Exchange-Transfusion.ppt for nursing students

Exchange transfusion

2. IT IS A MEDICAL TREATMENT IN WHICH SLOW
REMOVAL OF A PERSON’S BLOOD AND ITS
REPLACEMENT WITH EQUAL AMOUNT OF
DONOR’S BLOOD.

3. INDICATIONS
1. Alloimmune haemolytic disease of the newborn
Remove circulating bilirubin to reduce levels and
prevent kernicterus
Replace antibody-coated red cells with antigen-
negative red cells
2. Significant unconjugated hyperbilirubinaemia with
risk of kernicterus due to any cause when intensive
phototherapy is unsuccessful
3. Severe anaemia (where there is normal or
increased circulating blood volume)
4. Polycythaemia (to reduce haematocrit, usually
accomplished with partial exchange transfusion
using normal saline replacement)

4. Partial exchange transfusion:
It is typically performed for Polycythemia
(HCT>65%) that may be due to : delayed
clamping of the cord , twin -twin transfusion,
iatrogenic transfusion , and increased RBCs
production in utero due to hypoxia.
It consists of removing whole blood and replacing
it with albumin, plasma, or normal saline to
lower the HCT to approximately 55%.

5. Single blood volume exchange :
using (80 -100 ml/Kg ) and usually
performed for anemia with heart failure (i.e.
hydrops fetalis)
Double volume exchange
(160 -200 ml/ Kg of blood). Usually
performed for severe hemolytic disease of
newborn. Exchange transfusion is usually
done through umbilical venous catheter
taking 5 -10 ml/ Kg of blood out at a time
and replacing it ml for ml

6. Technique
Exchange transfusions are performed using
either one catheter or two catheter push-pull
method.

7. 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 arteryor
Peripheral vein Umbilical artery

9. 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.

12. Volume
The volume of blood for exchange is calculated using
an estimate of the neonate’s circulating blood
volume:
Term infants 80ml/kg
Preterm infants 100ml/kg
One blood volume removes 65% of baby’s red cells.
Two blood volumes removes 88%
Thereafter the gain is small.

13. Ensure appropriate samples for pre-
transfusion testing are sent to the Blood
Bank as early as possible.
Notify Blood Bank via telephone as soon
possible after decision is made to exchange
and Order appropriate volume of blood for
exchange
Order FFP for transfusion midway through
and at completion of exchange (10ml/kg per
transfusion)
Appropriate red cells for exchange will be
provided by Blood Bank.

14. Blood for exchange transfusion
should meet the following
criteria:
Have a known haematocrit of 0.5-0.6
Appropriate group based on infant and maternal
blood group and antibodies
Leukocyte depleted
Irradiated and used within 24 hours of
irradiation
CMV negative
As fresh as possible (ensure at least less than 5
days old)

15. Complications Prevention & Management
Hypothermia -if babysskin
temperature falls below 36oC
Hyperglycaemiadonor blood is
preserved in
dextrose.
Confirm placement of temperature
probe and take axillareading.
Confirm blood warmer is at 37oC
Turn up the servo control or
isoletteand slow the exchange.
Blood glucose levels can be
elevated during the exchange and
generally resolve without
intervention.

16. Complications Prevention & Management
Hypoglycaemia: may occur during and
shortly after the exchange.
If baby's reagent strip blood glucose is
less than
45mg/dlgiveslow push of 2 ml/kg of
10% dextrose (via peripheral line or
flush catheter dead space before &
after dextrose injection). Repeat
screening blood glucose level on next
cycle. Continue to monitor glucose
levels.

17. Complications Prevention & Management
Hyperkalaemia: unlikely to happen
with red blood cells less than 5 days
old but is more likely to
happen with a sick preterm infant
refer to hyperkalaemiaprotocol
Hypocalcaemia: This is rare with the
preservative anticoagulants used now
and will rarely need
treating
If K+ > 6.0mmol/L give calcium
gluconateif Ca <2.0 mmol/L and
recheck K+ frequently. Stop exchange
if K+ >7.0 mmol/L and treat until K+ <
6.0 and then restart exchange.
Peaked T waves / widened QRS / VEBs
can be seen with hyperkalaemia.
If Ca++ drops to < 1.5 mmol/l then
flush catheter dead space with normal
saline and give Urgent IV
Correction: 0.23-0.46mmol/kg (1-
2ml/kg of calcium gluconate10%) by
slow IV injection of diluted
solution over 10 minutes. Do not give
into a peripheral vein. Prolonged QT
interval can be seen
with hypocalcaemia

18. Complications Prevention & Management
Thrombocytopaenia: Stored red
cells are platelet depleted, so the
platelet count will tend to fall
during the exchange transfusion.
This rarely needs intervention.
Air Embolus:
If the platelet count falls to <
50,000 consider stopping exchange
and arrange a platelet transfusion
through a peripheral vein.
Ensure lines are set up and primed
correctly. Observe lines for
presence of air during exchange
& ensure 3-way taps are closed to
the infant when filling or expelling
contents of syringe.

