Yorkshire and Humber Children and Young People s Cancer Network

Transcription

1 Humber and Yorkshire Coast Cancer Network Yorkshire Cancer Network Yorkshire and Humber Children and Young People s Cancer Network Guideline for Blood Component Support in Paediatric and Adolescent Oncology and Haematology *** VALID ON DATE OF PRINTING ONLY - all guidelines available at *** page 1 of 18 version number: 2.2

2 i Document Control Title Author(s) Owner Blood Component Support in Paediatric and Adolescent Oncology and Haematology Dr Bob Phillips Professor Sally Kinsey Version Control Version/ Draft Date Revision summary 1 21/10/2009 Published 2 30/11/2011 Reviewed and updated /03/2012 Reviewed by LTHT Hospital Transfusion Team /12/2013 Changes to the transfusion factor from 3.5 to 5. For routine transfusions the target haemoglobin for children with malignancy - transfuse if Hb is 80 g/l or below to a desired post-transfusion Hb of 100 g/l (previously 120 g/l). Indications for CMV seronegative cellular blood componants have been expanded in line with national guidance. Contributors to current version Contributor Author/Editor Section/Contribution LTHT Hospital Transfusion Team CYP Cancer Network Guidelines Development Group Paediatric Quality Group Throughout Throughout *** VALID ON DATE OF PRINTING ONLY - all guidelines available at *** page 2 of 18 version number: 2.2

3 ii Information Reader Box Title Author(s) Blood Component Support in Paediatric and Adolescent Oncology and Haematology Dr Bob Phillips Publication date 15/04/2014 Review date 01/12/2016 Proposed Target Audience for Consultation / Final Statement Proposed Circulation List for Final Statement All consultations and notification of updated guidelines from the Yorkshire and Humber Children and Young People s Cancer Network. This document has been signed off by the Paediatric and Adolescent Oncology and Haematology Guideline review Group. All guidelines will be made available electronically at No hard copies will be circulated by the Group. Contact details Yorkshire Cancer Network Level 6 Bexley Wing St James s Institute of Oncology Beckett Street Leeds LS9 7TF Tel: *** VALID ON DATE OF PRINTING ONLY - all guidelines available at *** page 3 of 18 version number: 2.2

4 iii Table of Contents I DOCUMENT CONTROL... 2 II INFORMATION READER BOX... 3 III TABLE OF CONTENTS INTRODUCTION AND GENERAL PRINCIPLES POLICY STATEMENT STANDARD COMPONENTS IRRADATED AND CMV NEGATIVE COMPONENTS PLATELET REFRACTORINESS TRANSFUSION REACTIONS GUIDELINE EFFECT EQUALITY AND DIVERSITY STATEMENT CONSULTATION PROCESS APPENDIX *** VALID ON DATE OF PRINTING ONLY - all guidelines available at *** page 4 of 18 version number: 2.2

5 1 Introduction and General Principles Indication for transfusion of blood components As with any action undertaken in healthcare, the transfusion of blood components must be proposed in the belief that the benefits of the action outweigh the disadvantages. Avoidance of unnecessary transfusions is the SAFEST policy. Transfuse because the patient will, most likley, receive a benefit from the components proposed. All blood components must be checked against the patient at the bedside. This is the final opportunity to prevent transfusion of the wrong component. The indication for any transfusion should be documented in the medical notes and all transfusions must be prescribed by a doctor (see SHOT Report Serious Hazards of Transfusion - All components are now LEUCODEPLETED (but CMV seronegative and irradiated components must be specifically requested and prescribed - See section III). Rates of transfusion depend upon the clinical scenario but in a non-urgent situation the following are a guideline: Red cells Platelets FFP Volume as calculated below over 4 hours (this is the maximum allowable transfusion time for red cells because of the risk of bacterial contamination) 30 mins 30 mins 2 Policy Statement 2.1 Standard Components A. Red Cells The following formula is used to calculate the volume of blood required for a packed red cell transfusion. Volume (ml) = (desired Hb actual Hb) x weight (kg) x 5 NOTE: The transfusion factor has been calculated on the basis of actual pre/post values obtained in haematology/oncology patients. This is in keeping with values obtained from previous case reviews in PICU patients and the haematocrit of red cell donations. Page 5 of 18

