welcome
EXCHANGE
BLOOD
TRANSFUSION
INTRODUCTION
An exchange blood transfusion involves
removing aliquots of patient blood and replacing
with donor blood in order to remove abnormal
blood components and circulating toxins whilst
matching adequate circulating blood volume
definition
It is the process by which blood is removed from a
baby in a small aliquots and replaced by an equal
volume of fresh blood, plasma or saline.
It is life saving procedure that is done to counteract
the effects of serious jaundice or changes in the
blood due to diseases such as sickle cell anaemia. It
involves slowly removing the persons blood and
replacing it with fresh donor blood or plasma.
OBJECTIVES
To correct the anaemia by replacing
the Rh-positive sensitized red cells
with compatible Rh-negative red cells.
Remove the circulating antibodies.
Eliminating circulatory bilirubin.
Indication
Rh-positive with direct coomb’s test positive
babies having:
Cord blood haemoglobin less than 15gm%.
Previous definite history of an affected baby
due to haemolytic disease.
Birth weight less than 2500gm.
Rapidly developing jaundice with conjugated
bilirubin above 5mg%
Hyperbilirubinaemia : it is done in infants
with bilirubin levels high enough to cause
CNS toxicity , irrespective to cause. Two
volume exchange done over 60-70 minutes is
usually recommended, the slower the
exchange the better the bilirubin removal.
Haemolytic disease of the newborn: double volume
exchange helps in reducing the bilirubin level,
removing isoimmunising antibodies and correcting
anaemia.
Sepsis: double exchange volume will help in
removing bacteria, toxins , fibrin split products and
accumulated lactic acid. Fresh blood will provide
immunoglobulins , complement and congugating
factors.
Disseminated intravascular coagulation: single
or double volume exchange will help replace
coagulation factors.
Metabolic disorders: this may be done in
conjunction with peritoneal dialysis.
Severe fluid or electrolyte imbalance.
Cont…
Polycythaemia: symptomatic babies with
a hematocrit of above 65% may have
reduction in velocity and hematocrit if
performed with normal saline.
Severe anemia: specially with hydrops may
benefit from partial exchange with packed
cells.
TYPES OF EXCHANGE
Simple double volume
exchange.
Isovolumetric two volume
exchange transfusion.
Partial exchange transfusion.
Simple double volume exchange
The blood volume/kg weight in a newborn is
80ml. In a double volume exchange 160ml of
blood/kg is used. Thus a 3kg baby would need
160*3= 480ml of blood.
It involves push pull techniques through one
single cannula.
This is used for babies who are relatively well and
who can stand volume shifts during the
procedure.
The size of aliquots is determined by the weight of
the baby.
Infant weight Aliquot(ml)
More than 3kg 20
2-3kg 15
1-2 kg 10
850g-1kg 5
Less than 850g 1-3
Isovolumetric two volume
exchange transfusion
The volume of blood used and size of aliquots is
the same as above.
This uses a double set up with infusion via the
vein and withdrawal via the artery or another
vein.
The umbilical vein and artery may be used. It
can also be done from a periphery artery and
vein or any combination of both
This method is preferred for very small and
sick babies where large volume shifts
during exchange may not be tolerated.
Partial exchange transfusion
In this smaller volumes of blood are
exchanged as determined by the following:
Volume of exchange(ml)=estimated blood
volume x weight(kg) x (observed hematocrit –
desired hematocrit)
Observed hematocrit
Cont….
This is usually done for polycythemia with
normal saline and with packed cells for
hydrops fetalis.
EQUIPMENTS
Reusable Disposable
An autoclaved tray Gloves -2 pairs
containing:
Cup with cotton balls and Sterile blade no. 11 -1
gauze pieces.
Sponge holder -1 Micropore plaster -1
BP handle -1 Face masks -2
EQUIPMENTS
Reusable Disposal
Artey forceps -6 Umbilical arterial,venous -1 or
double lumen catheter -1
Non toothed forceps -1 3 way taps -2
Toothed forceps -1 Syringes -4
Vein dialator -1 Povidine - iodine
Reusable Disposal
Iris forceps-1 Blood set -1
Needle holder -1 Water feed bag
Square towel -1
Central hole towel -1
Sterile gown and protective
eye wear -1
OTHERS
Resuscitation trolley
Radiant warmer
Cardiopulmonary monitor
Pulse oximeter
Blood warmer
Pathology collection tubes as required
Packed red blood cells
Fresh frozen plasma
SELECTION OF BLOOD
PRODUCTS
Blood less than 72 hours old is preferred
Irradiated blood should be used if availale
For all iso-immunisations, the blood should be
cross matched with mothers plasma and RBC.
For Rh incompatibility: the blood should be O
group, Rh negative with low anti –A anti – B titres.
For ABO compatibility: the blood should be group
O with compatible Rh.
For minor group incompatibility : the blood
should be of the same group as the baby’s Rh
factor should be taken into consideration
while finding a match.
