I. LEUKOCYTE REDUCED RED BLOOD CELL CONCENTRATES (includes packed red blood cells, washed red blood cells, frozen deglycerolized cells)

Indications:

A. Acute blood loss (hemorrhage, surgery or iatrogenic) greater than 15% total blood volume (estimated blood volume = 70 mL/kg body weight) or 10% total blood volume in neonates (estimated blood volume 85 mL/kg) associated with:

1. Signs and symptoms of hypovolemia (tachycardia, tachypnea,
hypotension) unresponsive to crystalloid infusion.

2. Signs and symptoms of cerebral or coronary hypoxia, fatigue, weakness, dizziness or respiratory distress.

3. In neonates < 7 days old when the cumulative blood volume removed over a one-week period due to laboratory testing exceeds 10% of the infant's estimated blood volume.

B. Patients with present symptoms of anemia or at high risk to develop symptoms of anemia with any of the following.

1. Hemoglobin less than 7 gm/dL

2. Hemoglobin less than 10 gm/dL and:

• Further anticipated blood loss
• Shock
• FiO2>60%
• Neonates on NCPAP or HFNC

3. Hemoglobin less than 12 gm/dL in neonates with serve cardiopulmonary disease on mechanical ventilation.

4. Hemoglobin less than 15 gm/dL and:

• Cardiac disease
• Cardiovascular bypass
• ECMO

C. Exchange transfusion

D. To prime medical devices used during:

• ECMO
• Cardiopulmonary bypass
• Apheresis
• Hemofiltration

E. Hemoglobinopathy

1. Acute treatment of patients with sickle cell disorders who are symptomatic (cerebral symptoms, splenic, pulmonary or hepatic sequestration, priapism, or other sickle cell crisis).

2. Asymptomatic sickle cell disease if scheduled to undergo general anesthesia for surgical or therapeutic procedures.

3. Transfusion dependent (thalassemias)

4. Scheduled erythrocytapheresis, hypertransfusion, or exchange transfusion for prevention of stroke, or in-patients with history of significant sickle cell complications.

II. LEUKOCYTE REDUCED PLATELET PHERESIS

NOTE: A single donor platelet pheresis (containing greater than 3 X 10¹¹ platelets) is equivalent to 5-6 random donor platelet units (each containing greater than 5.5 x 10¹⁰ platelets).

Indications:

A. Active bleeding or at high risk of life threatening bleed with qualitative platelet defect regardless of platelet count due to:

• < 48 hours post Cardiac bypass or ECMO
• Medication (e.g. Aspirin)
• Known clinical conditions. May also consider using fibrinolytic inhibitors, desmopressin or concentrates enriched in von Willebrands factor.

B. Life or organ threatening bleeding during surgery, regardless of platelet count

C. With massive blood replacement of greater than 50% of total blood volume within 8 hours

D. Platelet count less than 150,000 per mm³ for patients on ECMO. (See specific ECMO guidelines)

E. Platelet count less than 100,000 per mm³ under the following conditions:

1. Patients with active bleeding

2. Critically ill neonate with:

• DIC
• Sepsis
• Necrotizing enterocolitis

3. Less than 5 kg patient undergoing major surgery

4. Associated with neurologic, cardiovascular, ophthalmologic, or other surgical procedures with potentially life or organ threatening blood loss during the perioperative time. (preoperative, intraoperative, up to 7 days postoperative)

5. CNS hemorrhage or infarct within 7 days

F. Platelet count less than 50,000 per mm³ under the following conditions:

1. Within 24 hours of an invasive medical or surgical procedure

2. Patients with documented coagulopathy: PTT greater than 41
seconds (>60 seconds in preterm infants <30 days old) and/or INR
greater than 1.5

3. Critically ill patient on mechanical ventilation

4. Stable preterm infant in the first week of life

G. Platelet count less than 20,000 per mm³ in stable neonate with platelet consumption.

H. Failure of platelet production, or platelet consumption with one of the following:

1. Inpatients with platelet count less than 10,000 per mm³

2. Outpatients or pending discharge with failing platelet count less than 15,000 per mm³

III. FROZEN PLASMA (FP) / FRESH FROZEN PLASMA (FFP)

Indications:

A. Documented coagulopathy: PTT greater than 41 seconds (>60 seconds in
preterm infants <30 days old) and/or an INR greater than 1.5 due to deficiency of soluble coagulation factors or anticoagulation therapy in patients for whom a specific factor concentrate is not available, with one or more of the following:

• Active bleeding
• Within 24 hours of an invasive procedure
• Critically ill neonate

B. Patients with suspected coagulopathy and excessive bleeding and coagulation studies are pending (or unable to obtain) at the time of the transfusion.

