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Exchange Transfusion in the Neonate : 

Exchange Transfusion in the Neonate Eddie Chang, M.D. Division of Neonatology Abington Memorial Hospital Clinical Assistant Professor Department of Pediatrics Drexel University College of Medicine

Types of Exchange Transfusion : 

Types of Exchange Transfusion Simple 2-Volume Exchange Exchanging 2x the infant’s blood volume Isovolumetric 2-Volume Exchange Exchanging 2x the volume Infusing and withdrawing blood at the same time through two separate ports Partial Exchange (<2 volumes) Exchanging < 2x the patient’s volume Usually used for Severe Anemia or Polycythemia

Indications : 

Indications Major Hyperbilirubinemia Hemolytic Disease of the Newborn Rh incompatibility ABO incompatibility Other blood group incompatibilities Severe Anemia Polycythemia Other Sepsis DIC Metabolic acidosis Severe fluid/electroyte imbalances

Blood : 

Blood Homologous blood Cytomegalovirus seronegative and leukodepleted Sickle negative Irradiated

Blood : 

Blood Rh incompatibility type O Rh-negative Low titer anti-A, anti-B Cross-matched with mother’s plasma and RBCs ABO incompatibility Type O Rh-compatible with mother and infant (or Rh-negative) Low-titer anti-A, anti-B blood Cross-matched with infant’s and mother’s blood Other blood group incompatibility Must be cross matched with mother’s blood to avoid offending antigens.

Blood : 

Blood Preferable to use blood or plasma collected in citrate phosphate dextrose (CPD) < 72hrs old However in newborns with severe asphyxia or hydrops fetalis blood that is < 24 hrs old is preferable.

Umbilical Central Catheters : 

Umbilical Central Catheters NRP Course Materials. www.aap.org/nrp/coursemats/coursemats_dvd10.html

Exchange Transfusion : 

Exchange Transfusion

Simple or Isovolumetric 2-Volume Exchange Transfusion : 

Simple or Isovolumetric 2-Volume Exchange Transfusion Normally used for hyperbilirubinemia Also for Hemolytic Disease (Rh incompatibility, ABO incompatibility, etc) Isovolumetric is preferred when there is cardiac insufficiency

Hyperbilirubinemia : 

Hyperbilirubinemia Bilirubin ~ jaundice (physical finding) Bilirubin is a breakdown product of Red Blood Cells In newborns jaundice is very common Must be differentiated from pathologic jaundice

Hyperbilirubinemia : 

Hyperbilirubinemia

Hyperbilirubinemia : 

Hyperbilirubinemia The level of bilirubin that is dangerous changes as a function of: Infant’s age Illness Weight

Hyperbilirubinemia : 

Hyperbilirubinemia First line therapy is phototherapy Goal of both phototheraphy and exchange transfusion is to prevent Kernicteris. Cerebral Palsy and other permanent neurological disorders.

Partial Exchange in Severe Polycythemia : 

Partial Exchange in Severe Polycythemia Asymptomatic Hematocrit > 75% Symptomatic > 60-65% Polycythemia can cause Tachypnea Congestive heart failur Seizures Priapism Gangrene of an extremity Testicular infarction Retinopathy of prematurity Necrotizing enterocolitis/Ileus Acute renal failure

Partial Exchange in Severe Polycythemia : 

Partial Exchange in Severe Polycythemia Exchange polycythemic blood for Normal Saline, Albumin, FFP. Volume of exchange (mL) = Blood Volume x Weight x (Observed Hct – Desired Hct) Observed Hct

Partial Exchange for Severe Anemia : 

Partial Exchange for Severe Anemia Restore circulating Red Blood Cell volume without introducing too much fluid. Usually for patients who are not acutely anemic Acutely anemic patients need simple emergent transfusion They have had time to compensate due to a slower process Fetal-maternal transfusion/hemorrhage Twin-twin transfusion

Partial Exchange for Severe Anemia : 

Partial Exchange for Severe Anemia Volume = Est. Blood Volume x Weight x (Hct desired – Hct observed) (70%-Hct observed)

Complications of Exchange Transfusion : 

Complications of Exchange Transfusion Introduction of Infection Vascular complications from the Umbilical Central Catheters Hypoglycemia Coagulopathies Potentially reduce circulating platelets, clotting factors Electrolyte abnormalities Hypocalcemia, hyperkalemmia Metabolic acidosis Using non CPD blood or older stored blood. Metabolic Alkalosis Necrotizing enterocolitis

Summary : 

Summary Exchange Transfusions are performed for many indications There are two types: 2-Volume Exchange Transfusion Simple or Isovolumetric Partial Exchange Transfusion