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Exchange Transfusion in the Neonate

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Introduction

Exchange Transfusion is a procedure performed within Newborn Services for the treatment/correction of anaemia, hyperbilirubinaemia, and to remove antibodies associated with red blood cell haemolysis. This guideline also covers partial exchange for treatment of polycythaemia.

Below are the recommended best practices of Exchange Transfusion in Newborn Services. See also Exchange Transfusion Checklist

  • Informed written consent must be obtained. 
  • Consent is documented on a consent form (Agreement to Treatment CR0111). 
  • Consent for blood is documented on the reverse side of form CR0111. 
  • In special circumstances (e.g. baby transferred, a shocked anaemic baby with a parent not available) verbal consent by a parent is acceptable provided it is documented in baby's clinical record and written consent obtained as soon as possible. 

Prescribing

  • Blood required for the transfusion must be charted by a Consultant/Registrar/NS-ANP on the Blood Transfusion/ IV Fluid form(CR5541) . 
  • The Nurse must be notified that the blood has been ordered, prior to it being requested from blood bank. 
  • The Consultant/Registrar/NS-ANP must record the treatment plan in the patient's clinical record

Volume

N.B: Blood Volume = 70-90 ml/kg for term and 85-110 ml/kg for preterm infants

  • One blood volume removes 65% of baby's red cells.
  • Two blood volumes removes 88%
  • Thereafter the gain is small.
<1000 gms Use 5ml aliquots
1000-2000 gm 10 ml
>2000 gm 4 15 ml

Procedure

  • Consent must be obtained by the Doctor from the parent(s) prior to commencement of the exchange transfusion.
  • All exchanges are to be conducted in NICU level 3 by either a Consultant or Registrar/NS-ANP under Consultant's authorisation
  • There must be at least one doctor/NS-ANP and one nurse exclusively involved in the exchange throughout its progress. If called away, the exchange is to be stopped and the lines flushed with NaCl 0.9%.
  • Resuscitation equipment and drugs must be checked and ready for use including adrenaline 1:10,000.
  • Ventilator must be set up ready for use at the bed space.
  • Blood and IV fluids must be prescribed by medical staff on appropriate charts.
  • Asepsis must be maintained throughout the procedure.
  • Meticulous care must be taken with volume balance, the rate of the exchange, the vital signs and any signs of air in the lines.
    During the exchange ensure volume in/volume out balance does not exceed
          5ml < 1000g baby
         10ml > 1000g baby
         15ml > 2000g baby
  • IF THERE ARE ANY DOUBTS ABOUT THE SET-UP OR THE METHOD OF DOING THE EXCHANGE TRANSFUSION, THEY MUST BE IMMEDIATELY REFERRED TO SENIOR MEDICAL OR NURSING STAFF AND THE EXCHANGE INTERRUPTED UNTIL THEY ARE ANSWERED SATISFACTORILY.
  • Nurse the baby on a radiant heat table.
  • If the exchange is being done for hyperbilirubinaemia, ensure optimal exposure to phototherapy and biliblanket is maintained
  • The infants cardiorespiratory status and oxygen saturation must be monitored continuously. Non-invasive blood pressures are to be taken every 15minutes.
  • Baby remains NBM throughout the exchange. Aspirate stomach contents prior to commencement of procedure and leave the gastric tube on free drainage. This eliminates the risk of aspiration.
  • If the exchange transfusion is stopped for any reason for longer than 2-3 minutes, disconnect blood line from the baby, remove blood line from heating sheath, remove line from under radiant heater1.
  • Observe carefully throughout the procedure that there is no air in the lines.
  • See Exchange transfusion record form (ADHB only)
  • In the event of a collapse during an exchange transfusion see 'Procedure in case of adverse reaction and/or negative outcome

Technique

Exchange transfusions are performed using either one catheter or two catheter push-pull method.  The exchange equipment is set up by nursing staff, but the specialist responsible for the exchange must check the set-up prior to commencing the exchange. This set-up is a joint responsibility between medical and nursing staff, but the specialist doing the exchange has overall responsibility for the procedure.

