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A walking donor program for an intensive care nursery
FETAL AND NEONATAL M E D I C I N E RichardE. Behrman, Editor
A walking donor program for an intensive care nursery Repeated transfusions of small increments of blood are frequently requiredfor the sick newborn infant to correct endogenous hypovolemia and~or to replace blood obtained repeatedly for monitoring purposes. Current practices of blood banks are rarely geared to supply the small amounts of blood used for these individual transfusions. To provide a more efficient system, a walking donor program was established in which an appropriate hospital-based individual is cross matched as a donorfor an infant for the duration of the infant's hospital stay. The program eliminates wastage of blood and donors and reduces the number of infectious agents to which the infant may be exposed.
Williard J. Blankenship, M.D.,* Boyd W. Goetzman, M.D., Ph.D., Sara Gross, M.T., and Paul G. Hattersley, M.D., Sacramento, Calif.
THE SICK NEWBORN INFANT, and especially the
small premature infant, may require frequent blood sampling for determination of blood gases, electrolytes, bilirubin, and other laboratory tests. Although modern techniques supply much information from small samples of blood, compromise of circulating blood volume may occur if repeated sampling is required. In addition, hypovolernia can occur in infants born to mothers with hemorrhagic complications of parturition (placenta previa, abruptio placenta, or cord and placental accidents), as a result of maternal-fetal transfusion, fetalfetal transfusion in multiple births and in infants who experience intrapartum asphyxia, particularly premature infants with hyaline membrane disease. 1-3 Ideally, transfusions for these infants should meet the following requirements: (1) If at all possible, all transfusions for an infant should come from the same donor, thus decreasing exposure to hepatitis and other infectious diseases, as well as decreasing the number of compatibility tests required. (2) The donor must meet the standards of the American Association of Blood
Banks, 4 which include appropriate health history, negative serologic tests for syphilis, negative test for hepatitis-associated antigen and acceptable hemoglobin or hematocrit values. (3) Appropriate compatibility testing. Donor erythrocytes should be cross matched with infant serum if maternal antibodies are absent, but with maternal serum if maternal antibodies are present in the infant's blood. (4) Adequate anticoagulation with heparin. (5) Normal acid-base and electrolyte values of donor blood. (6) Immediate administration of the blood following collection. Abbreviations used HAA: hepatic-associated antigen VDRL: Veneral Disease Research Laboratory Since present blood banking techniques fail to satisfy all these requirements, a walking donor program was established for the Intensive Care Nursery of the University of California, Davis, Sacramento Medical Center. 5 MATERIALS
Supported in part by grants .from United States Public Health Service No, PHS-OGM-O9-H-O00281 and No. HD-04335-06. *Reprint address:Directorof NewbornServices, Sacramento Medical Center of the University of California, Davis, 2315 Stockton Blvd. Sacramento, Calif. 95817.
AND METHODS
Beginning in September, 1969, donors were selected from hospital personnel who were willing to be available around the clock. Screening of donors included review of health history and laboratory tests for syphilis, hepatitis, isoimmunization disease, atypical antibodies,
Vol. 86, No. 4, pp. 583-585
584
Blankenship et al.
50 45
151
,t0
i::}:}:}::
I--
Z D
35
30
8
325 PATIENTS WITH 1 DONOR
i
~::~:.!:.!i!:. 77 ....:.: :.
