Blood transfusion (pRBCs)

( Version 1.0  09/12/01 - 09/01/02)

PRBCs are usually administered in 10-15 ml/kg aliquots over 1-4 hours. Two hours is standard; 4 hours may be needed if the baby has symptoms of volume overload or congestive heart failure. Blood may need to be administered faster for acute blood loss and hypovolemia.

Infant receive O- blood unless direct donor blood is provided. All pRBCs given in the NICU are leukofiltered and irradiated. (Leukofiltration diminishes the risk of CMV transmission and obviates the need for CMV-seronegative blood.)

Parents should be notified before their infant receives a blood transfusion. A Type & Screen and newborn state screen should be performed before blood is administered.

Administration

Universal precautions must be observed when administering blood products. The bedside nurse should verify the amount and type of the blood product prior to infusion and carefully cross-check the infant’s identification band. PRBCs should arrive from the blood bank filtered. Blood should be room temperature and administered preferably via PIV over 1- 4 hours. (Maximum rate of infusion 10 ml/kg/hr.)

PICC lines and UACs should not be used for blood transfusions due to the risks of line thrombosis and the consequences of embolism.

Infants up to 4 months old do not need to be assessed frequently for transfusion reactions. However, if parenteral glucose administration is interrupted during blood transfusion, check blood glucose q hour during transfusion. Temporarily discontinue transfusion to deliver glucose if the blood sugar falls below 40. The iv site must also be checked q 15 minutes for redness, edema, or discoloration.

At completion of transfusion, the line should be flushed with normal saline. The blood glucose should be checked for rebound hypoglycemia 30 minutes to 1 hour after transfusion. A follow-up hematocrit should be obtained 4-6 hours after transfusion or by physician order.

The bedside nurse should document the volume infused and the infant’s vital signs on the flow sheet. A procedure note should also be included in the progress notes with the start and stop time of transfusion and the patient’s response to the procedure.

Potential indications for pRBC transfusion:

  • Shock/acute blood loss (estimated 10% blood volume)

    In a critically ill infant,

  • Phlebotomy losses >7% of blood volume within one week
  • Severe hypoxemia (>40% O2 and mechanical ventilation) and hematocrit < 40%
  • Lower supplemental O2 or ventilatory requirements and Hct < 35%
  • Cyanotic congenital heart disease and Hct < 40%
  • ECMO and Hct < 45%

    In a more stable infant with a Hct < 30%, and

  • Low supplemental O2 requirement or CPAP
  • Significant increase in frequency or severity of apnea and/or bradycardia in a previously stable, uninfected neonate on therapeutic methylxanthines
  • Persistent (>24 hours) tachycardia (>180 bpm), tachypnea (RR >80), or increase in FiO2 requirement, in the absence of any other explanation
  • Weight gain < 10g/kg/d over 4 days despite > 100kcal/kg/d intake
  • Pre-operative

Any infant with Hct < 20%.

Prior to elective transfusion of a chronic NICU patient, one should check a reticulocyte count and carefully weigh the risks and benefits of transfusion. Document in the chart the signs and symptoms of anemia necessitating blood transfusion. Consider a dose of iv furosemide after transfusion in a fluid-sensitive patient with CLD.

These guidelines are also available in the 2001 NICU Manual pgs. 8-5 to 8-7, the NICU Nursing Guidelines 40:08.30, and in the Neonatal Nurse Practitioners Protocols NNP-16

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