Exchange Transfusion

EXCHANGE TRANSFUSION
• An exchange transfusion is
a medical procedure in
which the blood is removed
and replaced with plasma
or donor blood
Aims
• To lower the serum bilirubin level and reduce the risk of
brain damage (kernicterus);
• To remove the infants' affected red blood cells and
circulating maternal antibodies to reduce red cell
destruction;
• To correct anaemia and treat any potential for heart
failure whilst maintaining euvolaemia
Indications
• Early exchange transfusion has usually been performed because
of anemia (cord hemoglobin < 11 g/dL),
• Elevated cord bilirubin level 4.5 mg/dL)
• A rapid rate of increase in the serum bilirubin level 1 mg/dL/h)

was an indication for exchange transfusion
• Moderate rate of increase (0.5 mg/dL/h) in the presence of

moderate anemia (11-13 g/dL).
• The serum bilirubin level that triggered an exchange transfusion

in infants with hemolytic jaundice was (20 mg/dL)
BLOOD VOLUME
• The volume of blood for exchange is calculated using an
estimate of the neonate’s circulating blood volume:
• Term infants 80ml/kg
• Preterm infants 100ml/kg

TYPES
• Double volume exchange transfusion most commonly
used for removal of bilirubin and antibodies
• 2 x circulating blood volume (for example, for a term
infant 2 x 80ml/kg = 160ml/kg)
• Replaces approximately 85% of the blood volume
• This will cause an approximate reduction of 50% of the
pre-exchange bilirubin level
• Single volume exchange transfusion
• 1 x circulating blood volume (for example, for a term infant
80ml/kg)
• Replaces approximately 60% of the blood volume
• Consider when etiology is not Haemolytic Disease of the
Newborn
• Partial exchange transfusion for polycythaemia using
normal saline
• Where desired haematocrit following exchange
transfusion is 0.55, the volume of exchange (mls) can be
calculated as follows:
(actual Hct – desired Hct) x infant’s blood volume (mls)
actual Hct
Preparation of the Infant
• Medical staff should discuss the procedure with the
parents/guardian and obtain consent
• Exclusively allocate at least one doctor and one nurse to care of
the infant throughout the procedure
• Ensure resuscitation equipment and medications are easily
accessible
• Nurse infant under radiant warmer for accessibility
• Ensure infant is comfortable and settled – sedation and pain
relief are not usually required unless the infant is active and
likely to compromise line stability or sterile field
• Ensure full cardio-respiratory monitoring is initiated and
document full set of baseline observations (temperature,
respiratory and heart rate, blood pressure and
oxygenation)
• Infant should be nil orally as soon as decision is made to
perform exchange transfusion.
• Pass oro/nasogastric tube and aspirate stomach contents.
• Leave tube in-situ and on free drainage for duration of
procedure Before commencing exchange transfusion
collect blood samples for required baseline bloods and
any specific testing required.
• Tests may include (but not be limited to) blood cultures,
blood gas, serum bilirubin, blood glucose, LFT,
newborn screening test, haematological, chromosome or
metabolic studies Establish vascular access for procedure
• Check blood as per Procedure “Blood Transfusion”
Equipment
• Plastic aprons or protective gowns
• Protective eye wear
• Sterile gloves Blood warmer
• Blood administration set
• Urine drainage bag
• Exchange transfusion recording sheet
• Sterile drape
• 3-way taps
• Resuscitation equipment including medications and
fluids
• Pathology collection tubes as required
• Alcohol swabs
• Sterile gauze
• Packed red blood cells
• Fresh frozen plasma (ordered but do not collect from
blood bank until required)
Set-Up
• Exchange transfusion should be performed slowly over
approximately 2 hours to avoid major fluctuations in
blood pressure.
• Anticipate the need for increased oxygen requirement
during procedure (administer oxygen via nasal cannula
in self ventilating babies if required).
• Set blood warmer at 41oC.
PROCEDURE
• Using aseptic technique: Connect the blood
administration set to the blood warming coil and clamp
off the lines Insert the administration set spike into the
bag of red cells
• Release the clamp and prime the line/coil with blood.
• Clamp off the lines and maintain the sterility of the end of
the line
• Attach the IV set to the urine drainage bag.
• Secure with a strip of PLASTER.
• Fasten the urine drainage bag below the cot
• Strict aseptic technique should be maintained
throughout procedure.
• Record baseline observations (infant temperature, heart
rate, respiratory rate, blood pressure, oxygen
requirement, oxygen saturations, neurological status)
prior to commencement of procedure.
• Isovolumetric exchange
• Isovolumetric or simultaneous exchange where access is
via an umbilical venous catheter (blood in) and an
umbilical arterial catheter (blood out).
• Push pull method When using the same catheter that is
the RBCs / FFP are pushed in and pulled out through
the same umbilical venous catheter. (10-20ml)
• The minimum time for this procedure is 2 hours or more
depending on the volume of blood to be exchanged.
Post Exchange Care
• Remove the exchange circuit and prime new intravenous
infusion set
• Ensure all intravenous and arterial connections are secure,
the infusion pump is zeroed and alerts are set.
• Ensure infant is clean and dry and repeat all observations
• Notify parents that the procedure has been completed and
their infant is comfortable
• Perform blood glucose levels and ABGs (if indicated) 30
minutes after exchange
• . Repeat FBC, creatinine, sodium, potassium,
magnesium, calcium, glucose and SBR as indicated post
exchange
• . Monitor infant for abnormal signs and possible
complications including thrombocytopenia, bleeding,
signs of infection, feed intolerance or abdominal
distension
• Follow up should be arranged with attending staff
specialist as requested
COMPLICATIONS
Hypothermia
Hypoglycaemia
Hyperkalaemia
Hypocalcaemia
Thrombocytopaenia
Air Embolus
Anaemia/Polycythaemia
Necrotising Enterocolitis

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EXCHANGE TRANSFUSION

• Elevated cord bilirubin level 4.5 mg/dL)

• A rapid rate of increase in the serum bilirubin level 1 mg/dL/h)

• Moderate rate of increase (0.5 mg/dL/h) in the presence of

• The serum bilirubin level that triggered an exchange transfusion

• Term infants 80ml/kg

• Preterm infants 100ml/kg

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