Chapter 44 ■ Exchange Transfusions 321

Exchange Transfusion by Isovolumetric

Technique (Central or Peripheral Lines)

1. Scrub as for major procedure.

2. Select two sites for line placement, and insert (See page

320).

a. Venous for infusion

(1) UVC or

(2) Peripheral IV that is at least 23 gauge

b. Arterial for removal

(1) Umbilical artery catheter

(2) Peripheral, usually radial if infant’s size permits

3. Connect arterial line to three-way stopcock.

a. Use short, connecting IV tubing to extend peripheral line.

b. Attach additional connecting tubing to stopcock

and place into sterile waste container.

c. Attach empty 3- to 10-mL syringe to stopcock, for

withdrawal of blood.

An additional stopcock may also be placed on

this port so that a syringe of heparinized saline (5 U/

mL) may be attached for use as needed. Be cautious

about total volume infused.

4. Connect venous line to single, three-way stopcock,

which in turn connects to empty 5- to 10-mL syringe

and to blood-warming coil.

5. Start exchange-transfusion record.

6. Withdraw and discard blood from arterial side at rate of

2 to 3 mL/kg/min, and infuse at same rate into venous

side. Keep flow as steady as possible, and volumetrically

equal for infusion and removal.

7. Intermittently, flush arterial line with heparinized

saline to clear.

The heparin solution remaining in tubing will be

removed with next withdrawal, thus reducing significantly

the total heparin dose actually received by the patient.

8. Follow steps as for push–pull technique until exchange

is complete.

9. Total duration for isovolumetric ET: 45 to 60 minutes,

may be longer in sick, unstable infant.

H. Postexchange for All Techniques

1. Continue to monitor vital signs closely for at least 4 to

6 hours.

2. Rewrite orders: Adjust any drug dosages as needed to

compensate for removal by exchange.

3. Keep infant NPO for at least 4 hours. Restart feeds if

clinically stable. Monitor abdominal girth and bowel

sounds every 3 to 4 hours for next 24 hours if exchange

has been performed using umbilical vascular lines.

Observe for signs of feeding intolerance.

4. Monitor serum glucose levels every 2 to 4 hours for

24 hours.

5. Repeat blood gases as often as clinically indicated.

6. Measure serum ionized calcium levels and platelet

counts in sick infants immediately after the ET and

then as indicated.

7. Repeat hemoglobin, hematocrit, and bilirubin measurements approximately 4 hours after exchange, and

further as clinically indicated. A double-volume ET

replaces 85% of the infant’s blood volume but eliminates only about 50% of the intravascular bilirubin.

Equilibration of intra- and extravascular bilirubin and

continued breakdown of sensitized and newly formed

red cells by persisting maternal antibody results in a

rebound of bilirubin levels following initial ET and

may necessitate repeated ET in severe HDN.

I. Complications

1. Risk of death or permanent serious sequelae is estimated to be <1% in healthy infants, but as high as 12%

in sick infants. There may be some uncertainty in

ascribing adverse events to the ET in infants who are

already critically ill (1,31)

2. Many of the adverse events are hematologic or biochemical laboratory abnormalities which may be

asymptomatic. The most common adverse effects noted

during or soon after the ET, usually in infants who are

preterm and/or sick.

a. Apnea and/or bradycardia

b. Hypocalcemia

c. Thrombocytopenia (<50,000 in 10% of healthy infants,

up to 67% in infants <32 weeks’gestational age)

d. Metabolic acidosis

e. Vascular spasm

3. Complications reported from ET are related to the

blood transfusion and to complications of vascular

access (see Chapters 29, 30, and 43).

4. Potential complications include

a. Metabolic: Hypocalcemia, hypo- or hyperglycemia,

hyperkalemia

b. Cardiorespiratory: Apnea, bradycardia, hypotension,

hypertension

c. Hematologic: Thrombocytopenia, dilutional coagulopathy, neutropenia, disseminated intravascular

coagulation

d. Vascular catheter related: Vasospasm, thrombosis,

embolization

e. Gastrointestinal: Feeding intolerance, ischemic

injury, necrotizing enterocolitis

f. Infection: Omphalitis, septicemia

References

1. Steiner LA, Bizzarro MJ, Ehrenkrantz RA, et al. A decline in the

frequency of neonatal exchange transfusions and its effect on

exchange transfusion related morbidity and mortality. Pediatrics.

2007;120:27.

2. Johnson L, Bhutani VK, Karp K, et al. Clinical report from the

pilot USA Kernicterus Registry (1992 to 2004). J Perinatol. 2009;

29:S25.