SeminarDepartment of Neonatology

BSMMU

EXCHANGE TRANSFUSION

Historical perspectives

• In 1923, Dr James Sidbury, a North Carolina pediatrician, administered a blood transfusion through the umbilical vein to treat a newborn who had hemorrhagic disease.

• The first use of exchange transfusion (also called exsanguination, venesection, or substitution transfusion) for EF was reported by Dr A.P. Hart from Toronto’s Hospital for Sick Children in 1925.

• Postpartum administration of Rh immunoglobulin to Rh-negative mothers who have given birth to Rh-positive infants, which was implemented widely after 1968, has resulted in a dramatic decrease in maternal isoimmunization, cases of EF, and the need for exchange transfusions.

Current Situation

Developed country:

BSMMU:

November 2011 to till now : total 21 cases.

Definition

Repetitive withdrawal of small amounts of blood and replacement with donor blood, until a large proportion of the original volume has been replaced.

Mechanisms

• Exchange transfusion removes- partially hemolyzed and antibody-coated RBCs - Unattached antibodies

• And replaces them with donar RBCs, lacking the sensitizing antigen.

Indication of exchange transfusion

• When phototherapy fails to prevent a rise in bilirubin to toxic levels.• Hemolytic disease of the newborn ABO Incompatibility Rh Incompatibility• Severe sepsis• DIC from multiple causes• Metabolic disorders causing severe acidosis• Severe fluid or electrolyte imbalance• Polycythemia• Severe anemia causing cardiac failure• Acute renal and hepatic failure• Poisoning

In hemolytic disease immediate exchange transfusion is usually indicated if-

• The cord bilirubin level is > 4.5 mg/dl and the cord hemoglobin level is under 11 gm/dl

• The bilirubin level is rising > 1mg/dl/hr despite phototherapy

• The hemoglobin level is between 11 and 13 gm/dl and the bilirubin level is rising > 0.5 mg/dl/hr despite phototherapy.

• The bilirubin level is 20mg/dl or it appears that it will reach 20mg/dl at the rate it is rising.

• There is progression of anemia in in the face of adequate control of bilirubin by phototherapy.

Guidelines for Exchange transfusion for infants 35 or more weeks gestation

• • Risk factors: Isoimmune hemolytic anemia, G6PD deficiency,

asphyxia, temperature instability, hypothermia, sepsis, significant lethargy, acidosis and hypoalbuminemia.

GUIDELINES FOR EXCHANGE TRANSFUSION FOR INFANTS < 35 WEEKS GESTATION

Definition of High Risk group Any of the following factors: TSB at < 48 hours of life, Sepsis, Asphyxia, Acidosis, Direct Coombs’ test positive, G6PD deficiency

Birth wt(g) Normal Risk High Risk501-749 240 190750-999 260 210

1000-1249 280 2301250-1499 300 2501500-1999 320 2702000-2499 340 290

Types of exchange transfusion

• Simple 2- volume exchange transfusion

• Isovolumetric 2- volume exchange transfusion

• Single volume exchange transfusion

• Partial exchange transfusion

• Isovolumetric partial exchange transfusion

Volume exchanged Patient’s blood removed(of patient’s total blood volume) (% of total blood

volume)0.5 volume 39 %1.0 volume 63 %2.0 volume 86 %

4.0 volume 98 %

Antenatal planning

• When possible all high risk pregnancies should have been identified and an agreed care pathway prepared prior to delivery.

• If an infant is expected to have significant haemolytic disease and require exchange transfusion, it is the responsibility of the obstetric team to ensure that the appropriate blood will be available before delivery.

Cord blood if mother Rh negative

• Blood grouping and Rh typing• Hemoglobin• PBF• S. Bilirubin• Coombs test• Reticulocyte count

Donor blood issue• Discuss with the blood bank early and please remember to specify

the actual volume of blood needed.

• Blood bank needs time to prepare blood for an exchange transfusion. On average it takes approximately 1 to 2 hours to issue suitable blood.

However in the presence of complex maternal antibodies, blood bank

may take considerably longer to prepare a “least incompatible” unit.

Criteria of blood: Fresh, irradiated and reconstituted whole blood ( (hematocrit 45 – 50%) made from packed RBCs and fresh frozen plasma collected in CPD.