I--
Z U
The Journal of Pediatrics April1975
15 10
R4n 17 11 10
5
0 1
2
3
4
5
6
7
8
9
11 14
19
NUMBER OF TRANSFUSIONS
Fig. 1. Of the 325 patients with one donor, 53% received two or more transfusions and 30% received three or more transfusions. a n e m i a , a n d e x a m i n a t i o n o f a b l o o d s m e a r for spherocytes, i f the prospective donor was black, hemog l o b i n e l e c t r o p h o r e s i s and g l u c o s e - 6 - p h o s p h a t e deh y d r o g e n a s e d e t e r m i n a t i o n s were also p e r f o r m e d . Parents or relatives of the patient and any donor known to be taking medication were not used. (Personnel in the Renal Dialysis Unit and transplant services were excluded.) Information regarding acceptable donors was maintained in the nursery for quick reference. A bank of approximately 50 donors has been maintained. If a prospective donor is not used for transfusion within an eight week period, repeat V D R L and H A A teSting and hemoglobin and hematocrit determinations are required. At the time of an infant's admission to the Intensive Care N u r s e r y , 3 ml l a b e l e d , c l o t t e d s a m p l e s o f the b a b y ' s and m o t h e r ' s b l o o d are s e n t to the clinical laboratory. (Tubes of clotted maternal and cord blood are collected by the transport team for outborn infants.) Immediately after determinations of ABO and Rh (D) types, and a direct antiglobulin test on the b a b y ' s blood, an appropriate donor is selected and notified of the probable time and frequency of need. Response is usually immediate, since /he donor selected is Usually in the hospital. Compatibility testing is performed on cells of a freshly drawn sample of the donor's blood and the serum of the infant, including tests in bovine albumin and the indirect antiglobulin test (both at room temperature and 37~ If the infant and mother are of incom, patible ABO groups (i.e., mother Group O, infant group A or B) and the direct antiglobulin test on the b a b y ' s red cells is negative, the blood administered is of the infant's group. Only at times of extreme emergency is
transfusion performed before the results of the current V D R L and H A A testing are known. The p h y s i c i a n , after t h o r o u g h l y c l e a n i n g the antecubital area of the donor's skin with providone-iodine ( B e t a d i n e ) a n d rinsing with 70% i s o p r o p y l alcohol, draws the desired volume of blood from the donor in the nursery, using a No. 20 gauge scalp Vein needle att a c h e d to a plastic s y r i n g e c o n t a i n i n g two u n i t s of sodium heparin for each milliliter of donor blood. The blood is administered through a No. 5 F r e n c h indwelling umbilical arterial catheter over a 10- to 15-minute period. (In certain instances when red cell mass is critically low, sedimentation, with the syringe in a vertical p o s i t i o n , is desirable.) S u b s e q u e n t m i n i t r a n s f u s i o n s from the same donor may be performed without further compatibility testing, provided that (1) the donor does not develop symptoms of infection or (2) the infant does not show signs suggestive of transfusion reaction. If it becomes necessary to use a second donor, compatibility testing is again required. RESULTS During the 39-month period preceding D e c e m b e r 31, 1973, 376 patients were entered into the program: 247 males (65.7%) and 129 females (34.3%). Two hundred seventy were referred from outside hospitals. The majority (284 or 75.5%) were premature infants with hyaline m e m b r a n e disease. Respiratory distress type II accounted for 33 (8.8%) of the infants; the another 36 (19.7%) had meconium aspiration, septicemia, congenital heart disease, or were small-for-gestational age. The remaining 22 infants studied (6%) constituted a miscellaneous category including chromosomal abnormalities and other somatic defects. A total of 791 transfusions were administered, with no incidence of transfusion reaction. The mean volume o f each t r a n s f u s i o n was 19 ml ( r a n g e 3-40 ml). In general, transfusions were not given until a 10 ml deficit is experienced. One patient inadvertently received a 3 ml transfusion. The n u m b e r of transfusions received by the 325 patients who had a single donor are shown in Fig. 1. Fiftythree percent received two or more transfusions and 30% r e c e i v e d t h r e e or m o r e t r a n s f u s i o n s . F i f t y extremely ill patients received more than four transfusions. Some of the patients were sampled more than two times their blood volume within two weeks. All surviving infants have been Seen in follow-up. Karyotypes were performed on the lymphocytes of ten females (weighing less than 1,500 gm) who received blood from male donors; all karyotypes were of normal female type.
