A Medical Director of Transfusion Medicine at a hospital in Missouri reports that her hospital is looking into the possibility of providing only group O blood for their neonates. These units would be prepared from AS-1 RBCs that had undergone a hard spin to remove most of the plasma. They are interested in finding out how other institutions handle this and, if group O blood is used exclusively, have there been any problems with hemolysis in group A and group B infants? Currently they use group-specific red cells for their neonatal transfusions, but feel that switching to only group O would allow them to better manage their inventory and perhaps limit donor exposure for these infants.

The following responses have been received.

1. A facility in Alaska has a 40-bed neonatal intensive care unit. Their neonates needing RBC transfusions are given group O Rh Negative, CPDA-1 Leukoreduced Red Blood Cells, that are also CMV Seronegative. The units are aliquoted so that they may used throughout their shelf-life. They have not experienced any problems in transfusing group O RBCs to group A and group B infants.

2. A transfusion medicine colleague in Dallas, Texas reports that his hospital delivers approximately 17,000 babies a year (!). They provide only group O Rh-negative blood, in order to manage inventory as well as to avoid mismatched transfusion in a nursery that has over 100 neonates every day. They use AS-3 RBCs, which has no mannitol. They dedicate a unit to each infant and use aliquots from it to decrease the number of donors to which each is exposed. They have received no reports of hemolysis in group A or group B blood group neonates, probably due to the lower volume of plasma in this product and the poorly developed A and B antigens on neonatal red cells.

ADDENDA July 7, 2003

3. A Canadian colleague reports that at her blood bank they use group O Rh negative RBCs for all of their RBC transfusions to neonates, in order to minimize the outdate of RBC units for this patient group. They use AS-3 RBCs that are up to 21 days old.

ADDENDA July 8, 2003

4. A colleague in upstate New York reports that his hospital has been using group O red cells for many years for neonatal transfusions. Currently they are issuing group O, Rh compatible (Rh pos to Rh pos; Rh neg to Rh pos or Rh neg) leukocycte reduced AS-1 red cells without centrifugation. RBC's are irradiated for neonates with a birth weight less that 1200 grams.

ADDENDA July 10, 2003

5. Another colleague in Texas says that she cannot allow this commentary on group O's for neonates to go unanswered. In a previous life, she was medical director at a large children's hospital which provided care to many neonates. She reports that they always used group-specific blood for these patients. She thinks some blood bankers are uncomfortable with using group-specific blood because there is often a lack of a reverse grouping confirmation of the neonate. She believes this is a weak reason for using group O cells, which are usually in short supply. In her experience, hemolytic reactions are extremely rare in neonates. Often, when infants were transferred with group O cells instead of group-specific, there was an annoying mixed field pattern. In her practice they used washed group O red cells and group AB plasma to deal with these as long as necessary. They allocated one or two neonates to a unit of Adsol (AS-1) blood, and used the sterile connecting device to draw aliquots as needed, up to the day of expiration. She knows various elements of this approach are controversial, but there is substantial evidence of its safety. In her opinion, this minimizes donor exposure. Except in the tiniest of hospitals or those who use only the freshest blood, she doubts if using group O red cells truly saves inventory except at the cost of increased donor exposure.

ADDENDA July 11, 2003

6. A physician in Philadelphia who is the Director of Transfusion Medicine at a children's hospital in that city agrees with the response from the colleague in Texas (response #5) that it is fine to use group-specific red cells for neonatal transfusions when the reverse grouping of the neonate does not show ABO alloantibodies. (She comments that they see anti-A antibodies when doing back-typing occasionally in group A babies born to group O mothers, in which case they do use group O red cells for those neonates). She comments that, in her opinion to only use group O red cells for all neonates may give one a sense of security but when group O blood is in such short supply, and group A blood is more likely to expire on the shelf than be in short supply, her feeling is to do what is right for the community. Since as a blood bank director she feels responsible for the transfusions of all the patients in her hospital, she tries to think of what is best for all, while still ensuring individual patient saftey.

7. A blood bank medical director at a Children's Hospital in Northern California reports that they have chosen to use group O, Rh compatible, leukoreduced, washed red cells for neonatal transfusion. In their opinion, inventory management is much easier using a single unit for all of the neonatal transfusions in a 24-hour period. In addressing issues of risk, they feel the increased donor exposure from this technique provides very small risk of transfusion-transmitted infection, in complarison with the much larger risk of patient or blood misidentification and potential hemolytic transfusion reactions. He is aware that some colleagues may think that red cell washing is overkill, but they have experienced hemolytic reactions in group A babies who received standard red cells from group O donors with high-titered anti-A. They report having very little blood wastage with this approach.

8. A retired ARC Medical Director in Palo Alto asks his neighboring colleague (in response #7 above) whether the hemolytic reactions he has observed from unwashed group O blood were from red cells collected in CPDA-1 solution. With the trend toward use of red cells suspended in additive solution, in which there is very little residual plasma, it would seem that washing would be unnecessary.

9. The blood bank medical director (comment #7 above) responds to his Palo Alto colleague as follows: The anticoagulant was CPDA-1 in both cases.

ADDENDA July 14, 2003

10. A colleague from the UK would like to refer correspondents to the recent guidelines issued by the British Committee for Standards in Haematology Transfusion Task Force on Transfusions for neonates and older children, published on the website www.bcshguidelines.com (click on 'guidelines' then on 'blood transfusion' - PDF). These comprehensive guidelines advocate same blood group wherever possible.

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Ira A. Shulman, MD
CBBS e-Network Forum Editor & Moderator