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SUPPORTIVE CARE OF CHILDREN WITH CANCER: GENERAL RECOMMENDATIONS FOR BLOOD COMPONENT TRANSFUSION






A. General risks of transfusion

1. Blood component transfusions are costly in terms of both of the following.

a.     Costs related to the procurement/production of components

b.     Potential complications for patients receiving blood

component transfusions

i.     Acute intravascular hemolysis, extravascular

hemolysis, anaphylaxis, transfusion-related acute

lung injury, and graft-versus-host disease are potentially life-threatening noninfectious complications

of transfusion.

ii.     Other noninfectious complications resulting in morbidity include fluid overload, sodium overload, iron

overload, febrile reactions, allergic reactions, and

delayed hemolytic reactions.

iii.     With continuing improvements in screening, the

incidence of transfusion-acquired infections is

decreasing rapidly. However, as long as the blood

components are derived from human blood donations, the risk of acquiring blood-borne pathogens

will persist.

2. These risks must be balanced by consideration of the expected benefits each time a transfusion with blood-derived components is contemplated. For these reasons, obtain informed consent from patients/parents before nonemergency transfusions.

B.     Prevention of transfusion-acquired cytomegalovirus (CMV)

Transfusion-acquired CMV can produce significant morbidity and mortality in immunosuppressed patients.

Transfusion-acquired CMV may be prevented by

Providing CMV-seronegative blood products for CMV-negative patients, or

If CMV-seronegative blood products are not available, filtering blood components (red cell concentrates and platelet concentrates) with leukocyte-depleting filters capable of >3 log removal of white blood cells.

C.     Prevention of graft-versus-host reaction

1.     The incidence of transfusion-acquired graft-versus-host

disease can be decreased by

a.     Avoiding directed blood donations by close relatives

(except when indicated for aggressive bone marrow

rescue procedures), and

b.     Irradiating all blood transfusion components with the

potential to contain leukocytes (red cell concentrates,

white cell concentrates, and platelet concentrates; the

recommendation for irradiation of plasma has not

been clearly substantiated). The generally recommended dose for irradiation of blood products is

1500-2500 cGy to the midplane with at least 1500 cGy

in the field.

2.     In addition, the use of a leukocyte-depleting filter where

applicable will contribute to decreasing the risk of graft-

versus-host disease.

D.     Reduction of leukocyte sensitization

The use of leukocyte-depleted blood components can decrease the incidence of alloimmunization and platelet transfusion refractoriness.

E.     Reduction of immunomodulation effects of transfusion

The immunomodulating effects of transfusion appear to be related to the presence of lymphocytes in blood components. Removal of the transfused lymphocytes can decrease the immunosuppression secondary to transfusion. An additional postulated complication of the immunomodulation of transfusions is a decrease in the effectiveness of the individual's own natural immune mechanisms of cancer control.

Reduction in and treatment of febrile transfusion reactions

Febrile transfusion reactions are associated with the presence of leukocytes in the transfused products as well as tumor necrosis factor, interleukin-1, -6, and -8, and other cytokines released by the leukocytes.

Cytokines released into the plasma of blood components from the granulocytes increase with storage time.

Prestorage filtration of cellular blood components appears to be the most effective method to decrease these reactions.

Rule out serious red cell transfusion reaction in patients with febrile transfusion reactions.

Treat febrile transfusion reactions in patients who are otherwise not at risk for sepsis with antipyretics and meperidine (0.5-1.0 mg/kg) for rigors. Some febrile transfusion reactions can be prevented with premedication with antipyretics and Benadryl.

Take cultures from patients who have febrile reactions at the time of transfusion and are at risk for sepsis and treat patients with antibiotics if appropriate.

Storage of platelets at room temperature increases the risk of sepsis as a complication of platelet transfusion.

Precautions to ensure that the correct product is given to the correct patient

It is essential that the blood sample taken for type and screen and cross-match is clearly labeled and checked with the patient's identification. Before administering the blood product, check the physician order, patient identification, and blood product type and numbers. Clerical error and misidentification are major risks of transfusion. When error is suspected

Stop transfusion.

Inspect anticoagulated and centrifuged blood specimen from the patient for reddish discoloration of the plasma.

Inspect urine for dark discoloration of hemoglobinuria.

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