Slide 1

Slide 2

Exchange transfusion Dr. Mahmood Noori Shadkam MD-MPH Neonatologist Associated Professor of Pediatrics, Yazd University of Medical Sciences 1393

Slide 3

History of Exchange The technique first was reported by Wallerstein in 1946 as a useful method to treat severely affected erythroblastotic newborns in whom repeated transfusion of appropriately compatible rh_negative blood was ineffective He used a 60_minute simultaneous withdrawal and transfusion method that required two sites of vascular access. Wallerstein H:Treatment of severe erythroblastosis by simultaneous removal and replacement of the blood of the newborn infant,Science 103:583,1946

Slide 4

History of Exchange Diamond and associates in 1951 contributed significantly to the safety and ease of the procedure and included the alternate withdrawal and infusion of blood through a single polyethylene tube in the umbilical vein. Diamond LK,et al:Erythroblastosis fetalis.VII Treatmentwith exchange transfusion,N Engl J Med 224:39,1951

Slide 5

Slide 6

1- Intensive phototherapy has failed to reduce Bilirubin levels to a safe range. 2- The risk of Kernicterus exceeds the risk of the procedure. 3- Correction of sever anemia and Hyperbilirubinemia in Erythroblastosis Fetalis. additional factors supporting a decision for early exchange transfusion. Cord Hemoglobin value of 10g/dl or less Cord Bilirubin concentration of 5mg/dl or more. Previous Kernicterus or severe Erythroblastosis in a sibling Reticulocyte counts>%15 Prematurity

Slide 7

4- Polycythemia 5- Severe anemia with congestive cardiac failure or hypervolemia. 6- DIC 7- Congenital leukemia 8-Metabolic toxins Hyper ammonemia Organic acidemia Lead poisoning 9- Drug overdose or Toxicity 10-Removal of antibodies and abnormal protein 11- Neonatal sepsis or Malaria

Slide 8

principal indications Hyperbilirubinemia and Hemolytic disease Exchange transfusion aids in: 1. Removing antibody-coated RBCs 2. Removes toxic bilirubin 3. To restore oxygen_carrying capacity by providing Ag_Neg RBC 4. To provide additional free Albumin

Slide 9

Indications Sepsis Neonatal sepsis may be associated with shock caused by bacterial endotoxins Exchange may help remove bacteria, toxins, fibrin split products, and accumulated lactic acid It may also provide immunoglobulins, complement, and coagulating factors

Slide 10

Sepsis Benefits of exchange transfusion in neonatal sepsis : 1. Increase immunoglobulins [ IgM &IgA ] 2. Removal of bacterial and toxins 3. Increase of neutrophils 4. Improve perfusion and oxygenation Exchange transfusion for this indication remains controversial

Slide 11

Indications Polycythemia It is usually best to give a partial exchange transfusion using normal saline. Plasma protein fraction or 5% albumin in saline may also be used normal saline is preferred because it reduces both the polycythemia and the hyperviscosity of the infant's circulating blood volume.

Slide 12

Indications (Polycythemia). Partial exchange transfusion (PET) has been used to treat both symptomatic and asymptomatic patients. At present, no data support the use of PET in asymptomatic infants; the potential benefit in symptomatic infants depends on the symptoms. Studies of long-term neurodevelopmental status do not show any clear long-term benefits for PET Sarkar S, Rosenkrantz TS, Semin Fetal Neonatal Med. 2008 Aug;13(4):248-55

Slide 13

Indications Disseminated intravascular coagulation (DIC) The benefits of exchange in DIC : 1. Replace of coagulation factor and platelets 2. Replace of antithrombin III and protein C 3. To remove Fibrin degradation products 4. To remove toxic products 5. To remove damage RBC 6. To correct anemia 7. To supply deficiency host defense proteins

Slide 14

Indication Severe anemia Severe anemia causing cardiac failure, as in hydrops fetalis, is best treated with a partial exchange transfusion using packed RBCs. thus the formula is : RBCs in CPDA-1 usually have a Hct that approximates 70%

Slide 15

Remove of toxin 1. Drug : ( theophylline, vancomicin and other antibiotics overdose ) 2. Drug and chemicals given to the mother near the time of delivery 3. Ammonia and potassium 4. Renal failure 5. .

Slide 16

Indications Severe fluid or electrolyte imbalance eg, hyperkalemia or hypernatremia .. Isovolumetric exchanges are recommended to prevent Severe electrolyte imbalance with each aliquot of blood exchanged.

Slide 17

Indication Metabolic disorders causing severe acidosis Peritoneal dialysis may also be useful for treating some progressive metabolic disorders Partial exchange transfusion are usually acceptable

Slide 18

Kernicterus: * Bilirubin deposits typically in basal ganglia, hippocampus, substantia nigra, etc.

Slide 19

Clinical Symptoms: Acute Bilirubin Encephalopathy/Kernicterus: Irritability, jitteriness, increased high-pitched crying Lethargy and poor feeding Back arching Apnea Seizures Long-term: Choreoathetoid CP, upward gaze palsy, SN hearing loss, dental dysplasia

Slide 20

Slide 21

For infants at low risk (38 weeks GA and without risk factors), exchange transfusion is indicated for the following TB values. 24 hours of age: >19 mg/dL (325 micromol/L) 48 hours of age: >22 mg/dL (376 micromol/L) 72 hours of age: >24 mg/dL (410 micromol/L) Any age greater than 72 hours: 25 mg/dL (428 micromol/L)

Slide 22

For infants at medium risk (38 weeks GA with risk factors or 35 to 37 6/7 weeks GA without risk factors), exchange transfusion is indicated for the following TB values. 24 hours of age: >16.5 mg/dL (282 micromol/L) 48 hours of age: >19 mg/dL (325 micromol/L) 72 hours of age: >21 mg/dL (359 micromol/L)