1. Two Catheter Push-pull Technique

Blood is removed from the artery while infusing fresh blood through a vein at the same rate.

  In Out
  Umbilical vein Peripheral artery
or Umbilical vein Umbilical artery
or Peripheral vein Peripheral artery2
or Peripheral vein Umbilical artery

Two Catheter Push-Pull set up and management

  • Use prepacked Exchange Transfusion Two catheter push-pull set. See diagram below.
  • Attach Astoflo unit on to pole on ponta, switch unit on and adjust setting to 39.5 °C then press start (confirms the change or unit will reset to default settings)
  • Prime the blood filter, Alaris giving set and one way valve. 
  • When ready to commence the exchange, connect the outline to baby's arterial line
  • Place the Alaris line in the warming sheath (from the roller clamp down) and connect to the baby's venous line. 
  • The nurse assisting may manage one of the lines as directed by the Consultant / Registrar / NS-ANP. (If this happens another level 4 nurse must then be doing the recording of blood volumes.
  • The nurse is responsible for recording in and out blood volumes. Each cycle in and out should take approximately 4 minutes.

NB: The transfusion should not commence until nursing and medical staff agree that the circuit set up is correct.

Observe carefully throughout the procedure that there is no air in the line. 

 Diagram 1 - Two Catheter Push-pull Technique

Two Catheter push pull diagram

2. One Catheter Push-pull Technique

This can be done through an umbilical venous catheter. Exceptionally, an umbilical artery catheter can be used.

Ideally, the tip of the UVC should be in the IVC/right atrium (at or just above the diaphragm) but can be used if it is in the portal sinus. For 'high' UVC placement, position should be checked by an X-ray. This is not always necessary for a low position. A low positioned catheter is usually removed after each exchange.

Withdraw blood over 2 minutes, infuse slightly faster.

One Catheter Push-Pull set up and management

  • Use prepacked Exchange Transfusion One catheter push-pull set. See diagram below. 
  • Place Astoflo unit on to pole on ponta, switch unit on and adjust setting to 39.5 °C then press start (confirms the change or unit will reset to default settings)
  • Prime the blood filter, Alaris giving set and one way valve.
  • When ready to commence the exchange, connect the outline to baby's umbilical line via the second three way tap (furthest from the baby) 
  • Place the Alaris line in the warming sheath (from the roller clamp down) and connect to the baby's line.
  • The Consultant / Registrar / NS-ANP is responsible for turning the 3-way tap to the appropriate position to ensure correct direction of blood flow.
  • The nurse is responsible for recording in and out blood volumes. Each cycle in and out should take approximately 4 minutes.

NB: the transfusion should not commence until nursing and medical staff agree that the circuit set up is correct.

Observe carefully throughout the procedure that there is no air in the line.

 Diagram 2 - One Catheter Push-pull Technique

One Catheter push pull diagram

Preparation and Care of Blood/line

  • See also Blood Products guideline
  • Donor blood should be:
    • CMV negative. 
    • Haemolysin negative. 
    • Partially packed (i.e.100ml plasma removed). 
    • Less than 5 days old. 
    • Irradiated to reduce risk of Graft versus Host disease. Blood has a 24 hour expiry time post irradiation, as K+ level rises. 
  • Donor blood packs should be mixed every 15 minutes by gently squeezing the bag during transfusion to prevent settling of red blood cells and to prevent infant receiving mostly plasma at end of each unit.
  • Mix the blood before taking the samples.
  • If the exchange is interrupted, remove the blood from the blood warmer and from under the radiant heater to prevent overheating.
  • Each method of exchange transfusion uses the same out line for blood
  • Connect 2 x BC 538 extensions and drain into an empty bottle. Refer to appropriate exchange transfusion diagram above.

