Exchange transfusion

Replacing the infant's blood with donor blood by repeatedly exchanging small aliquots of blood over a short time is called exchange transfusion. As this is an invasive procedure involving a frequent change in hemodynamics of the baby, it should be performed only on a stable baby who is not in shock. Increased joint days due to ABO or RH incompatibility are the commonest indication for exchange transfusion.

The exchange transfusion should be planned only if indicated as per the guidelines after at least 6 hours of effective phototherapy. In some pre-tame babies who are at sick or show any sign of encephalopathy may need immediate exchange transfusion when the bilirubin level is in the exchange range.

The selection of blood group and the RH for the exchange transfusion is very important. The O positive blood or O negative blood should be used in cases of OA or OB incompatibility that is where mother's blood group is O positive and the baby's blood group is A or B. Only O negative or baby's blood group with RH negative should be used in cases of RH incompatibility that is when mother's blood group is

Any blood used for X-train transfusion should be always cross matched with the mother's blood. To calculate the amount used for the X-train transfusion, one can multiply the weight of the baby in kg into 2 and then again multiply with 80. This gives double the volume of blood the baby has and then one can add 25 to 30 ml to this volume

for the dead space of the tubing. Prior to starting exchange transfusion, the details of the blood to be exchanged should be checked thoroughly. One should check is it the same blood group, what is the date of the blood, what is the date of issue of the bag, what is the blood bank number and what is the baby's name. All the vitals of the baby should be recorded on a chart prior to initiation of exchange transfusion and this chart is called as the exchange transfusion chart.

Prior to starting the X-Train Transfusion, one should empty the infant's stomach, place an OG tube, remove the gastric contents and leave it open drainage. Do not feed the baby for 4 hours prior to procedure if possible. The baby should be securely stabilized using infant restraints. One can use the gauze rolls for this purpose. Sedation and pain relief are usually not required. One should always recheck the OG tube, secure the baby,

and the monitoring device should be checked prior to start of the procedure. In a baby on maintenance IV fluid continue the same through a patent peripheral line. This line may also be used for any emergency medications if they are needed during exchange transfusion. The materials which are important during an exchange transfusion include the resuscitation equipment and medications, suctioning equipment, two three-way stop cocks,

with locking connections, 5, 10 or 20 ml syringes, waste receptacle which can be empty IV bottle or bag, IV connecting tube, syringes and sampling EDTA vacutainers for pre and post exchange blood tests. One should ensure utmost asepsis and maximum barrier precautions while performing the exchange transfusion on the baby. Hence you can see that

The doctor should wear cap, mask, sterile gown, sterile gloves and the baby should be adequately draped. Now we will be describing the technique of exchange transfusion by the push-pull technique using two three ways. Connect the two three ways topcocks in serial and ensure that all junctions are tight to produce a closed sterile system ensuring there is no air in the system.

The proximal stopcock that is the stopcock which is near to the umbilical venous catheter is attached to the IV extension tubing which drains into a sterile waste container. The distal stopcock that is the stopcock away from the umbilical venous catheter is attached to the IV extension tubing which is connected to the blood bag which contains the blood with which the exchange will be done. The first step is to withdraw the blood from the baby.

Kindly note the position of the three ways for this step. The usual volume of the blood withdrawn in each aliquot is 5 to 10 ml. The sicker, the smaller the baby, the lesser aliquot should be used. The second step is to discard the withdrawn blood into the sterile waste container. Kindly note the position of the three ways for this particular step. The third step is to withdraw the blood from the bag

Note the position of the three way for this important step. The fourth step is to infuse the blood which is withdrawn from the blood bag into the baby. Note the position of the three way for this important step. Hence the single cycle needs these four steps to be done serially and in this way

One cycle is completed when all the four steps are done. Once a cycle is completed, it should be ticked and marked in the exchange transfusion chart. In a similar way, the repeat cycles are done until estimated cycles get completed. During exchange, one should always keep a watch on the vitals of the baby. If there is an undue fluctuation in the vitals or the baby has apnea, the cycle should be withheld immediately till the baby is stable.

Be sure that there is adequate volume of donor blood remaining to infuse after the last withdrawal and intermittently gently agitate the bag so that there is no accumulation of the RBCs beneath the bag. Clear the umbilical line of the bank blood and withdraw amount of infant's blood needed for laboratory testing at the end of the exchange transfusion.

After the exchange transfusion, the baby should again be closely monitored for at least 4 hours. There is no need to add routine antibiotics. The calcium should only be added if there was a demonstrated hypocalcemia and there is no role for using heparin routinely during exchange transfusion. Once the exchange transfusion is done, remove the catheter. Thank you.