6 Where possible, the calculated volume may be altered +/- 15% to make sensible use of resources. Transfuse with whole units of blood (approximately mls). 1. Patients with malignancies (anaemia secondary to chemotherapy) Transfuse if Hb is 80g/l or below to a desired post-transfusion Hb of 100 g/l This group of patients rarely require more than two units of blood (except on haematologist advice). 2. Thalassaemia Children with thalassaemia major are usually on a monthly transfusion programme, their desired post-transfusion Hb is 150g/l (maintain a pre-transfusion Hb of g/l). 3. Severe aplastic anaemia These children are transfused at the discretion of their consultant; the desired posttransfusion Hb is 100g/l. 4. Sickle cell disease Transfusion of sickle cell patients is reserved for exceptional cases not responding to conservative management. Discussion with a consultant haematologist is needed before transfusion of blood to these cases. 5. Patients undergoing radiotherapy These children should have Hb of at least 100 g/l, transfuse to 120 g/l. 6. Other indications (e.g. major trauma) Transfusion for indications outside the normal situatins above require specific responses. Seek specialised advice. B. Platelets Neonates should receive ml/kg Infants <1 year should receive 1-2 units Children >1 year should receive 1 adult therapeutic dose (equivalent to 4 units - this may be provided as a pool of 4 donor units or a single-donor apheresis unit) Indications 1. Patients with malignancy or post-transplant or severe aplastic anaemia Mucosal nose/gum bleeding that will not stop (with normal clotting) or Platelets <10 x 10 9 /l (asymptomatic/no clinical signs of bleeding) or Platelets <20 x 10 9 /l if septic or minor bleeding or Platelets <40 x 10 9 /l if brain tumour Page 6 of 18

7 GI Bleeding may require platelet transfusions if <75 x 10 9 /l Platelets <50 x 10 9 /l in patients undergoing Radiotherapy need discussion with clinical oncology team as complex and patient/protocol specific. 2. Lumbar Puncture and Bone Marrow This will vary depending on the patient s circumstances. Please discuss with the Haematology Registrar or Consultant who is doing the procedure if the count is <50 x 10 9 /l as the patient may require a transfusion beforehand. 3. Surgery Platelets >50 x 10 9 /l should be sufficient for a line insertion or biopsy. Patients having Vascath insertion for stem cell harvest require plt >50 x 10 9 /l. Please discuss if unsure. Contraindications Platelets are not routinely used in ITP or TTP unless there is severe bleeding. Please discuss with a Consultant before use. Specific patients or situations may require deviations from this guidance. C. Fresh Frozen Plasma NB FFP has the highest rate of serious adverse reactions (allergy, immune haemolysis, transfusion-related acute lung injury) of any blood component and must always be used for a firm clinical indication. If in doubt discuss. As a vcjd risk-reduction measure, all neonates and children born after Jan 1 st 1996 MUST only be transfused with methylene blue treated fresh frozen plasma (MB-FFP)) sourced from non-uk donors. This will automatically be issued by the Blood Bank. Indications for use (dose ml/kg) 1. In the face of bleeding and disturbed clotting FFP may be indicated, please discuss with Haematologist or Consultant on call. Vitamin K may also be indicated. 2. Factor deficiency with no factor concentrate e.g. factor V deficiency. Please discuss with Haematologist or Consultant on call. TTP FFP is usually given in conjunction with plasma exchange however may be given alone if urgently required out of hours when it is not practical to arrange plasma exchange immediately. 3. Plasma exchange the dose of FFP will depend upon the number of litres exchanged.. (NB for large volume plasma exchange, the DH now recommends the use of solvent-detergent treated pooled FFP (Octaplas) in the treatment of TTP. It is Page 7 of 18

8 virucidally inactivated, made from low vcjd-risk donors and is depleted of high MW vw multimers. Arranged via Blood Bank after discussion with Consultant Haematologist). FFP is no longer indicated for reversal of Warfarin effect, Prothrombin Complex Concentrate (PCC) iu/kg is now used for patients with major bleeding. For minor bleeding or no bleeding and INR>6 use vitamin K. Please review the relevant antithrombotic treatment in children guideline and discuss with haematologist. D. Cryoprecipitate Dose ml/kg This may be indicated in the context of deranged coagulation and bleeding, especially if there is DIC. However we would recommend that FFP is given first and a coagulation screen with D-Dimers and Fibrinogen is repeated. If the fibrinogen remains below 1.0 g/dl then treatment with Cryoprecipitate may be indicated. Please discuss with Haematologist or Consultant on call. E. Clotting Concentrates Patients with haemophilia A may require factor VIII and patients with haemophilia B may require factor IX when admitted. Patents with rarer coagulation disorders may require other specific concentrates. This should be discussed with a Haematology Consultant or Registrar or the Consultant on call. These are given as an intravenous bolus. Details of individual treatment are documented in the front sheet of the notes. See also Haemophilia Guidelines file. Patients with other bleeding disorders should be discussed with a Haematologist or the Consultant on call. Specific hospitals may have different models of care for patients with clotting disorders. F. Other Modalities of Therapy If bleeding occurs consider a local cause and local remedy (ie cauterisation for epistaxis or surgery if indicated). Other pharmacological interventions include: Vitamin K. Tranexamic acid (avoid in cases of macroscopic or heavy microscopic haematuria). NovoSeven (recombinant factor VIIa) (always discuss with a haematologist) refer to rviia guideline. Page 8 of 18

