Double volume exchange transfusion

I.                Population:

A double-volume exchange transfusion is to treat the isoimmunized infant with hemolysis and unconjugated hyperbilirubinemia.

 

II.              Indications: 

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 Total Bilirubin remains > 25mg/dL despite intensive phototherapy, hydration and IVIG, or if the Total Bilirubin is > 30 mg/dL or in any infant if there is a risk of kernicterus.

 

III.            Definitions:    N/A

 

IV.            Additional Competencies Required:

 

The provider will maintain necessary credentials for advanced procedures the patient may need such as:  umbilical arterial line placement, umbilical venous line placement, and emergency intubation.

 

V.              Assessment:

A.              Physical Exam:  Severe jaundice on exam, possible early signs of acute bilirubin encephalopathy

 

B.              Documentation:  Procedure note should be documented in Star Panel

 

VI.            Universal Protocol (UP):

 

VII.         Anesthesia:

 

Sedation and pain relief are not usually required

 

VIII.       Goal(s) of Procedural Intervention:

 

Double volume exchange transfusion replaces 85% of the circulating red blood cells in the infant, improving the infantís hematocrit and removing the offending antibody, and temporarily decreases serum bilirubin by about 50%.

 

IX.            Procedure: 

(Procedure should be in consultation with Attending Neonatologist)

 

A.              Order from the blood bank:

1.               Type O Rh negative Irradiated packed red blood cells (PRBCs) resuspended in AB plasma (no antiA or antiB antibodies) crossmatched against the maternal plasma and cells.

2.               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%.). Blood to be reconstituted to a hematocrit of 55%

3.               Obtain a volume = 170 ml/kg + 30 ml for tubing losses. The blood should be warmed to 37 C . Usually one unit of reconstituted blood

 

B.              Conduct final patient verification process (time-out)

 

C.              Gather supplies and equipment

1.               Radiant Warmer

2.               Resuscitation equipment and medications including 10% Calcium Gluconate should be readily available.

3.               Equipment for monitoring heart rate, blood pressure, respiratory rate, temperature, and Sao2

4.               Equipment for umbilical artery and umbilical vein catheterization

5.               specialized kit for an exchange transfusion

6.               Blood warmer and coils

7.               Appropriate blood products and tubing

8.               Syringes and tubes for pre and post procedure lab testing

 

D.              Infant should be restrained and closely monitored

E.               Maintain a separate IV infusion of glucose during the procedure

F.               Place orogastric tube and remove gastric contents; leave open to drain

G.              Don sterile gown, mask, hat, and gloves

H.              Place a 3.5 Fr or 5Fr UVC and 3.5Fr or 5 Fr UAC using standard techniques and sterile conditions and confirm the position of catheter by x-ray. (See Umbilical Artery and Vein Catheterization). Alternatively may use a single lumen 8Fr UVC exchange transfusion catheter

I.                 Blood should be obtained for labs before infusing any donor blood

 

1.               Neonatal state screen and any genetic tests

2.               Hematocrit, hemoglobin, platelets

3.               Total bilirubin

4.               Electrolytes including ionized Calcium.

5.               Blood gas

6.               Glucose

 

J.                Have the unit of blood prepared

 

1.               Verify blood product

2.               Attach blood administration set to blood warmer tubing and blood

3.               Allow blood to run through blood warmer

4.               Blood should be warmed to 37 C .

 

K.              Establish the volume of each aliquot

 

1.               Exchange blood in ~5 ml/kg passes

 

Weight

<850g

851-1000g

1-2kg

2-3kg

>3kg

 

Volume per pass

3ml

5ml

10ml

15ml

20ml

 

L.               Exchange blood in a push-pull fashion or isovolumetrically

 

1.               Push-Pull technique

a.                may be performed by the removal of blood from a UVC and withdrawing blood in set aliquots though the UVC

b.               Using the push-pull method, withdraw and replace blood at a rate of 2-4 ml/kg/min; each pass should take 3-5 minutes.

c.                Ensure that stages of drawing and infusing blood from and into the infant are done slowly, taking at least a minute each to avoid rapid fluctuations in blood pressure

d.               Discard blood into sterile bag

 

2.               Isovolumetrically technique

a.                is preferred in a smaller or unstable baby

b.               Isovolumetrically technique may be done using a steady withdrawal of blood from a UAC while an equivalent amount of donor blood is slowly infused through the UVC or PIV.

c.                Withdraw and infuse at a rate of 2-4 ml/kg/min. Slow down if the baby experiences hemodynamic instability (brady- or tachycardia, hypotension.)

 

M.             Have bedside nurse gently agitate the blood bag every 10 to 15 minutes to prevent red cell sedimentation, which may lead to exchange with relatively anemic blood towards the end of the exchange

N.              After each 100ml of exchange, observe closely for symptoms of hypocalcemia (tachycardia, tetany, long Q-Tc interval) and send an ionized Ca+ level.

O.              If there are symptoms or documented hypocalcemia, administer 100mg/kg of 10% calcium gluconate through a separate IV site

P.               Infantsí blood glucose should be checked every 30 minutes during the procedure.

Q.              Bedside nurse should record all appropriate data on the exchange transfusion record form

R.              After the exchange, vital signs should be monitored q 15 minutes for 1 hour then q 30 minutes for 2-3 hours until stable

S.               Check blood glucose every 30 minutes post-exchange, and at 1 and 2 hours post-exchange until stable

T.               Thirty minutes post-exchange, send the infantís blood for Total Bilirubin, CBC with platelets, blood gas, and electrolytes including ionized calcium.

U.              Total Bilirubin should be checked at 2, 4 and 6 hours post exchange and then q 6 hours (Rebound usually occurs at 2-4 hours)

V.              Resume phototherapy post-exchange

W.            Infant should resume feeding no sooner than 4 hours post-exchange

 

X.              Complications:

A.              Infection- strict sterile technique should be used

B.              Vascular complications-clot or air embolism, arteriospasm of lower limbs, thrombosis and infarction may occur. Monitor lower extremity capillary refill

C.              Coagulopathies-may result from thrombocytopenia or diminished coagulation factors lost with exchange transfusion. Monitor labs post exchange

D.              Electrolytes abnormalities-hyperkalemia and hypocalcemia can occur. Monitor BMP and iCa+ during and after procedure.

E.               Hypoglycemia-monitor glucose

F.               Metabolic Acidosis/alkalosis-from donor blood. Monitor Blood gas

G.              Necrotizing Enterocolitis-delay feeding for a minimum of 4 hours post procedure

 

XI.            Medications by Formulary: 

 10% Calcium Gluconate

 

XII.          References:

Gomella, Tricia Lacy, Cummingham, M. Douglas, Eyal, Fabien G. (2009) Neonatology: Management, Procedures, On-Call Problems, Diseases and Drugs. 6th Edition. U.S.A. The McGraw-Hill Companies, Inc.

Verger, J., Lebet, R. (Eds.). (2008). AACN Procedure Manual for Pediatric Acute and Critical Care. St. Louis, MO: Saunders , Elsevier