Slide 23

For infants at high risk (35 to 37 6/7 weeks GA with risk factors), exchange transfusion is indicated for the following TB values. 24 hours of age: >15 mg/dL (257 micromol/L) 48 hours of age: >17 mg/dL (291 micromol/L) 72 hours of age: >18.5 mg/dL (316 micromol/L)

Slide 24

Slide 25

Bilirubin/albumin ratio The bilirubin/albumin (B/A) ratio can be used as an additional factor in determining the need for exchange transfusion; it should not be used alone but in conjunction with TB values

Slide 26

Slide 27

Slide 28

Slide 29

For infants 38 weeks gestation, consider exchange transfusion when TB (mg/dL)/albumin (g/dL)ratio is >8.0 For infants 35 to 37 6/7 weeks and well or 38 weeks with high risk (eg, isoimmune hemolytic disease or G6PD deficiency), consider exchange transfusion when TB (mg/dL)/albumin (g/dL) ratio is >7.2 For infants 35 to 37 6/7 weeks with high risk (eg, isoimmune hemolytic disease or G6PD deficiency), consider exchange transfusion when TB (mg/dL)/albumin (g/dL) ratio is >6.8

Slide 30

Treatment: Bilirubin/Albumin Ratio Risk Category B/A Ratio at Which Exchange Transfusion Should be Considered Infants 38 0/7 wk 8.0 Infants 35 0/736 6/7 wk and well or 38 0/7 wk if higher risk or isoimmune hemolytic disease or G6PD deficiency 7.2 Infants 35 0/737 6/7 wk if higher risk or isoimmune hemolytic disease or G6PD deficiency 6.8

Slide 31

Bilirubin/Albumin Ratio It is an option to measure the serum albumin level and consider an albumin level of less than 3.0 g/dL as one risk factor for lowering the threshold for phototherapy use

Slide 32

Additional Albumin This is the rationale for the recommendation to administer 25% albumin either 1 hour before an exchange ( 1 gr / kg ) No evidence shows that this practice is of practical value in neonates with normal albumin levels. Side effects of this practice ( CHF, ..)

Slide 33

Slide 34

1- When alternatives such as simple transfusion or phototherapy would be just as effective with less risk. 2- When patient is unstable and the risk of the procedure out weights the possible benefit. In Infant with sever anemia, with cardiac failure or hyper volemia, partial ET may be useful 10 stabilize the patients conditions before a complete or double-volume ET is performed.

Slide 35

Slide 36

1-the infants stomach should be emptied before transfusion to prevent aspiration 2-body temperature should be maintained and vital signs monitored. 3- with strict aseptic technique,the umbilical vein is cannulated with a polyvinyl catheter to a distance no greater than 7 cm in a fulll-term infant 4-the exchange should be carried out over 45-60minute. 5-aspiration of 20ml of infant blood alternating with infusion of 20ml of donor blood. 6-smaller aliquots(5-10ml)may be indicated for sick and premature infants. 7- the goal should be an isovolumetric exchange of approximately two blood volumes of the infant (285 ml/kg)

Slide 37

Slide 38

Slide 39

Slide 40

Treatment of Indirect Hyperbilirubinemia: Exchange Transfusion: Double-volume exchange 2 x blood volume = 2 x 80 cc/kg = 160 cc/kg Takes about 1-1.5 hours Exchange at rate of ~5cc/kg/3 min Volume withdrawn/infused based on weight

Slide 41

Slide 42

1- if the blood is obtained before delivery,it should be taken from a type o,RH-negative donor with a low titer of anti-A and anti-B antibodies and should be determined compatible with the mothers serum by the indirect coombs test. 2- after delivery,blood should be obtained from an RH-negative donor whose cells are compatible with both the infants and the mothers sera. 3-when possible,type o donor cells are generally used,but cells of the infants ABO blood type may be used when the mother has the same type. 4- A complete cross match,including an indirect coombs test,should be performed before the 2nd and subsequent transfusions.

Slide 43

Slide 44

1-be as fresh as possible 2- be gradually warmed 3- maintained at a temperature between 35 and 37 c throughout the exchange transfusion. 4- be kept well mixed by gentle squeezing or agitation of the bag to avoid sedimentaition 5-whole blood or packed leukoreduced and irradiated RBCS reconstituted with fresh frozen plasma to an HCT of 40% should be used.

Slide 45

Types of exchange Three types of exchange transfusion are commonly used: 1 - 2-volume exchange 2 - Partial exchange ( For treatment polycythemia or anemia ) 3 - intrauterine exchanges

Slide 46

Two volume exchange A one volume exchange transfusion results in removal of 70% to 75% of the neonates RBC . A two volume exchange replaces 90% The optimal volume for an exchange transfusion is twice the infants blood volume

Slide 47

Simple 2-volume exchange transfusion blood volume in a full-term newborn ( 80 mL/kg) The blood volume of LBW and ELBW (which may be up to 95 mL/kg) should be taken into account when calculating exchange volumes.

Slide 48

Slide 49

+ : A= 2 85 wt = B= A = RBC 2 C= B = RBC 0.7 0.7 D=A - C = FFP 45 50

Slide 50

Establish the volume of each aliquot 20 ml > 3 Kg > 3 Kg 15 ml 2 - 3 Kg 10 ml 1 2 Kg 5 ml 850 gr _1Kg

Slide 51

Slide 52

Slide 53

Slide 54

Late complication 1-Anemia 2-Cholestasis 3-Inspissated bile syndrome 4-Portal vein thrombosis 5-Portal hypertension

Slide 55