C. Patients undergoing cardiopulmonary bypass surgery or ECMO at risk for coagulopathy and bleeding.

D. Exchange transfusions

E. Massive blood loss (greater than 50% blood volume).

F. Replacement therapy during therapeutic plasma exchange for disorders in which Frozen Plasma is beneficial (HUS/TTP).

G. Replacement therapy with one of the following:

• >25 mL/kg/day chylous loss
• Patients with protein C or S, or Antithrombin III deficiencies ncluding premature infants with thrombosis. Consider use of antithrombin III concentrate or activated protein C concentrates for specific deficiencies.
• Thrombolytic therapy to augment thrombolysis (plasminogen)
• Coagulation factor disorders in which specific factor concentrates are not available.

IV. CRYOPRECIPITATE

NOTE: Cryoprecipitate contains coagulation Factor VIII:C, Factor XIII, von Willebrand factor (factor VIII:vWf) and fibrinogen.

Indications:

A. Fibrinogen <200 mg/dL and <48 hours post cardiovascular bypass or ECMO.

B. Fibrinogen < 100 mg/dL with one of the following:

• Active bleeding
• Critically ill neonate
• Within 24 hours of invasive procedure

C. Dysfibrinogenemia with active bleeding or within 24 hours of invasive
procedure

D. Patients with factor VIII deficiency or von Willebrand's disease, although specific factor concentrates are preferred.

E. Patients with factor XIII deficiency and active bleeding or within 24 hours of invasive procedure.

F. Use as topical ingredient for invasive procedures, although proprietary products may be available.

G. Massive blood loss (greater than 50% blood volume)

V. WHITE BLOOD CELLS

NOTE: All granulocyte product transfusions require pathology consultation and must be ordered 24 hours in advance for donor preparation and product processing.

The use of white blood cell products is controversial and all usage will be audited. Granulocyte concentrates contain considerable numbers of lymphocytes, platelets and red cells. Red cell compatibility testing is to be performed prior to transfusion.

VI. ALBUMIN

5% and 25% albumin is available through Children’s Pharmacy.

VII. FACTOR CONCENTRATES IN PATIENTS WITH HEMOPHILIA AND OTHER HEREDITARY BLEEDING DISORDERS

The treatment of patients with hemophilia and other rare hereditary bleeding disorders is complex and requires consultation with a pediatric Hematologist/Oncologist and coordination with Children’s Pharmacy.

VIII. OTHER PRODUCTS

Immunoglobulins directed against viral or other undesirable antigens may be indicated in certain immunodeficient patients. The availability and composition of such products is variable. Consultation with a pediatric Hematology/

Oncology, and/or Infectious Disease are required. Immune Globulins are available through Children’s Pharmacy.

I. IRRADIATED COMPONENTS

Required only for cellular products including leukocyte reduced Red Blood
Cells, Platelet concentrates, and Granuloctyes. Irradiation of blood products is not required for patients pending solid organ transplant or diagnosed with AIDS due to HIV.

Indications:

A. Documented or suspected, acquired or congenital immunodeficiency disorders

B. Infants < 4 months old throughout the admission period

C. Therapy induced immunosuppression (aggressive chemotherapy, immunotherapy, or extensive radiation therapy)

D. Granulocyte concentrates/buffy coats

E. Directed donations from blood relatives

F. HLA-matched apheresis platelets/crossmatch compatible platelets

G. Exchange transfusion in newborns

II. FROZEN DEGLYCEROLIZED RED BLOOD CELLS

Indications:

A. Patients with IgA deficiency and antibodies to IgA

B. Patients with unusual antigenic phenotypes

III. WASHED BLOOD COMPONENTS

Indications:

A. Severe transfusion reactions related to plasma proteins