Volume 86 Number 4
DISCUSSION B a n k e d blood is k n o w n to u n d e r g o b i o c h e m i c a l changes, including degradation of labile clotting factors (V and VIII); decrease in 2, 3-diphosphogyceric acid; intracellular depletion of adenosine triphosphate and senescence of some of the erythrocytes, as well as complete i m m o b i l i z a t i o n of platelets. The metabolic changes due to citrate anticoagulants are well known, including an increase in hydrogen ion concentration and a leakage of potassium from the erythrocytes. In our own studies and those of Phibbs, 6 the pH of banked whole CPD and ACD blood and packed cells was 6.8 and 6.9, respectively. For these reasons, Bentley and associates 7 in 1962 and others including Oski and Naiman 8 and H e n d r e n 9 have recommended heparinized blood for exchange transfusion and for use in pediatric surgical cases. The availability of fresh blood from walking donors eliminates the degradation factors as well as the acidosis. In addition to the above, the major advantages of this program include: (1) A reduction in time from need to t r a n s f u s i o n since the donors are hospital based. A further reduction in time occurs since a repeat cross match procedure is eliminated when a single donor is used repeatedly. (2) The greater ease in monitoring donors' health made possible by the use of hospital personnel, (3) The reduction of exposure to infectious agents provided by the use of single donors whenever possible. (4) The elimination of wastage of blood since only the a m o u n t of blood needed for any given transfusion is drawn. (5) The marked monetary savings in blood bank charges and repeated compatibility testing. (6) Perhaps it should be recognized that the reluctance of the staff caring for the sick infant to draw needed samples, sometimes at 15-minute intervals, is greatly reduced since the donors are hospital based and readily available around the clock on short notice. The potential adverse factors associated with a walking donor program should be recognized. Hemorrhage following a t r a n s f u s i o n can be avoided by careful
Walking donor program
585
measurement of heparin. The potential hazard to the patient of graft-versus-host disease, although rare, does exist.10, 11 This problem could be overcome by irradiating the blood prior to administration of the transfusion. The possibility of immunization to erythrocyte antigens s e e m s remote since F l e t c h e r and associates n showed only one primary i m m u n i z a t i o n w i t h i n 10 weeks in 124 normal adult Rh negative recipients of infusions of Rh o(D) positive blood. REFERENCES
1. Ballard RA, Kitterman JA, Phibbs RH, Simpson H, and Tooley WH: Observations on hypovolemia in the newborn, Clin Res 20:278, 1972. :2. Janis KM, and McBride JW: Management of massive blood losses in small infants--incrementaltransfusion of fresh unanticoagulated adult blood, Anesthesiology 34:298, 1971. 3. McCormick RA, Christman, M, and Boyles R: "Mini transfusions" for neonatal patients, Wis Med J 71:248, 1972. 4. Technical Methods and Procedures of the American Association of Blood Banks, ed 6, 1974. 5. Blankenship WJ, Goetzman BW, Hattersley P, and Gross S: A walking donor blood program (WDP) for neonates, Clin Res 22:238A, 1974 (abstr.). 6. Phibbs RH: Personal communication. 7. Bentley HP, Newell RZ, and Kermit W: The use of heparinized blood for exchange transfusion in infants, Am J Dis Child 99:24, 1960. 8. Oski FA, and Naiman JL.: Hematologic problems in the newborn, Philadelphia, 1972, WB Saunders Company. 9. Hendren WH: Pediatric surgery, Part I, N Engl J Med 289:456, 1973. 10. Editorial: Lymphocyte hazards to the fetus, Lancet 1:718, 1974. 11. Parkman R, Mosier D, Umansky I, Cochran W, Carpenter CB, and Rosen FS: Graft-versus-host disease after intrauterine and exchange transfusions for hemolytic disease of the newborn, N Engl J Med 290:359, 1974. 12. Fletcher G, Cooke BR, and McDowall J: Attempts to immunize Rh (D) negative volunteers against the D antigen, Proc. Second Meeting Asian and Pacific Division, International Society Haematology. Melbourne, 1971.
