and Technique
  7. Granulocyte concentrates for neonatal use should be prepared by automated granulocytapheresis and contain 1 to 2 × 109neutrophils in 10- to 15-mL/kg volume. Steroid- or G-CSF-mobilized donor preferred.
  8. Daily transfusions may be necessary until there is clinical improvement and evidence of recovery of neutrophil counts.
  9. Component must be ABO- and Rh-compatible with recipient, and cross-match-compatible.
  10. Product should be irradiated, CMV-negative, and infused as soon as possible after collection.
  11. The product should not be refrigerated or warmed above room temperature.
  12. Standard 120- to 170-µm filters should be used for infusion; microaggregate and leukodepletion filters must be avoided.
  13. Precautions

Storage of product for >8 hours is associated with a rapid decrease in WBC function, making this a less than useful product. Fever, alloimmunization, TRALI, and CMV have all been reported complications.

Fresh Frozen Plasma, Frozen Thawed Plasma, and Cryoprecipitate

  1. Indications (234)

Clinically significant bleeding or for correction of hemostatic defects prior to invasive procedures in the presence of

  1. Complex factor deficiency unresponsive to Vitamin K
  2. Isolated congenital factor deficiency for which virus-inactivated-plasma-derived or recombinant factor concentrates are unavailable
  3. Congenital or acquired dys- or hypofibrinogenemia (cryoprecipitate is preferred)



  1. Contraindications
  2. None absolute
  3. Exert caution when possibility of volume overload exists.
  4. Necrotizing enterocolitis (NEC): Use with caution. May aggravate hemolysis in infant with NEC and T-activation (35, 36).
  5. Not indicated for hypovolemic shock in the absence of bleeding, nutritional support, treatment of immunodeficiency, or prevention of intraventricular hemorrhage.
  6. Equipment and Technique

See Platelet Transfusion.

  1. Cross matching is not required because type-specific or AB-negative product is usually issued.
  2. Dose of FFP is 10 to 20 mL/kg; multiple transfusions may be required until the underlying condition resolves.
  3. Once thawed, FFP should be transfused within 6 hours for labile factor replacement.
  4. In cases for which repeated FFP transfusions are required, a thawed unit from a single donor may be divided into smaller aliquots and used within 24 hours if stored between 1 and 6°C.

Directed Donor Transfusions

  1. Potential Problems

Directed donations provide no known benefit in terms of increased safety and may have several disadvantages (37):

  1. Possible increased risk of transmitting infectious disease because directed donors are often first-time or infrequent donors with no track record of safety, unlike established volunteer donors, whose screening tests are negative repeatedly.
  2. Possibility of serologic incompatibility between the recipient baby and the family donors.
  3. Plasma of biologic mothers may contain alloantibodies to blood cell antigens inherited by the infant from the father, which may lead to hemolysis, thrombocytopenia, and WBC aggregation in the infant, when transfused without the protective barrier of the placenta.
  4. Paternal blood cells may express antigens to which the neonate may have been passively immunized by transplacental transfer of maternal antibodies.
  5. Routine pretransfusion testing may not detect these serologic incompatibilities, which may result in hemolytic or other transfusion reactions.
  6. Although biologic parents may be interested in donating for their infants, many are likely to be ineligible for medical or serologic reasons.
  7. Precautions
  8. Directed donations must be screened as stringently as volunteer donations.
  9. Biologic mothers should not provide blood components containing plasma; maternal red cells and platelets should be given as washed concentrates.
  10. Fathers and paternal blood relatives should preferably not serve as donors for blood components containing cellular elements; a full antiglobulin cross-match should be performed to detect red cell incompatibilities if their use is unavoidable.
  11. All blood components obtained from first- or second-degree relatives should be irradiated prior to transfusion.

Autologous Fetal Blood Transfusions (38,39,40,41)

  1. Indications
  2. Delivery room resuscitation of infants with shock and profound anemia, when O Rh-negative bank blood is not readily available.
  3. Source of autologous PRBCs for elective transfusion to preterm infants.
  4. Source of cord blood for freezing for hematopoietic reconstitution.

Protocols for proper collection with appropriate anticoagulation, without bacterial contamination, are still being refined for these indications.

  1. Contraindications
  2. Maternal infection
  3. Chorioamnionitis
  4. Sepsis
  5. Hepatitis, HIV
  6. Prolonged rupture of membranes >24 hours



  1. Complications
  2. Bacterial sepsis from contaminated collection
  3. Insufficient volume collected for transfusion
  4. Over/undercollection for volume of anticoagulant used

Complications of Blood Transfusions

Transfusions are safer now than ever before, but they are not risk-free (4, 5).

