PROCEDURE OUTLINE

Exchange transfusions are a technique used most often to maintain serum bilirubin at levels below
neurotoxicity. Exchange transfusions are also used to control other conditions, such as polycythemia or
anemia. Three types of exchange transfusion are commonly used:
(1) 2-volume exchange,
(2) isovolumetric 2-volume exchange,
(3) partial exchange (<2 volumes) with normal saline, 5% albumin in saline, or plasma protein fraction
(Plasmanate).
These procedures are used primarily in sick newborn infants but may also be used for intrauterine
exchanges in fetuses at high risk for central nervous system toxicity (eg, erythroblastosis fetalis) by
percutaneous umbilical blood sampling and umbilical vein catheterization under ultrasound guidance.

I. Indications

A. Hyperbilirubinemia. Exchange transfusions are used in infants with hyperbilirubinemia of any

origin when the serum bilirubin level reaches or exceeds a level that puts the infant at risk for central
nervous system toxicity (eg, kernicterus) if left untreated. Two-volume exchange transfusions over 50-
70 min are usually recommended for removal and reduction of serum bilirubin. Efficiency of bilirubin
removal is increased in slower exchanges because of extravascular and intravascular bilirubin
equilibration.

B. Hemolytic disease of the newborn. This results from destruction of fetal red blood cells (RBCs)
by passively acquired maternal antibodies. Exchange transfusion aids in removing antibody-coated
RBCs, thereby prolonging intravascular RBC survival. It also removes potentially toxic bilirubin from
an increased bilirubin load resulting from RBC breakdown and provides plasma volume and albumin for
bilirubin binding. Repeated 2-volume exchange transfusions may be needed when RBC destruction is
rapid.

C. Sepsis. Neonatal sepsis may be associated with shock caused by bacterial endotoxins. A 2-volume
exchange may help remove bacteria, toxins, fibrin split products, and accumulated lactic acid. It may
also provide immunoglobulins, complement, and coagulating factors.

D. Disseminated intravascular coagulation (DIC) from multiple causes. A 2-volume exchange

transfusion is preferred; however, depending on the sick infant's condition, any one of the exchange
methods may help provide necessary coagulation factors and help reduce the underlying cause of the
abnormal coagulation. Repletion of clotting factors by transfusion of fresh-frozen plasma (10-15
mL/kg) may be all that is necessary in less severe cases of DIC.

E. Metabolic disorders causing severe acidosis (eg, aminoaciduria with associated

hyperammonemia). Partial exchanges are usually acceptable. Peritoneal dialysis may also be useful
for treating some progressive metabolic disorders.

F. Severe fluid or electrolyte imbalance (eg, hyperkalemia, hypernatremia, or fluid

overload). Isovolumetric partial exchanges are recommended to prevent large electrolyte
fluctuations with each aliquot of blood exchanged. Transfusions with blood products may bind
calcium; therefore, calcium gluconate should be available. Fresh blood products should be used to
prevent contribution of the by- products of older blood, such as excess potassium.
G. Polycythemia. It is usually best to give a partial exchange transfusion using normal saline. Plasma
protein fraction (eg, Plasmanate) or 5% albumin in saline may also be used; however, normal saline is
preferred because it reduces both the polycythemia and the hyperviscosity of the infant's circulating
blood volume. Either plasma protein fraction or 5% albumin may leave viscosity unchanged despite
reductions in circulating red cell mass.

H. Severe anemia (normovolemic or hypervolemic) causing cardiac failure, as in hydrops fetalis,

is best treated with a partial exchange transfusion using packed RBCs.

I. Any disorder requiring complement, opsonins, or gamma globulin. Infants with these
conditions may require frequent exchanges, and their fluid status must be carefully managed. Partial
exchanges are recommended.

II.Equipment

A. Radiant warmer.

B. Equipment for respiratory support and resuscitation (eg, oxygen or a suctioning device).
This equipment and medications used in resuscitation should be immediately available.

C. Equipment for monitoring the heart rate, blood pressure, respiratory rate, temperature, PaO2,
PaCO2, and SaO2.

D. Equipment for umbilical artery and umbilical vein catheterization

E. Disposable exchange transfusion tray.

F. Nasogastric tube for evacuating the stomach before beginning the transfusion.

G. A temperature-controlled device must be used for warming of the blood before and during the
transfusion. The device should have an internal disposable coil and connectors to the donor blood bag
and the exchange transfusion circuit. The blood should be warmed to a temperature of 37 C. Use of
makeshift water baths or heaters is not advised because blood that is too warm may hemolyze.

H. An assistant to help maintain a sterile field, monitor and assess the infant, and record the
procedure and exchanged volumes.