A walking donor program for an intensive care nursery Repeated transfusions of small increments of blood are frequently requiredfor the sick newborn infant to correct endogenous hypovolemia and~or to replace blood obtained repeatedly for monitoring purposes. Current practices of blood banks are rarely geared to supply the small amounts of blood used for these individual transfusions. To provide a more efficient system, a walking donor program was established in which an appropriate hospital-based individual is cross matched as a donorfor an infant for the duration of the infant's hospital stay. The program eliminates wastage of blood and donors and reduces the number of infectious agents to which the infant may be exposed.
Williard J. Blankenship, M.D.,* Boyd W. Goetzman, M.D., Ph.D., Sara Gross, M.T., and Paul G. Hattersley, M.D., Sacramento, Calif.
THE SICK NEWBORN INFANT, and especially the
small premature infant, may require frequent blood sampling for determination of blood gases, electrolytes, bilirubin, and other laboratory tests. Although modern techniques supply much information from small samples of blood, compromise of circulating blood volume may occur if repeated sampling is required. In addition, hypovolernia can occur in infants born to mothers with hemorrhagic complications of parturition (placenta previa, abruptio placenta, or cord and placental accidents), as a result of maternal-fetal transfusion, fetalfetal transfusion in multiple births and in infants who experience intrapartum asphyxia, particularly premature infants with hyaline membrane disease. 1-3 Ideally, transfusions for these infants should meet the following requirements: (1) If at all possible, all transfusions for an infant should come from the same donor, thus decreasing exposure to hepatitis and other infectious diseases, as well as decreasing the number of compatibility tests required. (2) The donor must meet the standards of the American Association of Blood
Banks, 4 which include appropriate health history, negative serologic tests for syphilis, negative test for hepatitis-associated antigen and acceptable hemoglobin or hematocrit values. (3) Appropriate compatibility testing. Donor erythrocytes should be cross matched with infant serum if maternal antibodies are absent, but with maternal serum if maternal antibodies are present in the infant's blood. (4) Adequate anticoagulation with heparin. (5) Normal acid-base and electrolyte values of donor blood. (6) Immediate administration of the blood following collection. Abbreviations used HAA: hepatic-associated antigen VDRL: Veneral Disease Research Laboratory Since present blood banking techniques fail to satisfy all these requirements, a walking donor program was established for the Intensive Care Nursery of the University of California, Davis, Sacramento Medical Center. 5 MATERIALS
Supported in part by grants .from United States Public Health Service No, PHS-OGM-O9-H-O00281 and No. HD-04335-06. *Reprint address:Directorof NewbornServices, Sacramento Medical Center of the University of California, Davis, 2315 Stockton Blvd. Sacramento, Calif. 95817.
AND METHODS
Beginning in September, 1969, donors were selected from hospital personnel who were willing to be available around the clock. Screening of donors included review of health history and laboratory tests for syphilis, hepatitis, isoimmunization disease, atypical antibodies,
Vol. 86, No. 4, pp. 583-585
584
Blankenship et al.
50 45
151
,t0
i::}:}:}::
I--
Z D
35
30
8
325 PATIENTS WITH 1 DONOR
i
~::~:.!:.!i!:. 77 ....:.: :.
