2004;121:590.

56. Roseff SD, Luban NL, Manno CS. Guidelines for assessing

appropriateness of pediatric transfusion. Transfusion. 2002;42:

1398.

315

Jayashree Ramasethu

44 Exchange Transfusions

Advances in prenatal and postnatal care have led a marked

decline in the frequency of exchange transfusions (ETs) in

United States (1), resulting in significantly less experience

in personnel performing the procedure (1). The reemergence of kernicterus as a public health problem underscores the importance of ET as a treatment modality that

could potentially prevent devastating neurodevelopmental

complications (2). In developing countries, ETs remain a

vital therapeutic intervention (3,4).

A. Definitions

ET: Replacing the infant’s blood with donor blood by

repeatedly exchanging small aliquots of blood over a short

time period.

B. Indications

1. Significant unconjugated hyperbilirubinemia in the

newborn due to any cause, when intensive phototherapy fails or there is risk of acute bilirubin encephalopathy (5).

a. Immediate ET may avert brain injury even when

there are intermediate or advanced signs of acute

bilirubin encephalopathy (6).

b. Figure 44.1 indicates the total serum bilirubin levels

at which ET is recommended for infants of 35 or

more weeks’ gestation.

c. Indications for ET in more immature infants are

variable and highly individualized, although some

countries have attempted to establish uniform

guidelines (7,8) (see Table 49.1).

2. Alloimmune hemolytic disease of the newborn (HDN)

(9)

a. For correction of severe anemia and hyperbilirubinemia

b. In addition, in infants with alloimmune HDN, ET

replaces antibody-coated neonatal red cells with

antigen-negative red cells that should have normal

in vivo survival and removes free maternal antibody

in plasma

3. Severe anemia with congestive cardiac failure or hypervolemia (10)

4. Polycythemia

Although partial exchange transfusion reduces the

packed cell volume and hyperviscosity in neonates

with polycythemia, there is no evidence of long-term

benefit from the procedure (11).

5. Uncommon indications for which ET has been used

a. Congenital leukemia (12)

b. Extreme thrombocytosis (13)

c. Neonatal hemochromatosis (14)

d. Hyperammonemia (15)

e. Organic acidemia (16)

f. Lead poisoning (17)

g. Renal failure (18)

h. Drug overdose or toxicity (19)

i. Removal of antibodies and abnormal proteins (20)

j. Neonatal sepsis or malaria (21,22)

C. Contraindications

1. When alternatives such as simple transfusion or phototherapy would be just as effective with less risk

2. When patient is unstable and the risk of the procedure

outweighs the possible benefit.

Partial ET, particularly to correct severe anemia

associated with cardiac failure or hypervolemia, can be

used to stabilize the patient’s condition before a complete or double volume ET is performed.

3. When a contraindication to placement of necessary

lines outweighs indication for ET. Alternative access

should be sought if ET is imperative.

D. Equipment

1. Infant care center (see Chapter 3)

a. Automatic and manually controlled heat source

b. Temperature monitor

c. Cardiorespiratory monitor

d. Pulse oximeter for oxygen saturation monitoring