Monitoring and Documentation

  1. Record baseline observations prior to commencing exchange transfusion.
    - Axilla/rectal temperature
    - Heart rate
    - Respiratory rate
    - Blood pressure
    - Oxygen saturation and colour
  2. Continuously monitor and record at 15 minute intervals on the record of Exchange Transfusion sheet(CR5730), the following observations:
    - Skin temperature
    - Heart rate
    - Respiratory rate
    - Oxygen saturation
    - Blood Pressure (non-invasive)
  3. Record axilla/rectal temperature recorded 15 minutes after each donor pack is commenced, and then every 30 minutes during the transfusion.
  4. Observe for any changes in neurological status - drowsiness, irritability.
  5. Record blood in/blood out on the Record of Exchange Transfusion sheet (CR5730). Keep a running total.
  6. Record blood results on the Exchange Transfusion Results Sheet (CR5729)
  7. Maintain continuous electronic monitoring of vital signs for at least two hours post transfusion (or longer if baby's condition is not stable).

Collection of Specimens

Secimens should be collected from Donor, Pre-exchange, During Exchange and Post-Exchange

Donor Blood Specimens

  • Mix blood well.
  • Specimen is to be taken from each unit as soon as it arrives.
  • Collect 0.3ml into a blood gas syringe and record haemoglobin and K+.
  • Blood should not be used if potassium result is:
    >15mmol/L in well babies
    >10mmol/L in small sick babies

Pre-Exchange Patient Specimens

  • Arterial blood gas, Na, K, Ca and glucose levels.
  • FBC and differential.
  • Urea, Creatinine, Bilirubin (total and direct).
  • Guthrie (unless previously done)
  • Coagulation screen should be collected if more than one exchange is performed ( 0.8ml into buffered citrate micro-container obtained from lab).

During Exchange Specimen

  • Blood gas, electrolytes and glucose are tested as ordered.

Post-Exchange Patient Specimens

(take from the last few ml of the exchange out volume)

  • Arterial blood gas, Na, K, Ca, Glucose.
  • FBC and differentials
  • Urea, Bilirubin (total and direct).
  • Coagulation screen should be performed if more than one exchange.

See Exchange transfusion blood results form (ADHB only)

Complications

  • Be aware of this possibility
  • Observe the baby carefully
  • Have resuscitation equipment ready

During Exchange

Air embolus Ensure the lines are correctly set up.
Watch the lines continuously for air.
Turn the line off instantly if air is seen.
Never have a 3 way tap open to air and the baby
Be very careful if there are large swings in intrathoracic pressure.
Volume imbalance The nurse is responsible for recording the volume balance throughout the exchange.
Arrhythmias  Can occur from a variety of causes.
Set the monitor to have an audible QRS complex.
Acidosis Blood for exchange transfusion is preserved in CPD (citrate, phosphate, dextrose) and can be quite acidotic.
Check the baby's blood pH before, during ( usually half way), and after the exchange
Check more frequently for a sick, unstable or small baby.
Respiratory distress  Monitor respiration and SpO2 constantly. 
Hyperkalaemia  CPD blood can have high potassium [K+] levels.
Check [K+] at the start of each bag.
Monitor the QRS complex. (for arrhythmia, widening QRS)
Monitor K+ with each blood gas. 
Anaemia/Polycythaemia  Check the PCV of each blood bag.
Agitate the bag every 15 minutes. 
Fluctuating BP and
cerebral blood flow 
Monitor rate of blood in and out carefully.