  1. Transmission of infectious diseases (42, 43)
  2. Viruses: Risk varies geographically
  3. Human immunodeficiency virus: Estimated potential risk in United States from a blood donor with negative serologic tests is <1 in 2,135,800.
  4. Human T-lymphotropic virus I and II: Risk 1 in 641,000
  5. Hepatitis B virus: Risk 1 in 1,205,000
  6. Hepatitis C virus: Risk 1 in 1,935,000
  7. Hepatitis A virus: Risk 1 in 1,000,000, asymptomatic in newborn, but may cause symptomatic infection in adults who are in contact with infected neonates.
  8. Cytomegalovirus: Transmitted by cellular blood products, not transmitted by FFP or cryoprecipitate; risk of transfusion transmitted CMV from cellular blood components from CMV-seropositive donors 8% to 25%, risk of CMV infection after transfusion of CMV-seronegative or effectively leukoreduced components is <1% to 4%.
  9. Hepatitis G, parvovirus B-19, Epstein–Barr virus
  10. Bacteria (44)
  11. Persistent problem, often unrecognized
  12. Platelet concentrates and PRBCs most often implicated
  13. Organisms: Yersinia enterocolitica, Serratia, and Pseudomonasgenus for RBCs; Staphylococcus epidermidis, Bacillusspecies for platelets.
  14. Treponema pallidum: Does not survive refrigeration; syphilis reported after transfusion of fresh blood.
  15. Red cell units with gross bacterial contamination may occasionally be identified by the darker color of the blood in the bag compared with the color of blood in the tubing.
  16. Protozoan
  17. Malaria: Rare in the United States but reported even in nonendemic areas (45)
  18. Babesiosis
  19. Chagas disease
  20. Creutzfeldt–Jacob
  21. Few proven cases of transfusion-transmitted new-variant Creutzfeldt–Jacob disease at present (46)
  22. Most blood collection centers attempt to minimize the risk by excluding donors considered to be at higher risk for possibly harboring the infection, by family and travel history and specific medical history (2).
  23. Hemolytic reactions
  24. Acute hemolytic immunologic reactions:Rare, because of absence in infant of naturally occurring anti-A or anti-B antibodies, and infrequent posttransfusion red cell alloimmunization despite multiple transfusions.
  25. T-activation:A severe form of immune-mediated hemolysis is associated with the transfusion of adult blood containing anti-T antibodies in neonates with activation of the normally cryptic T-antigen on the surface of neonatal red cell membranes (35, 36).
  26. Common in premature infants and associated with necrotizing enterocolitis and sepsis
  27. Suspect T-activation in neonates at risk with intravascular hemolysis, hemoglobinuria, hemoglobinemia following transfusion of blood products, or unexpected failure to achieve posttransfusion hemoglobin increment.
  28. Routine cross-matching will not detect T-activation when monoclonal antiserum is used.
  29. Diagnosis: By minor cross-matching, discrepancies in forward and reverse blood grouping, confirmed by specific agglutination tests using peanut lectins.
  30. Use washed red cells, platelets, and low-titer anti-T plasma only when hemolysis is confirmed (35).
  31. Nonimmunologic causes of hemolysis
  32. Mechanical, through excessive infusion pressure through small needles or 20- to 40-µm filters
  33. Accidental overheating or freezing of blood
  34. Simultaneous administration of incompatible drugs and fluids
  35. Transfusion of abnormal donor cells (glucose 6-phosphate dehydrogenase deficiency, hereditary spherocytosis)



  1. Other immunologic reactions

 .   Transfusion-associated graft-versus-host disease

See processing with irradiation for risk factors and prevention.