9 2.2 Irradated and CMV Negative Components blood components Cellular blood components can be irradiated to inactivate lymphocytes that could cause graftversus-host disease. Irradiation can increase RBC fragility and lower shelf. TA-GvHD (Transfusion Associated Graft versus Host Disease) is a very rare but usually fatal complication following transfusion of lymphocyte containing blood components (red cells, platelets and granulocytes). The risk associated with an individual transfusion depends on the number and viability of contaminating T-lymphocytes, susceptibility of the recipient s immune system to their engraftment and degree of immunological (HLA) disparity between donor and patient. TA-GvHD has been reported in children with severe primary T lymphocyte immunodeficiencies characterized by an absence of T lymphocytes or a severe defect of T cell function. In the newborn infant the presenting features of immunodeficiency syndromes may be unrelated to the immune defect (e.g. cardiac disease, hypocalcaemia, thrombocytopenia, eczema) and a high index of suspicion is required, particularly in infants less than 6 months old with recurrent or persistent respiratory or gastro-intestinal infections. In older patients, a severe T lymphocyte deficiency can be induced by certain acquired conditions (e.g. Hodgkin s disease) or certain immunosuppressive or cytotoxic treatments. All severe T lymphocyte immunodeficiency syndromes should be considered as indications for irradiation of cellular blood components. Once a diagnosis of immunodeficiency has been suspected, irradiated components should be given while further diagnostic tests are being undertaken. CMV Negative blood components The risk of transmission in multiply-transfused CMV negative recipients is greatly reduced by the provision of leucodepleted blood components and this is therefore viewed by the Department of Health (2012) as sufficient to prevent CMV transmission in the majority of patients. DH / SaBTO have reviewed the evidence around the replacement of CMV seronegative cellular blood components (both red cells and platelets) with leucodepleted blood components. The following conclusions were reached: i. CMV seronegative red cell and platelet components should be provided for intra-uterine transfusions and for neonates (i.e. up to 28 days post expected date of delivery), and therefore all small sized blood packs and other cellular blood components intended for neonates should be provided as CMV seronegative (however, for ease, LTHT blood bank will continue to provide CMV negative blood components up to 6 months post-delivery). Page 9 of 18

10 ii. Granulocyte components should continue to be provided as CMV seronegative for CMV seronegative patients. iii. CMV seronegative blood components should be provided where possible for pregnant girls regardless of their CMV serostatus, who require repeat elective transfusions during the course of pregnancy (not labour and delivery). This mainly applies to patients with haemoglobinopathies who are managed in specialist centres. However CMV seronegative blood components are not expected to be generally available in all hospitals and therefore for emergency transfusions in pregnant women, leucodepleted components are recommended. iv. All blood components (other than granulocytes) in the UK now undergo leucodepletion, which provides a significant degree of CMV risk reduction. This measure is considered adequate risk reduction for all other patients requiring transfusion (haemopoetic stem cell transplant patients, organ transplant patients, and immune deficient patients, including those with HIV) without the requirement for CMV seronegative components in addition. v. CMV PCR monitoring should be considered for all haemopoeitic stem cell and solid organ transplant patients (even CMV negative donor/negative recipients) to allow early detection of any possible CMV infection (whether transfusion-transmitted or primary acquired infection). Indications: Patient Group / Condition/Treatment Haematology Patients: Aplastic Anaemia - patients likely to receive PBSCT and/or treated with immunosuppressive therapy (ATG, ALG, alemtuzumab) Hodgkin s Disease (Hodgkin s Lymphoma) Patients who have unclassified T cell immunodeficiency Patients who have received Purine Analogue Drugs - Fludaribine - Cladribine - Deoxycoformicin - Chlorodeoxyadenosin - Nelarabine Patients who have received Purine Antagonist Drugs - Bendamustine - Clofarabine Special blood requirement Further information / Length of time to receive special blood requirements blood components for * blood components for 7 components for blood components for blood components for * Page 10 of 18

