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a. Low hematocrit of RBC unit (extended-storage AP

vs. CPDA-1 units)

b. Inappropriate calculation of transfusion requirement

c. Ongoing blood loss

d. Transfusion reaction

Fig. 43.1. Neonatal syringe set with filter. (Courtesy of Charter

Medical Ltd., Winston-Salem, North Carolina). 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.

Chapter 43 ■ Transfusion of Blood and Blood Products 307

e. Hemolysis due to ABO or other RBC incompatibility

(1) Infant has circulating anti-A, anti-B, and antiAB, which is bound to A or B antigens on transfused RBCs.

(2) Direct antiglobulin test 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.

(6) Hemolysis from T-activation

E

C

A B

D

Fig. 43.2. 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.

308 Section VIII ■ Transfusions

Whole or Reconstituted Whole Blood

Transfusions

A whole blood (WB) unit contains approximately 450 to

500 mL of blood and 70 mL of AP solution. WB stored longer than 48 hours has decreasing levels of coagulation factors

V and VIII, does not contain functional platelets or granulocytes, and concentration of K+

 is high. Reconstituted WB is

prepared by adding a unit of RBCs to a compatible unit of

FFP and is preferable to the use of stored WB (29,30).

A. Indications

1. Massive transfusion as in acute blood loss, in excess of

25% of total blood volume (TBV) when restoration of

blood volume and oxygen-carrying capacity are needed

simultaneously.

2. Exchange transfusions

3. Cardiopulmonary bypass (CPB)

4. Extracorporeal membrane oxygenation

5. Continuous hemofiltration

6. There currently exists no consensus within the United

States on the use of fresh WB, reconstituted WB, or

reconstituted fresh WB (RFWB) for CPB pump priming or postoperative transfusion support in neonates

with congenital heart disease.

a. Recent studies have questioned the use of WB (31)

and have suggested an advantage in clinical outcomes in infants with congenital heart disease

receiving RFWB during CPB surgery (32).

b. Additional prospective studies are warranted to

determine optimal age of reconstituted WB units for

neonates undergoing CPB surgery.

c. Fresh WB (<48 hours old) is not universally available.

B. Precautions

1. Not suitable for simple transfusion for anemia

2. Not suitable for correction of coagulation factor deficiencies

3. Hyperkalemia may result from rapid transfusion of

large volumes (24).

4. Anticoagulant (citrate) effects must be considered for

large volume transfusion (21,24).

C. Equipment and Technique

1. Same as for RBCs