Audit of Pediatric Transfusion Practices in a Tertiary Care Hospital: Expert's Opinion.

Abstract

To the Editor: Bahadur et al. reported a retrospective audit of pediatric transfusion practices over a period of 3 mo at Lady HardingeMedical College, NewDelhi in the April, 2015 issue of this journal [1]. The authors observed an appropriate usage of blood components in 59.65 % requests, of 2,145 units issued. Appropriate requests were considered as those which conformed to the guidelines of transfusion practices. They have considered the utility of whole blood for neonatal exchange transfusion (ET) as ‘appropriate’ and observed that whole blood was appropriately (100 %) utilized for ET. In a correspondence, Aydin et al. from Turkey, have deliberated the subject of reconstituted packed red blood cells (PRBCs) vs. whole blood for neonatal ET [2]. They have commented that whole blood is generally an inappropriate choice for transfusions, particularly in pediatrics-neonatology. The argument favoring PRBCs reconstituted with plasma for ET is to minimize the anti-A and anti-B titers, in the appropriate setting. In ABO hemolytic disease, when ET is planned with O Rh-negative blood, O Rh-negative PRBCs suspended in AB plasma is ideal to minimize the anti-A and anti-B titers [3, 4]. For non-group O neonates, RBC units for ET (group O) are best resuspended in AB plasma or plasma of the baby’s blood group due to concerns over possible risks of hemolysis from the residual group O plasma [5]. Whole blood is rarely used for ET in the western world [5]. Whole blood is not readily available in most areas of the United States [6]. However, several centers prefer to reconstitute PRBCs for ET with plasma from the same donation where possible [5]; this practice, intended to reduce donor exposure, effectively renders the unit as a ‘whole blood’ from a single donor. As stated in British Transfusion Guidelines-2004, while there is no consensus, plasma-reduced red cells with a hematocrit of 0.50–0.60 should be suitable for ET [7]. Whole blood, with a hematocrit of 0.35–0.45 may result in a postexchange Hb of <12 g/dl in a severely anemic baby and thus increase subsequent donor exposure [7]. Surprisingly, there is a dearth of clinical evidence favoring the use of reconstituted PRBCs over whole blood for ET. In a study of 381 neonates by Yigit et al. fromTurkey, the reexchange rate was higher in the whole blood group, compared with the reconstituted PRBC for ABO hemolytic disease [3]. However, the study was retrospective. In addition, the two groups were significantly varied in gestational age, birth weight, as well as pre-ET bilirubin [3]. In contrast to the developed countries, whole blood is still available in majority of blood banks in India. Whole blood continues to be used for ET at several centers in India, plausibly for reasons of easy availability of whole blood and an unquestioned continuation of ‘conventional’ practice. With increasing availability of blood components and trained personnel in transfusion medicine and neonatology, this practice is likely to change with time. The note of caution is that the reconstitution of PRBCs should be conducted in the blood bank and ideally performed with a closed system [4]. This may not be available round the clock at all centers. A reconstitution performed at bedside with a three-way stop cock may result in a greater risk for error in appropriate dilution. The use of reconstituted PRBCs has gained favor over whole blood for ET for the above stated reasons. The clinical * Deepak Bansal deepakbansaldr@gmail.com