Double volume exchange transfusion

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The most common indication for a double-volume exchange transfusion is to treat the isoimmunized infant with hemolysis and indirect hyperbilirubinemia. Double volume exchange transfusion replaces 85% of the circulating red blood cells in the infant, improving the infant’s hematocrit and removing the offending antibody, and temporarily decreases serum bilirubin by about 50%.

A double volume exchange transfusion should be done in any infant with active hemolysis and a total bilirubin (mostly indirect) of > 20 mg/dL despite intensive phototherapy, hydration and IVIG.

An exchange transfusion may be indicated sooner in a premature infant or one with simultaneous anemia and a rapidly rising serum bilirubin.

Consider an exchange transfusion in a term infant with severe nonhemolytic hyperbilirubinemia if the TBili remains > 25mg/dL despite intensive phototherapy, hydration and IVIG, or if the TBili is > 30 mg/dL.

Order from the blood bank: Type O Rh – PRBC s resuspended in AB plasma (no antiA or antiB antibodies) crossmatched against the maternal plasma and cells. Specify for "exchange transfusion." The blood bank will use as fresh irradiated blood products and check the pH, potassium, and hematocrit of the donor blood (should be > 50%.) Obtain a volume = 170 ml/kg + 30 ml for tubing losses. The blood should be warmed to 37° C .

The infant should be restrained and closely monitored. Resuscitation equipment should be readily available.

A 5 or 8Fr UVC should be placed using standard techniques and sterile conditions. A specialized kit for an exchange transfusion is available. A separate iv infusion of glucose should be maintained during the procedure.

Blood should be obtained for labs before infusing any donor blood.  Order neonatal state screen, PCV, T bili and electrolytes including iCA.

Exchange blood in ~5 ml/kg passes. The exchange may be done in a push-pull fashion through a double-lumen UVC, PIV and UAC or, in a smaller, unstable baby, may be done isovolumetrically with a steady withdrawal of blood from a UAC while an equivalent amount of donor blood is slowly infused through the UVC or PIV.

Withdraw and infuse at a rate of 2-4 ml/kg/min. Using the push-pull method, each pass should take 3-5 minutes. Slow down if the baby experiences hemodynamic instability (brady- or tachycardia, hypotension.)

After each 100ml of exchange, observe closely for symptoms of hypocalcemia (tachycardia, tetany, long QTc) and send an ionized Ca level. If there are symptoms or documented hypocalcemia, administer 100mg/kg of 10% calcium gluconate through a separate iv site.

The infants’ blood glucose should be checked every 30 minutes during the procedure. The bedside nurse should record all appropriate data on the exchange transfusion record form.

After the exchange, vital signs should be monitored q 15 minutes for 1 hour then q 30 minutes for 2-3 hours until stable. The blood glucose should be checked 30 minutes post-exchange, and at 1 and 2 hours post-exchange until stable. Also 30 minutes post-exchange, send the infant’s blood for TBili, CBC with platelets, blood gas, and electrolytes including an ionized calcium. The TBili should be checked at 2, 4 and 6 hours post exchange and then q 6 hours. (Rebound usually occurs at 2-4 hours.) An infant should resume feeding no sooner than 4 hours post-exchange.

References:

Fletcher MA, MacDonald MG. Atlas of Procedures in Neonatology, 1993. Philadelphia: J.B. Lippincott Company, pp. 363-371.

AAP. Practice Parameter: Management of hyperbilirubinemia in the healthy term newborn. Pediatrics 1994; 94.