11 Patient Group / Condition/Treatment Patient undergoing BM or PBSC harvest Post Allo BMT/PBSCT Post Auto PBSCT Patients receiving HLA matched components Patient who have received immunosuppressive antibody treatments - anti-thymocyte globulin (ATG) - anti-lymphocyte globulin (ALG) - alemtuzumab / Campath (anti-cd52) - Muromonab (OKT3) Patients receiving granulocytes Bone marrow/stem cell donors Renal Patients: Patient who have received immunosuppressive antibody treatments - alemtuzumab (anti- CD52)/Campath - Muromonab (OKT3) Renal Transplant (if in receipt of Campath / Muromonab or, transplanted after 1/4/2011) Special blood requirement CMV Neg (for all CMV Neg patients) Further information / Length of time to receive special blood requirements blood components from 14 days prior to & during stem cell harvesting. blood components from 14 days prior to preconditioning chemo for all allograft BMT/PBSCT Patients proceeding to autograft will remain on irradiated blood components for * blood components for * blood components for * Only the HLA matched components need to be irradiated blood components for Once irradiated, transfuse with minimum delay In patients receiving granulocytes only, it is only the granulocytes that need to be irradiated/cmv Neg red cells/platelets for 14 days prior to and/or during bone marrow/stem cell harvest blood components for blood components for Page 11 of 18

12 Patient Group / Condition/Treatment Live renal organ donors Obstetric Patients: Pregnancy Intra-Uterine Transfusion (IUT) Special blood requirement CMV Neg CMV Neg Group O Neg Further information / Length of time to receive special blood requirements For 7 days prior to and during organ transplantation All women receiving elective antenatal transfusion should receive CMV negative blood components - not necessary during labour or post natal Platelets transfused in-utero to treat allo-immune thrombocytopenia Red cells will be less than 5 days old with a Hct no greater than 0.75 Transfuse irradiated blood components within 24 hours of irradiation Baby must receive irradiated blood components for 1 year post expected date of delivery* Neonates: All children <6months to receive CMV negative blood components Baby must receive CMV negative blood components until 6 months old * Red cells will be less than 5 days old Exchange Transfusion (Neonatal) CMV Neg Group O Neg Transfuse irradiated blood components within 24 hours of irradiation Must have irradiated if previous IUT; otherwise irradiated if time allows Post Intra-Uterine Transfusion Babies post IUT must receive irradiated blood components for 1 year after expected date of delivery* Paediatrics: All children <6months to receive CMV negative blood components Di George syndrome (3 rd and 4 th blood components for arch/pouch syndrome) SCID Severe Combined Immunodeficiency Wiskott Aldrich Syndrome Purine nucleoside phosphorylase deficiency (PNP) Leiner s disease (Leiner- Moussous disease, Erythrodermia desquamativa Leiner) Page 12 of 18 blood components for blood components for blood components for blood components for

13 Patient Group / Condition/Treatment Reticular dysgenesis (aleukocytosis) Adenosine deaminase deficiency MHC class I or class II deficiency (Bare Lymphocyte Syndrome) Leucocyte adhesion deficiency Omenn s syndrome Ataxia telangiectasia (Louis Bar syndrome, Boder-Sedgwick syndrome) Cell-Mediated Immunodeficiency General: Patient who have received immunosuppressive antibody treatments - anti-thymocyte globulin (ATG) - anti-lymphocyte globulin (ALG) - alemtuzumab (anti-cd52) - Muromonab (OKT3) Patients receiving components from a first or second degree relative Patients receiving umbilical cord blood transplant under trial conditions Special blood requirement CMV Neg Further information / Length of time to receive special blood requirements blood components for blood components for blood components for blood components for blood components for blood components for blood components for blood components for Only the components from the relative need to be irradiated blood components for CMV negative blood components for the duration of the cord blood transplant trial and then follow local policy Key: * for ease and to prevent confusion, this time limit recommendation (which does not follow national recommendations) has been lengthened for LTHT policy to ensure patient safety. NB: there is no need to routinely irradiate blood components for patients with HIV. NB: there is no need to provide CMV negative blood components for patients with HIV and/or organ transplant patients. Page 13 of 18