  1. Transfusion-related acute lung injury
  2. Secondary to transfusion of donor blood containing antigranulocyte and anti-HLA antibodies, leukoagglutinins directed against recipient granulocyte antigens, or to transfusion of plasma cytokines/mediators that affect recipient granulocytes, causing pulmonary endothelial adhesion defects
  3. Initiates life-threatening hypoxemia secondary to complement activation and microvascular lung injury
  4. Rarely reported in neonates; may be difficult to distinguish from other causes of respiratory deterioration in sick infants.
  5. Circulatory overload

Alterations in pulmonary compliance and blood pressure

  1. Adverse metabolic effects

 .   Hyperkalemia

  1. Blood that is irradiated and then refrigerator-stored may have K+levels of 30 to 50 mEq/L or higher in the supernatant plasma.
  2. Small-volume transfusions of stored red cells do not cause clinically significant elevations in serum K+levels.
  3. Life-threatening hyperkalemia has been described in sick infants and in those receiving rapid infusions of large volumes of stored red cells.
  4. Washed or fresh (<14 days) red cells are recommended for infants with profound hyperkalemia, renal failure, or when large volumes are transfused rapidly.
  5. Hypoglycemia or hyperglycemia
  6. Hypocalcemia
  7. Alterations in acid–base balance with large transfusions


  1. American Association of Blood Banks.Standards for Blood Banks and Transfusion Services. 23rd ed. Bethesda, MD: AABB; 2004.
  2. American Association of Blood Banks.Technical Manual. 14th ed. Bethesda, MD: AABB; 2003.
  3. Ferguson D, Hebert PC, Lee SK, et al. Clinical outcomes following institution of universal leukoreduction of blood transfusions of premature infants. JAMA. 2003;289:1950–1956.
  4. Luban NL.Neonatal red blood cell transfusions. Vox Sang. 2004;87(suppl 2):184–188.
  5. Ramasethu J, Luban NL.Red cell transfusions in the newborn. Semin Neonatol. 1999;4:5–16.
  6. Strauss RG.Data driven blood banking practices for neonatal RBC transfusions. Transfusion. 2000;40:1528–1540.
  7. Frey B, Eber S, Weiss M.Changes in red blood cell integrity related to infusion pumps: a comparison of three different pump mechanisms. Pediatr Crit Care Med. 2003;4:465–470.
  8. Nakamura KT, Sato Y, Erenberg A.Evaluation of a percutaneously placed 27-gauge central venous catheter in neonates weighing <1200 grams. J Parenter Enteral Nutr. 1990;14: 295–299.
  9. Oloya RO, Feick HJ, Bozynski ME.Impact of venous catheters on packed red cells. Am J Perinatol. 1991;8:280–283.
  10. Parshuram CS, Joffe AR.Prospective study of potassium-associated acute transfusion events in pediatric intensive care. Pediatr Crit Care Med. 2003;4:65–68.
  11. Wilcox GJ, Barnes A, Modanlou H.Does transfusion using a syringe infusion pump and small gauge needle cause hemolysis.Transfusion. 1981;21:750–751.
  12. Wong EC, Schreiber S, Criss VR, et al. Feasibility of red blood cell transfusion through small bore central venous catheters used in neonates. Pediatr Crit Care Med. 2004;5:69–74.
  13. Gibson BE, Todd A, Roberts I, et al. Transfusion guidelines for neonates and older children. Br J Haematol. 2004;127:233–234.
  14. Roseff SD, Luban NL, Manno CS. Guidelines for assessing appropriateness of pediatric transfusion. Transfusion. 2002;42: 1398–1413.
  15. Shannon KM, Keith JF, Mentzer WC, et al. Recombinant human erythropoietin stimulates erythropoiesis and reduces erythrocyte transfusions in very low birth weight preterm infants. Pediatrics. 1995;95:1–8.
  16. Bell EF, Strauss RG, Widness JA, et al. Randomized trial of liberal vs. restrictive guidelines for red blood cell transfusion in preterm infants. Pediatrics. 2005;115:1685–1691.
  17. Luban NL, Strauss RG, Hume HA.Commentary on the safety of red cells preserved in extended-storage media for neonatal transfusion. Transfusion. 1991;31:229–235.
  18. Strauss RG, Burmeister LF, Johnson K, et al. Feasibility and safety of AS-3 red blood cells for neonatal transfusions. J Pediatr. 2000;136:215–219.
  19. Strauss RG.Controversies in the management of the anemia of prematurity using single-donor red blood cell transfusions and/or recombinant human erythropoietin. Transfus Med Rev. 2006;20:34–44.
  20. Luban NL, Mikesell G, Sacher RA.Techniques for warming red blood cells packaged in different containers for neonatal use. Clin Pediatr (Phila). 1985;24:642–644.
  21. Strauss RG, Bell EF, Snyder EL, et al. Effects of environmental warming on blood components dispensed in syringes for neonatal transfusions. J Pediatr. 1986;109:109–113.
  22. Manno CS, Hedberg KW, Kim HC.Comparison of the hemostatic effects of fresh whole blood, stored whole blood, and components after open heart surgery in children. Blood. 1991;77: 930–936.
  23. Mou SS, Giroir BP, Molitor-Kirsch EA, et al. Fresh whole blood versus reconstituted blood for pump priming in heart surgery in infants. N Engl J Med. 2004;351:1635–1644.
  24. Brown KA, Bissonnette B, McIntyre B.Hyperkalaemia during rapid blood transfusion and hypovolaemic cardiac arrest in children.Can J Anaesth. 1990;37:747–754.
  25. Martchenke J, Boshkov L.Heparin-induced thrombocytopenia in neonates. Neonatal Network. 2005;24:33–37.
  26. Roberts IA, Murray NA.Neonatal thrombocytopenia. Curr Hematol Rep. 2006;5:55–63.



