Exchange Transfusion (ET) for Neonatal Jaundice
1. To lower the serum bilirubin level and reduce the risk of brain damage and kernicterus. 2. To remove the infants’ sensitised red blood cells and the circulating antibodies and reduce the degree of red cell destruction. 3. To control the blood volume and relieve potential heart failure..
Preparation of infant
a. Ensure pulse, temperature and respiration are stabilised and maintained. b. Continue feeding the child and omit only the LAST feed before ET. If needed, empty gastric content by doing NG aspiration before ET. c. Proper restraint. d. Check resuscitation equipment. e. Set a peripheral IV line. f. Get a signed informed consent from parent (mortality from ET is 1%).
Grouping of Blood to be used
Rh isoimmunisation- ABO compatible, Rh negative Other conditions - X match with baby and mother's blood Emergency - 'O' Rh negative Fresh whole blood collected in citrate phosphate dextrose ( CPD) Fresh blood not more than 24 hours old for sick or hydropic infants Not more than 48 hours (definitely not > 5 days) for other neonates.
1. Nurse to assist. 2. Connect baby to cardiac monitor if available. 3. Nurse checks the baseline observations (either via monitor or manually) and record down on the neonatal exchange blood transfusion sheet. The following observations are recorded every 15 minutes; apex beat, respirations, colour, tone and behaviour. Dextrostix is to be done hourly, 4. Doctor performs the ET (See Protocol). At the same time the Nurse keeps a record of apex beat, condition of baby and the amount of blood given or withdrawn. The whole process takes at least 90 minutes. 5. Doctor to scrub, gown and mask. 6. Drape the umbilical area. 7. Cannulate the umbilical vein to depth NOT > 5-7cm. 8. Aliquot for removal and replacement : < 2kg - 5 mls 2 to 3 kg - 10 mls > 3kg - 20 mls Alternatively blood can be replaced as a continuous infusion into a large vein while removing blood from an arterial catheter. In smaller infant pumps delivering 120mls an hour allowing 10 ml of blood to be removed every 5 mins can be used. Higher rates will be necessary for bigger infants. .
Points to note
Volume of blood to exchange 160mls/kg body weight. Pre-warm blood if possible.
- 1ml of 4.2% NaHCO3 given for every 100mls of blood * - 1ml of 10% Calcium gluconate for every 160mls of blood exchanged * * Agitate Blood bag frequently to prevent settling. NEVER give the two solutions together. Give via peripheral vein and NOT UVC. b. c. d. e. f. g. h. Rate of exchange 3 minutes/cycle (1 min in, 1 min pause and 1 min out) and total exchange should be about 90 minutes. Exchange should start with removal of blood, so that there is always a deficit to avoid cardiac overload. If child anaemic (Hb < 15) give an extra aliquot volume of blood at the end, leaving a positive balance). Always discard the serum and the last portion of blood remaining in the tubing to avoid electrolyte imbalance. If initial SB is > 25mg%, DO NOT remove the UVC as ET may need to be repeated. Place back under phototherapy lights after the procedure Feed after 3 hours.
Complications of ET Investigations
a. Pre-exchange (1st volume of blood removed) i) Serum Bilirubin ii) FBC iii) Blood glucose iv) Serum electrolytes v) Serum calcium vi) Blood gases vii) Others e.g. Blood C&S as indicated b. Post-exchange (Last volume of blood removed) i) Serum Bilirubin ii) FBC iii) Blood Sugar iv) Serum electrolytes v) Serum Calcium vi) Blood gases c. 6 hour post-exchange i) SB
1. Catheter related a. Infection b. Haemorrhage c. NEC d. Portal and splenic vein thrombosis e. Air embolism 2. Haemodynamic problems a. Overload cardiac failure b. Hypovolaemic shock c. Arrhythmia (Catheter tip near sinus node in R Atria) 3. Electrolyte imbalance a. K+ b. Ca c. or Blood glucose d. Acidosis (sometimes late alkalosis due to breakdown of citrate) Tissue hypoxia (old blood)
Follow-up 1. Review SB at Polyclinic 2 days after discharge. 2. For infant who had exchange transfusion, follow-up for 2 years and discharge if normal. Look for signs of deafness, cerebral palsy and mental retardation.