14 2.3 Platelet Refractoriness Some patients may not get good increments from platelet transfusions; this should be suspected clinically by failure to ameliorate bleeding/bruising symptoms. It is defined by failure to increment the platelet count after transfusion. Practically, this is suggested by an increment of <20 x 10 9 /l 1 hour post-transfusion or <10 x 10 9 /l 24 hours post-transfusion, confirmed on 2 consecutive transfusion episodes. The most common causes are non-immune (sepsis, bleeding, DIC, antibiotic or antifungal therapy) rather than immune (anti-hla or antiplatelet antibodies). If a patient fails to achieve an increment on more than two occasions then non-immune causes should be considered and treated if possible. Blood should be sent to the tissue typing laboratory at the National Blood Service at Sheffield (NOT the local hospital) to look for antibodies. This must be discussed with them first (Tel: ) and the transfer of samples arranged through the LGI Blood Bank. If a report confirms a relevant antibody then the patient will require HLA matched platelets please discuss with Haematology Registrar or Consultant. It is essential that the local Blood Bank are kept in the picture as any matched platelets will be issued through the lab. When transfusing HLA matched platelets a 1 hour increment must be done to check whether the platelets are effective. Failure to do so may result in no further HLA matched platelets being issued as the team at the NBS would be unable to assess the efficacy of the platelets already issued leaving them unable to provide suitable platelets. Rarely platelet specific antibodies may be encountered please discuss with Haematologist. Expert transfusion medicine advice is available 24/7 through the Blood Service. 2.4 Transfusion Reactions Transfusion reactions (other than mild febrile and urticarial reactions) must be reported to the Blood Bank as they will need to be investigated by the Hospital Transfusion Team (HTT) and may be discussed at the Hospital Transfusion Committee and, if indicated, be reported to SHOT and SABRE. Severe and rare reactions should also be reported to a Haematologist for advice on management. Severe Reactions (Defined as: a rise in temperature >2ºC above patient baseline +/- threatening symptoms) If a severe reaction is suspected the transfusion must be stopped immediately and the unit, together with the attached infusion set, returned to Blood Bank along with appropriate blood samples from the patient (discuss with laboratory). Further management should be discussed with a Haematologist. NB in the case of serious reactions, ALWAYS check that the identity details on the blood bag label correspond with those on the patient s wristband. Remember, if your patient is getting the wrong blood, another patient may be receiving the other bag! Acute Haemolytic Transfusion Reaction suspect if patient feels back pain, shivery, feverish, or there is hypotension, haemoglobinuria, oliguria or evidence of DIC, often within Page 14 of 18

15 the first few ml of transfusion. This is usually due to the transfusion of ABO incompatible blood and has a high mortality rate. Bacterial contamination of blood component all blood components should be inspected before administration. If there is any evidence of contamination (unexpected cloudiness, odd colour or haemolysis) then the component must be returned to blood bank immediately (administration of infected components is often fatal). This should be suspected if the patient becomes febrile (>39 C or greater than 2 C higher than the baseline) and hypotensive soon after commencing the transfusion, usually within transfusion of 100 ml). The symptoms and signs of bacterial sepsis and acute haemolysis can, initially, be indistinguishable and both diagnoses should always be considered if a patient becomes acutely ill soon after starting transfusion of a blood component. Less Severe Reactions (Defined as: a rise in temperature <2ºC above patient baseline 1. Febrile Reaction ( non-haemolytic febrile transfusion reactions ) These are commonly seen towards the end of a transfusion or shortly afterwards. The patient develops a temperature and may complain of headache and/or shivering. If the temperature rise is less than 2ºC and the transfusion is still running, slow the transfusion and assess the patient carefully. If the patient is well and not neutropenic, give paracetamol and restart the transfusion at the original rate. If the patient is neutropenic but well, give paracetamol and complete the transfusion. Antibiotics should be started (after culturing the patient) if the criteria for febrile neutropenia are met (temperature >38 C, neutrophil count <0.5 ). If the patient becomes unwell or a severe reaction is suspected then the transfusion must be stopped immediately and the patient managed as for a severe transfusion reaction. Neutropenic patients should be cultured and started on antibiotics if not already on them. 2. Urticarial or allergic reactions These are commonly caused by allergy to plasma proteins and therefore more commonly occur following transfusion of platelets or plasma components. These reactions do not necessarily recur with subsequent transfusions and a single episode does not require the routine prescription of premedication. Hydrocortisone and Chlorphenamine cover should be reserved for patients with recurrent reactions. IgA deficiency, with anti-iga antibodies (very rare), should be excluded if there is recurrent severe urticaria or anaphylactoid reactions. Whenever blood components are transfused, there should be immediate access to a crash trolley containing adrenaline injection in case of anaphylactic reactions. Page 15 of 18