After Exchange

Infection Prophylactic antibiotics are not indicated.
Observe closely for signs of infection.
Hypocalcaemia Monitor calcium [Ca++] and give replacement Ca++ in IV fluids as per clinical guidelines
Hypoglycaemia Unlikely during the exchange as CPD blood has 19mmol/L [glucose].
However rebound hypoglycaemia may occur afterwards.
Commence a 10% glucose infusion post exchange, or if the exchange is interrupted.
Hypernatraemia CPD blood has a high [Na+]. Monitor [Na+] with each gas.
Thrombocytopenia Very common, and more severe after more exchanges (due to increased platelet consumption).
Recovers in a few days.
Monitor platelets serially for a week post exchange.
Polycythaemia or anaemia From poorly mixed or packed blood.
Coagulopathy or neutropenia More likely the multiple transfusions.
Necrotising enterocolitis Umbilical catheter related (especially with a low UVC) and maybe due to BP and blood volume fluctuations.
Take care with feeding post exchange
Blood transmitted infections For a detailed list refer to Blood Products - RBC guideline 
Graft versus Host disease There have been several case reports.
It seems to be more likely with more preterm infants, intrauterine transfusions, multiple exchanges, and related donors.
Irradiate the donor blood.

In the event of a collapse during an exchange transfusion follow the steps below.

Procedure in Case of Adverse Reaction and/or Negative Outcome

  1. At first sign of any adverse reaction - STOP the blood being infused.
  2. Initiate resuscitative measures as indicated.
  3. The IV cannulae/catheter may be re-used once flushed with 0.9% NaCl.
  4. All blood and infusion lines used in the Exchange Transfusion must be returned to the Blood Bank for investigation.
  5. Document adverse reaction using the on-line reporting system (Datix). Document the file number in the medical notes.
  6. In the case of infant's death resulting from an Exchange Transfusion:
    Inform the Duty Manager and Clinical Director of Newborn unit.
    Photograph the transfusion set up and bedspace, in as much detail as possible
    The Consultant/Registrar contacts the Police and Coroner. The Consultant/Registrar must ask the Coroner's permission before any lines can be removed.
    If lines and blood pack are removed they must be sent to Blood Bank for proper analysis.
    Blood Bank must hold all blood samples, the units of blood and lines until the Police or Coroner state otherwise. (Notify Blood Bank to ensure this happens)
    All clinical records for the baby are photocopied prior to being sent to the Coroner.
    NB Do not dispose of anything used in the Exchange Transfusion. It will be required by the Police and the Coroner.

Urgent Exchange Transfusions

May be necessary for a severely anaemic baby. Such a baby is usually hypovolaemic and a straight transfusion is done as part of the exchange.

Considerations

  1. Non-irradiated blood may be used as irradiation can result in unacceptable delay.
  2. Once there is central venous or arterial access, the exchange can commence.

Suggested Equipment (use one catheter push-pull set up for guidance)

  • 2 x 3 way taps
  • A series of 10ml or 20 ml syringes filled with checked filtered blood. Donor blood is tested as per recommended best practice.
  • 2 x BC 538 extensions plus empty bottle

NB: The exchange transfusion is not to commence until nursing and medical staff are in agreement that the circuit set-up is correct

Partial Exchange Transfusion

A partial exchange transfusion is a procedure performed to correct polycythaemia or severe anaemia without hypovolaemia. This can be performed using either the one catheter or two catheter push pull technique.

The treatment/correction of polycythaemia

  • Polycythaemia is used as a crude measure for hyperviscosity and is defined by a venous haematocrit of greater than 65% (0.6-0.65)
  • Affected infants often have associated thrombocytopenia, hyperbilirubinaemia and hypoglycaemia.
  • Treatment is generally based upon the presence of consistent signs and symptoms.
  • The aim is to decrease the haematocrit by removing the red cells and simultaneously replacing the volume with an equal amount of 4% albumin or normal saline (NaCl) or a combination of both.

Common Reasons for polycythaemia:

  • Delayed cord clamping may increase the blood volume and red cell mass of the infant by as much as 55%.
  • Twin to twin transfusion.
  • Maternal factors:
      - diabetes
      - smoking
      - hypertension syndromes
  • Fetal factors:
      - Beckwith Wiedemann Syndrome
      - Neonatal thyrotoxicosis

Partial Exchange Transfusion Procedure

This procedure is still to be treated as an exchange transfusion and must follow the same technique and procedure guidelines as a full exchange transfusion above.

