Iowa Neonatology Fellows
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If an exchange transfusion is necessary, compatible blood must be ordered. If a severely affected ( i.e. hydropic) infant with Rh hemolytic disease is anticipated at birth, it may be necessary to have blood available in the nursery prior to the delivery. The request should be for O negative packed red blood cells of the specific volume needed and of the appropriate CMV status. This blood may be utilized in any one of the following ways:

  1. The RBC's may be given as a simple transfusion (with or without additional Plasmanate) while stabilization of the infant is accomplished.
  2. The RBC's may be used for a partial exchange transfusion to acutely elevate the hematocrit without changing the blood volume in a severely anemic baby. 

When the need for an emergency, complete exchange transfusion is virtually certain, arrangements can be made in advance for O negative whole blood or O negative PRBC's resuspended in fresh frozen plasma. 

For double-volume exchange transfusions for hemolytic disease of the newborn or for hyperbilirubinemia without hemolysis, the blood used will be packed cells (type O, Rh specific for the infant) resuspended to the desired hematocrit in compatible fresh frozen plasma. 

A partial exchange transfusion is often done for polycythemia (see section on polycythemia). 

Although the standard anticoagulant (CPD) is acidic, the blood need not be buffered. If the infant is severely acidemic, consult the staff neonatologist. 

If possible, the infant should be NPO and the stomach contents aspirated prior to the procedure. 

The exchange transfusion should be done under a radiant warmer using sterile technique.

The donor blood should be warmed using the blood warmer to a temperature not exceeding 37oC. 

The infants blood pressure, respiratory rate, heart rate and general condition should be monitored during the exchange transfusion according to standard nursing protocol.

If the serum bilirubin concentration is at a dangerous level and the blood for exchange transfusion is not yet ready, consider priming the infant with 1 gram/kg (4 ml/kg) of a 25% solution of salt-poor albumin to bind additional bilirubin and keep it in the circulation until the exchange can be accomplished..

The umbilical vein catheter should be inserted until there is free flow of blood immediately prior to starting the exchange transfusion. See section on placement of umbilical catheters for technique. The exchange transfusion should not be done through an umbilical artery line unless the UAC is used only for blood withdrawal with simultaneous replacement through the umbilical vein or peripheral IV. At the beginning of the exchange transfusion, the first blood sample withdrawn should be sent for for 1)total and direct bilirubin; 2) hemoglobin and hematocrit; 3) glucose; and 4) calcium. 

Use the "exchange transfusion kit", which contains catheters, stopcocks, waste bag, and calcium gluconate. 

Ideally, blood (or colloid in the event of a partial volume exchange) should be infused through a peripheral vein at a rate equal to blood withdrawal from the UVC. If the "push-pull" (single catheter) technique is utilized, no more than 5 ml/kg body weight should be withdrawn at any one time. 

The exchange volume is generally twice the infant's blood volume, (generally estimated to be 80 ml/kg). The total volume exchange should not exceed one adult unit of blood (450-500 ml). A standard two-volume exchange will remove approximately 85% of the red cells in circulation before the exchange and reduce the serum indirect bilirubin level by one-half. The exchange of blood should require a minimum of 45 minutes.

The need for giving supplemental calcium is controversial. If used give 0.5 to 1.0 ml of 10% calcium gluconate IV, after each 100 ml of exchange blood. Monitor heart rate for bradycardia. 

At the end of an exchange transfusion blood should be sent for sodium, glucose, calcium, total and direct bilirubin, and hemoglobin and hematocrit. 

At the end of an exchange transfusion, the umbilical vein catheter is usually removed. In the event of a subsequent exchange, a new catheter can be inserted.

Hypoglycemia often occurs in the first or second hour following an exchange transfusion. It is therefore necessary to monitor blood glucose levels for the first several hours after exchange. 

The serum bilirubin concentration rebounds to a value approximately halfway between the pre- and post- exchange levels by two hours after completing the exchange transfusion. Therefore, the serum bilirubin concentration should be monitored at two to four hours after exchange and subsequently every three to four hours. 

Feedings may be attempted two to four hours after the exchange transfusion.