16 3. Delayed Haemolytic Transfusion Reaction (DHTR) This should be suspected if there is a poorer than expected Hb response to transfusion or the patient becomes jaundiced a few days after transfusion. These are due to a secondary immune response of antibodies to antigens on the transfused red cells. The patient was primed by a previous transfusion, but the antibodies had become undetectable in the pre-transfusion antibody screen (most often seen with Kidd antibodies). The patient is typically jaundiced, may have a raised LDH, a positive Direct Antiglobulin (Coomb s) Test and spherocytes on the blood film. DHTR occasionally cause significant renal dysfunction. If suspected, discuss with the Blood Bank and Haematologist to arrange further investigation and advice on management. Blood transfusion reactions should be treated as per the Trust Policy for Safer Transfusion Procedures Rare but potentially severe reactions The following reactions are rare but should be considered in sick patients. If suspected they must be discussed with a Haematologist. 1. Transfusion-related acute lung injury (TRALI) This usually occurs within 6 hours of transfusion. It is especially associated with plasmarich components but may occur after any transfusion). It is usually due to antibodies in the transfused plasma reacting against host leucocytes and sequestering in the lungs. Implicated donors are often females sensitised by pregnancies. Clinically the patients display an ARDS-like picture (non-cardiogenic pulmonary oedema) which may be misinterpreted as LVF due to fluid overload. A high percentage require ventilation. If the patient survives the acute phase there are not usually any long term sequelae. TRALI is probably the commonest cause of transfusion-related mortality in developed countries. The incidence is falling in the UK as most plasma is now sourced from male donors. 2. Transfusion associated graft versus host disease (TA-GVHD) This was the commonest single cause of death associated with transfusion in the UK until 1997 (SHOT Reports). It is caused by donor T cells in the blood component reacting against an immunocompromised or HLA-haploidentical recipient. Clinically there is fever, rash, liver and renal failure and pancytopenia occurring 4-30 days posttransfusion. It is almost uniformly fatal. Prevention is by irradiation of blood components given to susceptible individuals (see earlier section on irradiated blood components). Universal leucodepletion has now made this a very rare complication (two cases reported to SHOT since 1997) but irradiation is still essential for complete protection. Page 16 of 18

17 3 Guideline Effect All staff administering blood components must do so within local Trust and national policies with regard to blood transfusion. This Guideline is intended to assist staff in making decisions on the clinical management of children and young people receiving treatment under the care of the Paediatric and Adolescent Oncology and Haematology unit at Leeds Teaching Hospitals Trust. 4 Equality and Diversity Statement The Leeds Teaching Hospitals NHS Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups. 5 Consultation Process Consultation has taken place throughout the development of this Guideline with the following parties: The Hospital Transfusion Team at Leeds Teaching Hospitals Trust The Paediatric and Adolescent Oncology and Haematology Guideline review Group The Paediatric and Adolescent Oncology and Haematology clinical Management Group at Leeds Teaching Hospitals Trust The Humber and Yorkshire Coast and Yorkshire Cancer Networks Child and Adolescent Group Page 17 of 18

18 6 Appendix RED CELLS Malignant disease on chemotherapy Trigger 80g/L Target 100g/L Undergoing Radiotherapy 100g/L 120 g/l Thalassaemia Major Routine 150 g/l Sickle cell disease ONLY ON CONSULTANT HAEMATOLOGIST ADVICE Volume = (desired Hb current Hb) x 5 x weight PLATELETS Neonates Infants <1 year Children >1 year 10-20ml/kg 1-2 Paediatric Units 1 Adult Dose (= 4 Paediatric Units) No specific procedures LP / Trephines Other procedures <10 x 10 9 /l unless <20 x 10 9 /l if septic or history of minor bleeding <40 x 10 9 /l if brain tumour <75 x 10 9 /l & continuing bleeding or fresh petechiae Discuss if <50 x 10 9 /l Note: marrow aspirates less critical Line insertion VasCath <50 x 10 9 /l Page 18 of 18