JOURNAL CLUB PRESENTATION

28 June 2022

Dr Nurliyana Binti Mohamad Ghani

INTRODUCTION

• Hemolytic disease of the fetus and Newborn (HDFN) is characterized by presence of IgG antibodies in maternal circulation, which causes hemolysis in the fetus by crossing the placenta and sensitizing red cells for destruction by macrophages in the fetal spleen with consequent hyperbilirubinemia. _{Hardley et al}
• It is classified as :
1. RhD HDFN
2. ABO HDFN
3. HDFN due to other blood group antibodies (non-ABO, non-RhD)
• Exchange transfusion (ET) with or without phototherapy is one of the choice for treating the newborn with ongoing hemolysis.
• ET removes indirect serum bilirubin, circulating mother’s antibodies and antibody coated neonate’s red blood cells (RBCs) from the circulation and provides RBCs compatible with neonate’s serum and albumin with new bilirubin binding sites. _{Peevy et al}
• ET can be performed using many different combinations of blood components,
• fresh whole blood
• packed RBCs reconstituted with fresh frozen plasma (FFP).
• In the present study, reconstituted blood was used for ET.
• The objective of this study was to establish the role of reconstituted blood for ET in HDFN to decrease indirect bilirubin level and to increase hemoglobin level.

​

​

​

MATERIAL AND METHODS �

MATERIAL AND METHODS

The reconstituted blood was prepared in the blood bank by standard method of preparation of component, i.e., centrifugation and separation method followed by mixing fresh frozen plasma (FFP) and Red cell concentrates / saline- washed RBCs as below mentioned:

• Take fresh O negative red cells which are preferably less than 5 days old.
• Add 0.9% normal saline equal to the amount of red cell with the help of sterile connective device and laminar air flow under aseptic condition.
• Centrifuge at 3500 rpm for 10 minutes in refrigerated blood bag centrifuge at 4 ̊ c.
• Once the spin is over, put the bag in plasma expresser. Break the seal and express out the entire plasma and saline under laminar air flow. Seal the segment with the tube sealer.
• Repeat the whole procedure three times.
• Thaw AB positive/negative FFP at 37ºC in a plasma bath and add FFP in red blood cell bag with the help of sterile tube connecting device.
• Transfer the volume of FFP which is equivalent to 1/3rd volume of red cell. Mix well and issue as early as possible.
• It has to be used within 24 hours.

​

MATERIAL AND METHODS

Volume of RBCs and FFP to be ordered

• The volume required is dependent on the reason for exchange and is determined by the formula below.

�(1) Single volume exchange (anaemia with normovolaemia)

• Estimated single blood volume = 85ml x weight (kg)

(2)Double volume exchange (for established hyperbilirubinaemia or to prevent hyperbilirubinaemia)

• Estimated double volume to be exchanged (ml) = 85ml x {2 x weight (kg)}�= 170 ml x weight (kg)

​

• Under all aseptic precautions, exchange transfusions were performed under antibiotic coverage in the PICU by CONTINUOUS technique where access was via an umbilical venous catheter (blood in) and an umbilical arterial catheter (blood out).

​

• Blood withdrawal at each cycle is about 10ml/kg. Blood exchange at each cycle varied with the weight, maturity and general condition of the newborn.

​

• In the present study, the volume of blood used for exchange transfusion was calculated as 160 ml/kg in term neonates and 180 ml/kg in preterm neonates.

​

• Post-exchange blood was collected for estimation of hemoglobin, hematocrit, indirect serum bilirubin and direct antiglobulin test

​

​

~This was an observational study in which the fall of serum indirect bilirubin level and rise of hemoglobin level after using reconstituted blood for ET was observed in neonate suffering from HDFN.

​

Result�

• ET was done in total 31 cases by reconstituted blood.
• The total numbers of male cases were 21 (68%) whereas total numbers of female cases were 10 (32%) as shown in figure 1.

​

​

​

​

​

In this study average age of newborn was 3 days (range 0 - 9 days), average weight of newborn was 2.40 kg (range 1.1 – 3.2 kg), and average volume of reconstituted blood used was 384 ml (range 176 - 512 ml)

(Table 1)

​

Result

• Pre and Post Exchange transfusion; indirect bilirubin and hemoglobin values are shown in table 2.

​

Post-ET mean of fall of indirect serum bilirubin among different groups was 52.12% in RhD HDFN, 56.59% in ABO HDFN and 54.12% in other group HDFN while average increase in Hemoglobin was 3.06 gm/dl in RhD HDFN, 2.4 gm/dl in ABO HDFN and 4.67 gm/dl in other group HDFN. (Figure 4 and 5)

Rise in Hb (hemoglobin) after ET (exchange transfusion)

Fall in billirubin after ET (exchange transfusion)

Result

�

​

​

Most common cause of HDFN in this study was RhD HDFN, which constituted 20 cases (64.51%) while ABO HDFN and other group HDFN (non-ABO, non-RhD) were 8 (25.80%) and 3 (9.6%) respectively. (Figure 2)

​

​

The range of pretransfusion indirect bilirubin in all the cases was 18.0 - 44.2.0 mg/dl.

​

​

Out of 31 cases, in 19 cases (61%) ET has been performed once while 12 cases (39%) required ET twice.