  • Consent for treatment is documented on a consent form (Agreement to Treatment CR0111).
  • Use either One Catheter or Two Catheter push pull set up.

The Consultant MUST give guidance as to the requirements for this procedure.

Note: for polycythaemia, saline can be given through an IV as blood is removed from the UVC.

Polycythaemia (see Nicu tools: partial exchange calculator)

Volume exchanged (ml) = Blood Volume x (PCV initial - PCV desired)
                                                          PCV initial

Anaemia

Volume exchanged (ml) = Blood Volume (ml) x (Hb desired - Hb initial)
                                                    (Hb Donor - Hb Initial)

Blood volume = 70-90 ml/kg for term and 85-110 ml/kg for preterm infants.

References

  1. Shaw, N. (1998). Assessment and management of haematologic dysfunctions. In C. Kenner, J. Wright Loft & A. Applewhite Flandermeyer, Comprehensive neonatal nursing: A physiologic perspective p 520-563. Philadelphia: W.B. Saunders Co.
  2. Thayyil S, Milligan D. Single versus double volume exchange transfusion in jaundiced newborn infants. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD004592. DOI: 10.1002/14651858.CD004592.pub2
  3. Chen HN, Lee ML, Tsao LY. Exchange transfusion using peripheral vessels is safe and effective in newborn infants. Pediatrics. 2008 Oct;122(4):e905-10.
  4. Iowa_Neonatology_Fellows. Exchange Transfusion. In: Bell EF, Segar JL, editors. Iowa Neonatology Handbook. Iowa City, Iowa: http://www.uihealthcare.com/depts/med/pediatrics/iowaneonatologyhandbook/procedures/exchangetransfusion.html; 2008.
  5. Benders MJ, Meinesz JH, Dorrepaal CA, Steendijk P, van Bel F, van de Bor M. Effect of exchange transfusion on brain perfusion and electrocortical brain activity in newborn lambs. Biol Neonate. 1999;75(2):130-6.
  6. Robitaille N, Nuyt A-M, Panagopoulos A, Hume HA. Exchange Transfusion in the Infant. In: Hillyer CD, Strauss RG, Luban NLC, editors. Handbook of Pediatric Transfusion Medicine. San Diego, California: Elsevier Academic Press; 2004. p. 159-66.
  7. Hartel G, Payton D, Carmod F, O'Regan P, Thong Y H. Graft Versus Host Disease Following Intrauterine and Exchange Transfusions for Rhesus Haemolytic Disease. Aust NZ J Obst Gynaecol 1997;37(3): 319 
  8. Oskan H, Oren H, Duman N, Ozkan S, Sarioglu S, Anal O, Simsek A, Sagol O, Irken G. Transfusion-associated graft-versus-host disease following exchange transfusion in a newborn. European Journal of Paediatrics 1999; 158(4):343
  9. Ozek E, Soll R, Schimmel MS. Partial exchange transfusion to prevent neurodevelopmental disability in infants with polycythemia. Cochrane Database of Systematic Reviews. 2012, Issue 1. Art.No.: CD005089. DOI: 10.1002/14651858.CD005089.pub2.
  10. Dempsey EM, Barrington K. Short and long term outcomes following partial exchange transfusion in the polycythemic newborn: a systematic review. Arch Dis Child Fetal Neonatal Ed. 2006 Jan;91(1):F2-6.
  11. Schimme; MS, Bromiker R, Soll RF. Neonatal polycythemia: is partial exchange transfusion justified? Clinics in perinatology. 2004;31(3):545-553.

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Document Control

  • Date last published: 15 October 2018
  • Document type: Clinical Guideline
  • Services responsible: Neonatology
  • Owner: Newborn Services Clinical Practice Committee
  • Editor: Sarah Bellhouse
  • Review frequency: 2 years