III. Blood transfusion

A. Blood collection

1. Homologous blood. Blood donated by an anonymous donor with a compatible blood type is
most commonly used. Donor-directed blood (blood donated by a selected blood type-compatible person)
is another option.

2. Cytomegalovirus (CMV). Seronegative donor blood is preferred. White blood cells

harboring CMV can be removed using leukodepletion filters during blood preparation. The use of
frozen deglycerolized RBCs, reconstituted with fresh-frozen plasma, is another means of using
seropositive blood free of viable CMV.
3. Hemoglobin S (sickle cell trait). Precautions should be taken to avoid exchange transfusion
with donor blood from a carrier. If the donor blood with sickle trait becomes acidic, sickling can occur
with expected complications to the patient.

4. Graft-vs.-host disease. Consideration should be given for using irradiated donor blood to avoid
graft-vs.-host disease in known immune-compromised infants and low birth weight infants. Preterm
infants who have been transfused in utero or who have received more than 50 mL of transfused blood
are candidates for irradiated blood.

B. Blood typing and cross-matching

1. Infants with Rh incompatibility. The blood must be type O, Rh-negative, low-titer anti-A, anti-
B blood. It must be cross-matched with the mother's plasma and RBCs.

2. Infants with ABO incompatibility. The blood must be type O, Rh-compatible (with the
mother and the infant) or Rh-negative, low-titer anti-A, anti-B blood. It must be cross-matched with
both the infant's and mother's blood.

3. Other blood group incompatibilities. For other hemolytic diseases (eg, anti-Rh-c, anti-Kell,
anti- Duffy), blood must be cross-matched to the mother's blood to avoid offending antigens.

4. Hyperbilirubinemia, metabolic imbalance, or hemolysis not caused by isoimmune

disorders.
The blood must be cross-matched against the infant's plasma and RBCs.

C. Freshness and preservation of blood. In newborn infants, it is preferable to use blood or

plasma that has been collected in citrate phosphate dextrose (CPD). The blood should be <72 h old.
These two factors will ensure that the blood pH is >7.0. For disorders associated with hydrops fetalis
or fetal asphyxia, it is best to use blood that is <24 h old.

D. Hematocrit (Hct). Most blood banks can reconstitute a unit of blood to a desired Hct of 50-
70%. The blood should be agitated periodically during the transfusion to maintain a constant Hct.

E. Potassium levels in donor blood. Potassium levels in the donor blood should be determined if
the infant is asphyxiated or in shock and renal impairment is suspected. If potassium levels are >7
mEq/L, consider using a unit of blood that has been collected more recently or a unit of washed RBCs.

F. Temperature of the blood. Warming of blood is especially important in low birth weight and
sick newborn infants.

IV. Procedure

A. Simple 2-volume exchange transfusion is used for uncomplicated hyperbilirubinemia.

1. The normal blood volume in a full-term newborn infant is 80 mL/kg. In an infant weighing
2 kg, the volume would be 160 mL. Twice this volume of blood is exchanged in a 2-volume
transfusion. Therefore, the amount of blood needed for a 2-kg infant would be 320 mL. Low birth
weight and the blood volume of extremely premature newborns (which may be up to 95 mL/kg) should
be taken into account when calculating exchange volumes.
2. Allow adequate time for blood typing and cross-matching at the blood bank. The infant's
bilirubin level will increase during this time, and this increase must be taken into account when
ordering the blood.

3. Perform the transfusion in an intensive care setting. Place the infant in the supine position.
Restraints must be snug but not tight. A nasogastric tube should be passed to evacuate the stomach
and should be left in place to maintain gastric decompression and prevent regurgitation and aspiration
of gastric juices.

4. Scrub and put on a sterile gown and gloves.

5. Perform umbilical vein catheterization and confirm the position by x-ray film. If an
isovolumetric exchange is to be performed, then an umbilical artery catheter must also be placed and
confirmed by x-ray film.

6. Have the unit of blood prepared.

a. Check the blood types of the donor and the infant.

b. Check the temperature of the blood and warming procedures.

c. Check the Hct. The blood should be agitated regularly to maintain a constant Hct.

7. Attach the bag of blood to the tubing and stopcocks according to the directions on the
transfusion tray. The orientation of the stopcocks for infusion and withdrawal must be double-
checked by the assistant.

8. Establish the volume of each aliquot.

B. Isovolumetric 2-volume exchange transfusion. Isovolumetric 2-volume exchange transfusion

is performed using a double setup, with infusion via the umbilical vein and withdrawal via the
umbilical artery. This method is preferred when volume shifts during simple exchange might cause or
aggravate myocardial insufficiency (eg, hydrops fetalis). Two operators are usually needed: one to
perform the infusion and the other to handle the withdrawal.