I--
Z U
The Journal of Pediatrics April1975
15 10
R4n 17 11 10
5
0 1
2
3
4
5
6
7
8
9
11 14
19
NUMBER OF TRANSFUSIONS
Fig. 1. Of the 325 patients with one donor, 53% received two or more transfusions and 30% received three or more transfusions. a n e m i a , a n d e x a m i n a t i o n o f a b l o o d s m e a r for spherocytes, i f the prospective donor was black, hemog l o b i n e l e c t r o p h o r e s i s and g l u c o s e - 6 - p h o s p h a t e deh y d r o g e n a s e d e t e r m i n a t i o n s were also p e r f o r m e d . Parents or relatives of the patient and any donor known to be taking medication were not used. (Personnel in the Renal Dialysis Unit and transplant services were excluded.) Information regarding acceptable donors was maintained in the nursery for quick reference. A bank of approximately 50 donors has been maintained. If a prospective donor is not used for transfusion within an eight week period, repeat V D R L and H A A teSting and hemoglobin and hematocrit determinations are required. At the time of an infant's admission to the Intensive Care N u r s e r y , 3 ml l a b e l e d , c l o t t e d s a m p l e s o f the b a b y ' s and m o t h e r ' s b l o o d are s e n t to the clinical laboratory. (Tubes of clotted maternal and cord blood are collected by the transport team for outborn infants.) Immediately after determinations of ABO and Rh (D) types, and a direct antiglobulin test on the b a b y ' s blood, an appropriate donor is selected and notified of the probable time and frequency of need. Response is usually immediate, since /he donor selected is Usually in the hospital. Compatibility testing is performed on cells of a freshly drawn sample of the donor's blood and the serum of the infant, including tests in bovine albumin and the indirect antiglobulin test (both at room temperature and 37~ If the infant and mother are of incom, patible ABO groups (i.e., mother Group O, infant group A or B) and the direct antiglobulin test on the b a b y ' s red cells is negative, the blood administered is of the infant's group. Only at times of extreme emergency is
transfusion performed before the results of the current V D R L and H A A testing are known. The p h y s i c i a n , after t h o r o u g h l y c l e a n i n g the antecubital area of the donor's skin with providone-iodine ( B e t a d i n e ) a n d rinsing with 70% i s o p r o p y l alcohol, draws the desired volume of blood from the donor in the nursery, using a No. 20 gauge scalp Vein needle att a c h e d to a plastic s y r i n g e c o n t a i n i n g two u n i t s of sodium heparin for each milliliter of donor blood. The blood is administered through a No. 5 F r e n c h indwelling umbilical arterial catheter over a 10- to 15-minute period. (In certain instances when red cell mass is critically low, sedimentation, with the syringe in a vertical p o s i t i o n , is desirable.) S u b s e q u e n t m i n i t r a n s f u s i o n s from the same donor may be performed without further compatibility testing, provided that (1) the donor does not develop symptoms of infection or (2) the infant does not show signs suggestive of transfusion reaction. If it becomes necessary to use a second donor, compatibility testing is again required. RESULTS During the 39-month period preceding D e c e m b e r 31, 1973, 376 patients were entered into the program: 247 males (65.7%) and 129 females (34.3%). Two hundred seventy were referred from outside hospitals. The majority (284 or 75.5%) were premature infants with hyaline m e m b r a n e disease. Respiratory distress type II accounted for 33 (8.8%) of the infants; the another 36 (19.7%) had meconium aspiration, septicemia, congenital heart disease, or were small-for-gestational age. The remaining 22 infants studied (6%) constituted a miscellaneous category including chromosomal abnormalities and other somatic defects. A total of 791 transfusions were administered, with no incidence of transfusion reaction. The mean volume o f each t r a n s f u s i o n was 19 ml ( r a n g e 3-40 ml). In general, transfusions were not given until a 10 ml deficit is experienced. One patient inadvertently received a 3 ml transfusion. The n u m b e r of transfusions received by the 325 patients who had a single donor are shown in Fig. 1. Fiftythree percent received two or more transfusions and 30% r e c e i v e d t h r e e or m o r e t r a n s f u s i o n s . F i f t y extremely ill patients received more than four transfusions. Some of the patients were sampled more than two times their blood volume within two weeks. All surviving infants have been Seen in follow-up. Karyotypes were performed on the lymphocytes of ten females (weighing less than 1,500 gm) who received blood from male donors; all karyotypes were of normal female type.