19. Complications Prevention & Management
Anaemia/Polycythaemia:
.
Ensure HCT of RBCs / FFP infusion
is kept consistent throughout
procedure. Gently agitate
burette at frequent intervals to
prevent separation of red cells and
FFP
.

20. Complications Prevention & Management
Hypothermia -if babysskin
temperature falls below 36oC
Confirm placement of temperature
probe and take axillareading.
Confirm blood warmer is at 37oC
Turn up the servo control or
isoletteand slow the exchange.

21. Complications Prevention & Management
Hypothermia -if babysskin
temperature falls below 36oC
Confirm placement of temperature
probe and take axillareading.
Confirm blood warmer is at 37oC
Turn up the servo control or
isoletteand slow the exchange.

22. Arrhythmias
Bradycardia
Neutropenia,
dilutional coagulopathy
Feed intolerance
Septicaemia,
blood born infection
Hypo or hyperthermia

23. Plastic aprons or protective gowns
Protective eye wear
Sterile gloves
Blood warmer –Beigler BW585
Beigler blood warming extension set
Blood administration set
Urine drainage bag

24. Exchange transfusion recording sheet
Sterile drape
3-way taps
Syringes assorted sizes as required
Blood gas syringes
Drawing up needles
Sleek tape
Sodium chloride 0.9% and Water for
Injection ampoules

25. Emergency resuscitation equipment including
medications and fluids
Calcium gluconate 10%
Sodium bicarbonate 8.4%
Glucose 10%
Frusemide (20mg/2ml)
Pathology collection tubes as required
 Alcohol swabs
Sterile gauze and
 Packed red blood cells
Fresh frozen plasma (ordered but do not
collect from Blood Bank until required)

26. PRE PROCEDURE
Blood and Plasma from Blood Bank
• Red Blood Cells (RBCs) less than 5 days old
• Type O Rh negative RBCs and cross-matched
against infant and mother
• 10% Dilution of RBCs with FFP or Albumin is
recommended
e.g 90mL RBC + 10mL FFP or Albumin

27. Volume of RBCs and FFP to be Prescribed:-
ESTIMATED SINGLE VOLUME EXCHANGE =
85mL x weight (kg).
ESTIMATED DOUBLE VOLUME EXCHANGE = 85
x2 x weight (kg) = 170 mL x weight (kg).

28. PROCEDURE
P:Ensure the procedure is explained to parent/s
and a written
consent is obtained.
R:Written consent for use of blood
product is required .
2.p: Identify the infant for exchange transfusion.
Proceduralist performs a “Time Out” on the
infant.
R:Time Out”: Correct Patient; Correct
Procedure; Correct Site; Correct
equipment.

29. Transfer infant to Level 3. Place infant on an open
bed under
radiant heater if not in an incubator.

30. Record baseline observations prior to
commencing exchange transfusion.
Axilla/rectal temperature
Heart rate
Respiratory rate
Blood pressure
Oxygen saturation and colour

31. Continuously monitor and record at 15
minute intervals on the record of Exchange
Transfusion sheet, the following
observations:
Skin temperature
Heart rate
Respiratory rate
Oxygen saturation
Blood Pressure (non-invasive)

32. Record axilla/rectal temperature recorded 15
minutesafter each donor pack is commenced,
and then every 30 minutes during the
transfusion.
Observe for any changes in neurological status -
drowsiness, irritability.
Record blood in/blood out on the Record of
Exchange Transfusion sheet.
Keep a running total.
Record blood results on the Exchange
Transfusion Results Sheet
Maintain continuous electronic monitoring of
vital signs for at least two hours post transfusion
(or longer if baby’s condition is not stable)

33. Resuscitation equipment and drugs must be
checked and ready for use including
adrenaline.
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.

34. Consent must be obtained by the Doctor from the
parent(s) prior to commencement of the exchange
transfusion.
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.

35. During the exchange ensure volume
in/volume out balance does not exceed
5ml < 1000g baby
10mls > 1000g baby
15ml > 2000g baby
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
heater
.
Observe carefully throughout the procedure that
there is no air in the lines.