  1. Moroff G, Friedman A, Robkin-Kline L, et al. Reduction of the volume of stored platelet concentrates for use in neonatal patients.Transfusion. 1984;2:144–146.
  2. Haspel RL, Walsh L, Sloan SR.Platelet transfusion in an infant leading to formation of anti-D: implications for immunoprophylaxis.Transfusion. 2004;44:747–749.
  3. Holman P, Blajchman MA, Heddle N.Noninfectious adverse effects of blood transfusion in the neonate. Trans Med Rev. 1995;9:277–287.
  4. Sanchez R, Toy P.Transfusion related acute lung injury: a pediatric perspective. Pediatr Blood Cancer. 2005;45: 248–255.
  5. Wu T-J, Teng R-J, Yau K-IT.Transfusion-related acute lung injury treated with surfactant in a neonate. Eur J Pediatr. 1996;155:589–591.
  6. Kenton AB, Hegemier S, Smith EO, et al. Platelet transfusions in infants with necrotizing enterocolitis do not lower mortality but may increase morbidity. J Perinatol. 2005;25:173–177.
  7. Engelfriet CP, Reesink HW, Klein HG, et al. International forum: granulocyte transfusions. Vox Sang. 2000;79:59–66.
  8. Chalmers EA, Gibson BES.Clinical aspects of paediatric and perinatal transfusion: plasma products. Vox Sang. 1994;67: 54–58.
  9. Boralessa H, Modi N, Cockburn H.RBC T activation and hemolysis in a neonatal intensive care population: implications for transfusion practice. Transfusion. 2002;42:1428–1434.
  10. Ramasethu J, Luban NL.T activation. Br J Haematol. 2001;112:259–263.
  11. Strauss RG, Burmeister LF, Johnson K, et al. Randomized trial assessing feasibility and safety of biologic parents as RBC donors for their preterm infants. Transfusion. 2000;40: 450–456.
  12. Brune T, Garritsen H, Witteler R, et al. Autologous placental blood transfusion for the therapy of anemic neonates. Biol Neonate. 2002;81:236–243.
  13. Eichler H, Schaible T, Richter E, et al. Cord blood as a source of autologous RBCs for transfusion to preterm infants. Transfusion. 2000;40:1111–1117.
  14. Garritsen HS, Brune T, Louwen F.Autologous red cells derived from cord blood: collection, preparation, storage and quality controls with optimal additive storage medium (Sag-mannitol). Transfus Med. 2003;13:303–310.
  15. Imura K, Kawahara H, Kitayama Y, et al. Usefulness of cord-blood harvesting for autologous transfusion in surgical newborns with antenatal diagnosis of congenital anomalies. J Pediatr Surg. 2001;36:851–854.
  16. Dodd RY, Notari EP 4th, Stramer SL.Current prevalence and incidence of infectious disease markers and estimated window-period risk in the American Red Cross blood donor population. Transfusion. 2002;42:975–979.
  17. Stramer SL, Glynn SA, Kleinman SH, et al. Detection of HIV-1 and HCV infections among antibody-negative blood donors by nucleic acid-amplification testing. N Engl J Med. 2004;351: 760–768.
  18. Fang CT, Chambers LA, Kennedy J.Detection of bacterial contamination in apheresis platelet products: American Red Cross experience, 2004. Transfusion. 2005;45:1845–1852.
  19. Mungai M, Tegtmeier G, Chamberland M, et al. Transfusion transmitted malaria in the United States from 1963 through 1999. N Engl J Med. 2001;344:1973–1978.
  20. Ludlam CA, Turner ML.Managing the risk of transmission of variant Creutzfeldt Jakob disease by blood products. Br J Haematol. 2006;132:13–24.