​

​

Among 20 (64.51%) cases of Rh HDN, 12 cases (60.00%) in which indirect bilirubin was < 30 mg%, required exchange transfusion only once; and for 8 (40.00%) cases, in which pretransfusion indirect bilirubin was ≥30 mg%, required two ET. (Figure 3)

Discussion

• Present study was conducted to evaluate the usefulness of reconstituted blood in ET in HDFN.
• In this study, Rh HDFN was the main cause of HDFN with 20 cases (64.51%) while incidence of ABO- HDFN and other group HDFN (non ABO non Rh) were 8 cases (25.80%) and 3 cases (9.6%) respectively.
• Study done by Sharma DC et al published in the year 2013, which was having 25 cases of HDFN, 15 (60%) cases were of Rh HDFN and 06 (24%) cases were of ABO HDFN, whereas 4 (16%) cases were of other group HDFN.
• In all cases mean fall in post ET indirect serum bilirubin was 53.47%, which was better than the other studies in which fall in post ET indirect serum bilirubin was, 52.01% (Sharma et al), 51.9% (Odell et al)and 52% (Merchant et al) respectively while it was comparable to mean fall in post ET indirect serum bilirubin level (54.6%) of study done by Sharma DC et al. (2013)
• In 8 cases of ABO-HDFN where average post-ET indirect serum bilirubin fall was 56.59%, which is more than the previous studies done by Sharma DC et al (2007) in which it was 54.3% and Sharma DC et al (2013) 54.12%.

• In the present study the mean total serum bilirubin level before ET was 29.59±6.88 mg/dl and immediately after ET was 11.51±3.72 mg/dl. P value was < 0.05, so the difference was statistically significant so the ET was effective treatment.

​

• In present study, out of these 31 cases, in 19 cases (61%) ET has been performed once while 12 cases (39%) required ET twice and the range of total serum bilirubin was 18.0 - 44.2 mg/dl and 30 - 39 mg/dl respectively.

​

• In the present study, pre transfusion mean hemoglobin (Hb) is 12.00 gm/dl and post transfusion mean Hb is 15.06 gm/dl, concluded an average increase of post transfusion Hb by 3.06 gm/dl, which was comparable with the study done by Sharma DC et al (2013) in which pre transfusion mean Hb was 12.46 gm/dl and post transfusion mean Hb was 16.17 gm/dl, so average increase in post transfusion Hb was 3.71 gm/dl.11

​

• In the present study an average increase of Hb in RhD HDFN by 3.12 gm/dl, in ABO HDFN by 2.4 gm/dl and in other group HDFN by 4.67 gm/dl.

​

• In the present study, the third group was of other blood group HDFN categorized as non-RhD and non ABO HDFN, in which irregular antibodies were anti C in two cases and in one case it was anti c.

​

• Prior to the introduction of ET, liveborn infants with severe rhesus hemolytic disease had a 35-40% mortality, with a 90% risk of severe neurological damage among survivors, A reduction in mortality to 20% and reduction in adverse neurological outcome to 30% was observed following the introduction of double volume ET.

​

• The efficacy of ET with regards to long term neurological outcome is related to the etiology of hyperbilirubinemia and the population in which ET is undertaken. ABO incompatibility often results in a less severe hemolytic disease, needing fewer ET compared to rhesus incompatibility.

Table 3. TSB Levels for Phototherapy and ET in Babies ≥35 Weeks Gestation

(Adapted from Malaysian Neonatal Jaundice Clinical practice Guidelines)

Conclusion

• In the present study, an average fall in indirect serum bilirubin was 53.47%, and an average increase of Hb was 3.06 gm/ dl which was resulted from removal of sensitized RBCs and circulating mother’s antibodies.

​

• Fresh whole blood of the appropriate blood group is not always readily available, reconstituted blood is an alternative blood component for exchange transfusion.

​

• Hence it can be concluded that exchange transfusion in HDFN should be carried out by reconstituted blood, provided that reconstitution of the blood components done as per standard guidelines.

​

PDN DATA REGARDING WHOLE BLOOD RECONSTITUTE AND WHOLE BLOOD

Work Instruction

PROCEDURE FOR RECONSTITUTE WHOLE BLOOD IN PDN�

1. Received request from hospital for reconstitute and then from the Blood Supply Management Section; BSM (Inventory)
2. BSM (Inventory) will pass blood bag red cell AS 42 Leucodepleted and the pathogen inactivated (PI) AB Rh(D) positive Fresh Frozen Plasma units from BSM (Inventory)
3. Before reconstitution, all red cell must be filtered. Reconstitution must be completed within 3 Hours (between time of RC and fFFP received) and time they are issuing back to BSM (inventory)
4. Calculation of RC to FFP must be 85%:15%.

Add plasma volume by following the calculation below:

​

Volume of Red Cell AS 42 Leuco-depleted X 15 = Volume of PI FFP

85

• Thaw the PI FFP unit(s) using water bath. Make sure FFP immerse for 15 minutes or until its defrost. If any evidence of leakage or contamination, all product must be discarded

​

​

​

6. Red cell AS 42, leucodepleted connect PI AB Rh (D) positive FFP using sterile docking device
7. Then transfer AB FFP into Red cell AS 42, leucodepleted bag and mix blood thoroughly.
8. Heat seal the blood bag tubing and make 3 segment (3cm each) using blood tube sealer.
9. Collect approximately 2 mls reconstituted, whole blood from segment into plain tube for haematocrit reading. Fill in form with the requirement investigation, FBC for hematocrit value.

**Acceptable haematocrit value should be between 45%-55%.

• Make sure once product ready for issuing, write the new DOE and time of expiry 24 hours from the preparation date.

​

​

​

FORM RELATED TO RECONSTITUTE WHOLE BLOOD

THANK YOU