Type and volume of blood for exchange transfusion SN Condition Type of blood1 Rh isoimmunization Rh negative and blood group ‘O’ or that of baby

Suspended in AB plasmaCross matched with baby’s and mother’s blood

2 ABO incompatibility Rh compatible and blood group ‘O’ ( Not that of baby)Suspended in AB plasmaCross matched with baby’s and mother’s blood

3 Other conditions Baby’s group and Rh typeCross matched with baby’s and mother’s blood

Volume of blood: Twice the blood volume of baby (total volume: 160 to 180 mL/kg) To prepare blood for DVET, mix two thirds of packed cells and one-third of plasma

Prior to exchange• Admit baby to the NICU.• Immediately start phototherapy • When plotting the SBR, use total serum bilirubin (do not subtract direct or

conjugated bilirubin)• Stop feeds and insert IV to ensure that the baby receives hydration for the

duration of the procedure.• Aspirate stomach contents and leave nasogastric tube on free drainage.

Keep nil by mouth.• Check with blood bank that they are aware of a possible exchange

transfusion. Request blood on standby if this has not been ordered antenatally.

• Once a decision to perform an exchange transfusion is made by the neonatal consultant, PHONE blood bank AGAIN so that the blood can be irradiated.

• Irradiated blood must be used within 24 hours.• Explain treatment to parents and obtain written consent.

Procedure of exchange Equipments:

• Radient warmer• Equipment for respiratory support and resuscitation• Equipment for monitoring the heart rate, RR, tem, SpO2.• Equipment for umbilical catheterization.• Disposable exchange transfusion tray.• Nasogastric tube for evacuating the stomach before beginning the

transfusion.• A temerature controlled device• An assistant

Umbilical catheterization

• Aseptic precaution • wrap a diaper around both legs and tape the diaper to the bed.• Clean the umbilical cord area with antiseptic solution. • Place sterile drapes around the umbilicus.• Tie a piece of umbilical tape around the base of the umbilical cord• Excess umbilical cord is cut transversely with a surgical blade or

scalpel, leaving a stump of 1 to 1.5 cm.• Umbilical vessels are identified.• The cord is kept upright and steady by the grip of thumb and fingers

of the left hand of the operator or by the curved hemostat.• The umbilical vein is opened and dilated with the forceps or dilators.• Size of the umbilical catheter: 5 F for infants < 3.5 kg, 8F for >3.5 kg

Correct length of catheter to be inserted:For umbilical vein:• The preferred position of the UVC catheter tip is in the IVC above the

level of the diaphragm (usually at T9).• There are different formulas- - ( 2 x Wt in kg) + 5 + stump length (in cm) - Shoulder tip to umbilicus measurement and follow the graph. - The length from the xiphoid to the umbilicus and add 0.5 – 1.0

cm.For umbilical catheter: - ( 3 x Wt in kg) + 9 + stump length (in cm) - Shoulder tip to umbilicus measurement and follow the graph.

• Once the catheter is in position, aspirate to verify blood return.

• When free flow of blood is obtained, the catheter is usually in a large hepatic vein or the IVC.

• Usually catheter needs not to be passed beyond 7 cm.• Catheter is secured

• Obtain a radiograph to confirm the position. The correct position for UVC is with the catheter tip 0.5 to 1.0 cm above the diaphragm.

• Never advance a catheter once it is secured in place.

If catheter meet resistant• Withdraw the catheter 2 – 3 cm, rotate it and try to reinsert it.

• Try injecting flush as you advance the catheter.

• Pass another catheter through the same opening.

• Apply mild manual pressure in the right upper quadrant over the liver.

Procedure of exchange transfusion

• Aliquot size Weight (grams) Aliquot size (ml) < 1500 5 ml 1500 - 2500 10 ml 2500 - 3500 15 ml > 3500 20 ml

• A temperature controlled device must be used for warming of blood before and during the transfusion

• The blood should be gently mixed after every deciliter of exchange to prevent the settling of RBCs and the transfusion of anemic blood at the end of the exchange.

• The recommended time for exchange transfusion is 1 hr.

• After exchange transfusion Phototherapy is continued.

• Antibiotic prophylaxis after the transfusion should be considered on an individual basis.

Post exchange investigations

• S. bilirubin (total) • S. electrolytes• S. calcium• RBS• CBC

Complications Complication and problems related to catheter:• False passage• Haematoma • Entry into the urachus or peritonium• Catheterization of wrong vessels• Haemorrhage from the umbilical vessels• Ischemia and thrombosis• Infection

Complication related to exchange:• Hypothermia• Cardiac – dysrhthmias, arrest, failure from hypervolemia• Electrolyte abnormalities- Hyperkalemia, hypocalcemia• Metabolic acidosis, metabolic alkalosis• Hypoglycemia• Hyperglycemia• Vascular complications• Coagulopathies• NEC• Oxygen toxicity• Rarely hemolysis- Hemoglobinemia, hemoglobinuria.• Hazards of blood transfusion

Chronic complications:• Anemia• Cholestasis• Portal vein thrombosis, portal hypertension• Graft- versus- host disease• Inspissated bile syndrome