Volume 86 Number 4
DISCUSSION B a n k e d blood is k n o w n to u n d e r g o b i o c h e m i c a l changes, including degradation of labile clotting factors (V and VIII); decrease in 2, 3-diphosphogyceric acid; intracellular depletion of adenosine triphosphate and senescence of some of the erythrocytes, as well as complete i m m o b i l i z a t i o n of platelets. The metabolic changes due to citrate anticoagulants are well known, including an increase in hydrogen ion concentration and a leakage of potassium from the erythrocytes. In our own studies and those of Phibbs, 6 the pH of banked whole CPD and ACD blood and packed cells was 6.8 and 6.9, respectively. For these reasons, Bentley and associates 7 in 1962 and others including Oski and Naiman 8 and H e n d r e n 9 have recommended heparinized blood for exchange transfusion and for use in pediatric surgical cases. The availability of fresh blood from walking donors eliminates the degradation factors as well as the acidosis. In addition to the above, the major advantages of this program include: (1) A reduction in time from need to t r a n s f u s i o n since the donors are hospital based. A further reduction in time occurs since a repeat cross match procedure is eliminated when a single donor is used repeatedly. (2) The greater ease in monitoring donors' health made possible by the use of hospital personnel, (3) The reduction of exposure to infectious agents provided by the use of single donors whenever possible. (4) The elimination of wastage of blood since only the a m o u n t of blood needed for any given transfusion is drawn. (5) The marked monetary savings in blood bank charges and repeated compatibility testing. (6) Perhaps it should be recognized that the reluctance of the staff caring for the sick infant to draw needed samples, sometimes at 15-minute intervals, is greatly reduced since the donors are hospital based and readily available around the clock on short notice. The potential adverse factors associated with a walking donor program should be recognized. Hemorrhage following a t r a n s f u s i o n can be avoided by careful
Walking donor program
585
measurement of heparin. The potential hazard to the patient of graft-versus-host disease, although rare, does exist.10, 11 This problem could be overcome by irradiating the blood prior to administration of the transfusion. The possibility of immunization to erythrocyte antigens s e e m s remote since F l e t c h e r and associates n showed only one primary i m m u n i z a t i o n w i t h i n 10 weeks in 124 normal adult Rh negative recipients of infusions of Rh o(D) positive blood. REFERENCES
1. Ballard RA, Kitterman JA, Phibbs RH, Simpson H, and Tooley WH: Observations on hypovolemia in the newborn, Clin Res 20:278, 1972. :2. Janis KM, and McBride JW: Management of massive blood losses in small infants--incrementaltransfusion of fresh unanticoagulated adult blood, Anesthesiology 34:298, 1971. 3. McCormick RA, Christman, M, and Boyles R: "Mini transfusions" for neonatal patients, Wis Med J 71:248, 1972. 4. Technical Methods and Procedures of the American Association of Blood Banks, ed 6, 1974. 5. Blankenship WJ, Goetzman BW, Hattersley P, and Gross S: A walking donor blood program (WDP) for neonates, Clin Res 22:238A, 1974 (abstr.). 6. Phibbs RH: Personal communication. 7. Bentley HP, Newell RZ, and Kermit W: The use of heparinized blood for exchange transfusion in infants, Am J Dis Child 99:24, 1960. 8. Oski FA, and Naiman JL.: Hematologic problems in the newborn, Philadelphia, 1972, WB Saunders Company. 9. Hendren WH: Pediatric surgery, Part I, N Engl J Med 289:456, 1973. 10. Editorial: Lymphocyte hazards to the fetus, Lancet 1:718, 1974. 11. Parkman R, Mosier D, Umansky I, Cochran W, Carpenter CB, and Rosen FS: Graft-versus-host disease after intrauterine and exchange transfusions for hemolytic disease of the newborn, N Engl J Med 290:359, 1974. 12. Fletcher G, Cooke BR, and McDowall J: Attempts to immunize Rh (D) negative volunteers against the D antigen, Proc. Second Meeting Asian and Pacific Division, International Society Haematology. Melbourne, 1971.