Exchange Transfusion Flashcards
Exchange transfusion definition
Replacing an infant’s blood with donor blood (or isotonic fluid) by repeatedly removing and replacing small aliquots of blood over a short time period
Types of exchange transfusions
Single volume: replaces approx 60% of infant blood volume
Double volume: replaces approx 85%
Partial volume exchange: variable; for polycythemia or severe anemia correction (in some cases)
Exchange transfusion primary indications
Significant hyperbilirubinemia (from any cause) with concern for actual or impending neurotoxicity (most common)
Alloimmune Hemolytic Disease of the Newborn (HDN)
Severe anemia with congestive heart failure or hypervolemia
Polycythemia, particularly with signs and symptoms of hyperviscosity
Exchange transfusion secondary indications
Metabolic toxin removal (hyperammonemia, organic acidemia)
Drug overdose/toxicity
Severe disseminated intravascular coagulation (DIC)
Sepsis
Congenital Leukemia
Exchange transfusion contraindications
When alternatives would be as effective with less risk (phototherapy, simple transfusions, +/- peritoneal dialysis)
Unstable patients where risks of exchange transfusion out- weigh the benefits
Double Volume Exchange Transfusion (DVET)
2 x infant’s blood volume + tubing dead space volume
Term infant approx 80ml/kg blood volume
Preterm infant approx 100ml/kg blood volume
Example: 3kg term infant and 25 ml dead space in tubing
2 x (3kg x 80ml/kg) + 25ml = 505 ml
Partial Exchange Transfusion
Most commonly used for polycythemia with signs and symptoms of hyperviscosity
Consider for initial correction of severe anemia with CHF/hypervolemia
For correction of polycythemia (replace with 0.9%NS)
Estimated blood volume = EBV
Volume of exchange (ml)=
EBV (ml) x weight (kg) x (Observed Hct-Desired Hct)
Observed Hct
Blood Product Selection- Double Volume
Plasma-reduced whole blood or PRBC’s reconstituted with plasma (goal 50-60% RBC’s)Special attention to compatibility testing
Infants with Rh incompatibility:
Must be Rh negative, either type O or same blood type as infant
Infants with ABO incompatibility:
Must be type O, Rh compatible with infant and mother, low-titer anti-A and anti-B.
Must be cross matched to both infant and mother.
Can consider Type O cells with AB plasma but then infant would have 2 donor exposures.
Blood Product Selection- partial exchange
Use isotonic saline (not plasma or albumin)
Equipment
Blood warmer
Blood products
Sterile exchange transfusion tray
Equipment for line placement, if not already done
Personnel (Primary RN, NNP/MD, Recorder, Backup personnel)
Infant prep for exchange transfusion
Infant should by on a warmer with all monitoring equipment in place
Emergency resuscitation equipment should be readily available including medications and suctioning equipment
NPO with OGT (empty stomach)
Vascular access: Optimal UVC, UAC (or PAL) and at least 1 peripheral IV to continue uninterrupted glucose infusion and medications as indicated.
Infant restraints as needed
Continue phototherapy during procedure if hyperbilirubinemia
Lab tests prior to exchange
CBC
Electrolytes, Glucose, Calcium, Blood Gas
Coagulation studies
Fractionated Bilirubin
Newborn Metabolic screen
Other diagnostic testing as indicated
Push-Pull technique
Alternate pushing in aliquots of new blood (or saline) with pulling out old
Aliquot for each pass in push-pull technique=
5% of estimated blood volume plus dead space in catheter/stopcock
Minimum 5ml per pass
Maximum 20ml per pass
Each pass should take 3 to 5 minutes
Total 90-120 minutes for Double Volume Exchange
Isovolumetric Technique
Simultaneous withdrawal and infusion
Withdraw and discard blood at steady rate of 2-3 ml/kg/min while infusing at same rate. Keep volumes equal
Arterial Line (usually UAC) for withdrawal
Venous Line (usually UVC) for infusion
Total time for double volume: approx 45 to 60 minutes
Labs during Exchange Transfusion
Glucose every 30-45 minutes
Consider
iCa, Electrolytes, Blood gas
Post-exchange
Monitor closely
Leave infant NPO for at least 4 hours (usually 24 hrs)
Monitor Serum glucoses every 2-4 x 24 hours
Other labs as indicated: Bilirubin,CBC (Hct/plts),Electrolytes, iCa,Blood gas
If for hyperbili due to hemolysis:
check Bili,Hct every 4 hours
May need 2nd exchange
Consider modifying drug orders as needed to compensate for removal
Exchange complications
Most common: Lab abnormalities (may be asymptomatic)
Hypocalcemia
Thrombocytopenia
Acidosis
Hypoglycemia
Hyperkalemia
Apnea and bradycardia
BP disturbances
Vasospasms
Thrombosis
Feeding intolerance/NEC
Sepsis
Omphalitis
Transfusion related complications (infectious disease transmission, hemolytic reactions, transfusion related acute lung injury etc.)