1. Perform steps 1-6 as in simple 2-volume exchange transfusion. In addition, perform

umbilical artery catheterization.

2. Attach the unit of blood to the tubing and stopcocks attached to the umbilical vein
catheter. If the catheter is to be left in place after the exchange transfusion (usually to monitor central
venous pressure), it should be placed above the diaphragm, with placement confirmed by chest x-ray
film.

3. The tubing and the stopcocks of the second setup are attached to the umbilical artery
catheter and to a sterile plastic bag for discarding the exchanged blood.

4. If isovolumetric exchange is being performed because of cardiac failure, the central venous
pressure can be determined via the umbilical vein catheter; it should be placed above the diaphragm in
the inferior vena cava.

C. Partial exchange transfusion. A partial exchange transfusion is performed in the same

manner as 2-
volume exchange transfusion. If a partial exchange is for polycythemia (using normal saline or another
blood product) or for anemia (packed RBCs), the following formula can be used to determine the
volume of the transfusion.

D. Isovolumetric partial exchange transfusion with packed RBCs is the best procedure in cases
of severe hydrops fetalis.

E. Ancillary procedures

1. Laboratory studies. Blood should be obtained for laboratory studies before and after
exchange transfusion.

a. Blood chemistry studies include total calcium, sodium, potassium, chloride, pH, PaCO2,
acid- base status, bicarbonate, and serum glucose.

b. Hematologic studies include hemoglobin, Hct, platelet count, white blood cell count, and
differential count. Blood for retyping and cross-matching after exchange is often requested by the
blood bank to verify typing and re-cross-matching and for study of transfusion reaction, if needed.

c. Blood culture is recommended after exchange transfusion (controversial).

2. Administration of calcium gluconate. The citrate buffer binds calcium and transiently lowers
ionized calcium levels. Treatment of suspected hypocalcemia in patients receiving transfusions is
controversial. Some physicians routinely administer 1-2 mL of 10% calcium gluconate by slow
infusion after 100-200 mL of exchange donor blood. Others maintain that this treatment has no
therapeutic effect unless hypocalcemia is documented by electrocardiogram showing a change in the
QT interval.

3. Phototherapy. Begin or resume phototherapy after exchange transfusion for disorders involving
a high bilirubin level.

4. Monitoring of serum bilirubin levels. Continue to monitor serum bilirubin levels after
transfusion at 2, 4, and 6 h and then at 6-h intervals. A rebound of bilirubin levels is to be expected 2-4
h after the transfusion.

5. Remedication. Patients receiving antibiotics or anticonvulsants will need to be remedicated.

Unless the cardiac status is deteriorating or serum digoxin levels are too low, patients receiving digoxin
should not be remedicated. The percentage of lost medications is extremely variable. As little as 2.4%
of digoxin is lost, but up to 32.4% of theophylline may be lost during a 2-volume exchange transfusion.
Determination of drug levels after exchange transfusion is advisable.

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

basis. Infection is uncommon but is the most frequent complication.

V. Complications

A. Infection. Bacteremia (usually caused by a Staphylococcus organism), hepatitis, CMV infection,

malaria, and AIDS have been reported.

B. Vascular complications. Clot or air embolism, arteriospasm of the lower limbs, thrombosis,
and infarction of major organs may occur.

C. Coagulopathies. Coagulopathies may result from thrombocytopenia or diminished

coagulation factors. Platelets may decrease by >50% after a 2-volume exchange transfusion.

D. Electrolyte abnormalities. Hyperkalemia and hypocalcemia can occur.

E. Hypoglycemia. Hypoglycemia is especially likely in infants of diabetic mothers and in those with
erythroblastosis fetalis. Because of islet cell hyperplasia and hyperinsulinism, rebound hypoglycemia
may result in these infants in response to the concentrated glucose (300 mg/dL) contained in CPD donor
blood.

F. Metabolic acidosis. Metabolic acidosis from stored donor blood (secondary to the acid load)
occurs less often in CPD blood.

G. Metabolic alkalosis. Metabolic alkalosis may occur as a result of delayed clearing of

citrate preservative from the donated blood by the liver.

H. Necrotizing enterocolitis. An increased incidence of necrotizing enterocolitis after exchange

transfusion has been suggested. For this reason, the umbilical vein catheter should be removed after
the procedure unless central venous pressure monitoring is required. Also, we recommend that
feedings be delayed for at least 24 h to observe the infant for the possibility of postexchange ileus.

TABLE: ALIQUOTS USUALLY

USED IN NEONATAL
EXCHANGE TRANSFUSION
Infant weight Aliquot
>3 kg (mL)20
2-3 kg 15
1-2 kg 10
850 g-1 kg 5
<850 g 1-3