For other conditions the blood should be cross
matched with baby’s plasma and RBC.
For sepsis, blood less than 24 hours old should
be used.
The blood should be warmed to 37*C by
leaving it at room temperature for a while or
using a blood warmer, if available.
Appropriate volume of blood exchange.
PREPARATION OF THE INFANTS
Medical staff should discuss the procedure with the
parents/ guardian and obtain consent.
Advice consultant neonatologist on duty as soon as
decision to exchange is made.
At least 1 doctor and 1 nurse should are for the infant
through out the procedure.
When exchange transfusion is taking place the
consultant neonatologist on duty should be present on
the unit to provide support and to
carry out procedure without interruption.
Ensure resuscitation equipments and easily
available and accessible.
Nurse infant under radiant warmer for
accessibility.
Ensure infant is comfortable and settled.
Ensure full corresponding monitoring is initiated
and document full set of baseline observations .
Infant should be nil per orally as soon as decision
is made to perform exchange transfusion. Pass
NG/ Oral 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.
Establish access for procedure if not
already in-situ depending on whether the
procedure will be performed via arterial
and venous access or via single venous
access.
Check blood as per RCH procedure
“blood transfusion”
PROCEDURE
• The procedure should be explained in
detail to the parents and a written
consent must be obtained.
• The exchange should be performed in
an NICU setting under a servo control
radiant warmer.
The baby should be placed under the
warmer, the stomach should be emptied
and a NG tube must be inserted. Baby
should not be fed orally during
exchange and at least for 4 hours
thereafter.
A peripheral TV dextrose line should be
commenced for maintenance during
procedure.
SIMPLE DOUBLE VOLUME
EXCHANGE
The umbilical cannula is connected
through 2-3 way taps.
the blood is withdrawn from the baby
as per the aliquot determined earlier.
This is discarded.
An equal quantity of blood is drawn
from the donor bag and pushed into the
baby.
This procedure is continued till the
calculated amount of blood is
exchanged.
This cannula should be pulled out
and pressure applied for 5 minutes.
ISOVOLUMETRIC VOLUME EXCHANGE
O Two operators are required for this procedure.
O Both umbilical vessels or one peripheral
artery and vein or two peripheral veins are
cannulated.
O The donor bag with plasma, blood or saline is
connected to the vein through a 3 way
stopcock from a syringe pump.
O Blood is withdrawn from the arterial end into a
syringe through a 3 way tap.
O The aliquot required is withdrawn from the
arterial end and at the same time an exact
volume is infused through the venous end.
PARTIAL EXCHANGE
TRANSFUSION
O For a partial exchange, a cannula
can be inserted into a peripheral
vein and blood allowed to drip into
a container or gently drawn into a
syringe. For a small partial
exchange, two peripheral veins are
sufficient.
POST TRANSFUSION CARE
Baby is placed under a radiant warmer.
The umbilicus is to be examined frequently for any
evidence of bleeding.
Serum bilirubin is to be estimated 4 hours after
transfusion and to be repeated after transfusion and
to be repeated as required. Ocassionally , the level
of conjugated bilirubin may remain higher and
phototherapy shoud be continued.
Hypoglycaemia is to be checked by blood
glucose estimation post transfusion 4 hourly.
Keep infant NBM for at least 4 hours post
transfusion, as the direction of medical officer.
Measure urea and electrolytes, fill blood
examination, haematocrit and blood gas on a
regular basis until infant is stable.
INDICATIONS OF REPEAT
EXCHANGE TRANSFUSION
Bilirubin level again rising to near
the critical level of 20%.
Hb. Level again falls to less than
11gm.
complications
Immediate complications:
Cardiac failure due to raised venous
pressure and overloading of the heart.
Air embolism.
Clotting and massive embolism.
hyperkalaemia.
Tetany.
Acidosis
Sepsis.
Hypoglycaemia.
Coagulopathies due to
thrombocytopenia.
Delayed complications:
Narcotizing entero – colitis.
Extrahepatic portal hypertension due
to thrombosis of portal vein.
ADJUVANT THERAPY
Phototherapy
Photochemical
Phenobarbitone.
antibiotics
PHOTOTHERAPY:
• It is continued for 24 hours. Blue or
blue green light of 420-470nm
wavelength degrades bilirubin by
photo- oxidation and structural
isomerization and excreted through
urine and bile.
PHENOBARBITONE:
• 3-5 mg/kg body weight is to be
administered thrice daily IM. It increases the
glucuronyl transferase enzyme activity in
the fetal and neonatal liver to conjugate the
bilirubin which hastens its clearance.
PHOTOCHEMICAL:
• Reaction converts bilirubin into
less toxic and water soluble polar
isomer or to lumirubin.
ANTIBIOTICS:
• Should be given for 3-5 days.
Summary
• An exchange transfusion requires that the
patient’s blood can be removed and
replaced. In most cases, this involves
placing one or more thin tubes called
catheters, into blood vessels.
Thank you
