CHILD HEALTH NURSING

Exchange Transfusion (lectures) - by Mrs Sunita Bhandari (Shah)

Exchange transfusion is a potentially life-saving procedure .The procedure involves slowly removing the patient's blood and replacing it with fresh donor blood or plasma.
 
Types of exchange blood transfusion
  • Double volume: 90% of the circulating plasma and cells. It follows that while a single volume exchange transfusion will be partially effective
  • Single volume: replaces approximately 70-75%of the infant’s circulating blood volume. Less effective than a double volume exchange.
  • Partial: 65%exchange transfusion done with normal saline, albumin or plasma.
 
Indication
  • When phototherapy fails to prevent a rise in bilirubin to toxic level
  • Healthy full term infants- 23-29mg/dl
  • Sick and preterm infants, and infants with haemolysis - 17-23mg/dl
  • Small infants weight <1500g- 15mg/dl
  • In addition, even in the absence of high serum bilirubin levels, the procedure may be indicated in infants with erythroblastosis

 
Investigation:
  • Donor blood:
  • Body’s blood: At the beginning of exchange transfusion
  • Post- exchange
  • Bacteriological investigation
 
Technique
  • It should be performed either in the operation theatre or nursery with absolute aseptic precautions.
  • The baby must be kept adequately warm during the procedure.
  • The content of the stomach should be aspirated.
  • Baby fixed with use of cotton pads and bandages
  • Telethermometer and electrocardiography are attached to baby to monitor temperature and cardiac status.
  • Prepare the exchange transfusion chart.
  • With absolute aseptic and antiseptic precautions umbilical vein should be cannulated
  • The catheter is attached to two three way stopcocks so that its leads are connected to umbilical catheter, syringe, donor blood and a sterile container for waste.
  • The blood is withdrawn with gentle suction and donor’s blood is injected slowly in a aliquots of 10-20 ml depending upon the size and condition of the baby.
 
Volume of blood for each aliquot is recommended as follows
  • For babies <1000 gm-3.5ml
  • For babies 1000-2000gm-5.0ml
  • For babies 2000-2500 gm-10 ml
  • For babies 2500-3000 gm- 15ml
  • For babies >4000 gm- 20ml
 
Procedure
  • During the procedure the bottle of the donor blood should be gently agitated from time to time to keep the cell and plasma well mixed.
  • An accurate record of in/ out of each cycle, condition of the baby and medicine used during procedure.
  • Whenever any untoward sign develops like respiratory distress, grunting, tachycardia or bradycardia, fall in oxygen saturation, deterioration in colour of the baby or umbilical blood, the procedure should be withheld for some time, till the baby improves
  • After completion of procedure, the catheter is removed; its tip is cut and sent for culture and sensitivity test.
  • The umbilical stump should be pressed for some time and then dressed with antibiotic powder and sterile gauze.
  • Pre and Post Exchange sample should be labeled properly and sent for examination.
  • Completed usually within 60-90minutes.
 
Precautions
  • As small cannula should be used
  • Cannulation should be done by percutaneous route rather than by a cutdown.
  • Air should not be allowed to enter the vessels.
  • Isotonic saline should be used for flushing.
  • The cannula should be heparinized.
  • Volume of the fluid for the flushing the cannula should be kept as small as possible.
  • Rate of the flushing should be controlled, o.5ml over 5 to 10 seconds.
  • If the cannula gets obstructed, it should be removed and with a fresh one it should be tried at another place.

 
Post procedure management
  • Vital parameters are monitors
  • The baby is kept nil by mouth for least 4hours.
  • Watch for convulsion-monitor blood glucose, serum calcium.
  • Phototherapy is continued.
  • Monitor serum bilirubin level after exchange transfusion.
 
Complications
  • Infection
  • Cardiac failure
  • Air embolism
  • Thromboembolism
  • Anemia
  • Hypoglycemia