II. Indications
- Severe Hyperbilirubinemia refractory to Phototherapy
- Hemolytic Disease of the Newborn (or other Hemolysis, e.g. G6PD Deficiency)
- Acute Bilirubin Encephalopathy signs
III. Indications: AAP 2022 - Exchange Transfusion in LOW risk TERM infants (>36 weeks and >2 kg, or >35 weeks and >2.5 kg)
- Background
- Use BiliTool or PediTools calculators for exact indication thresholds (thresholds here are rough estimates summarizing guidelines)
- Thresholds updated in AAP 2022 are considerably higher than prior thresholds for initiating exchange transfusion
- Escalate care to NICU when Total Bilirubin is within 2 mg/dl of exchange transfusion threshold
-
Gestational age 38 to 40 weeks - Thresholds
- Age 24 hours: >=21.5 mg/dl
- Age 48 hours: >=24.0 mg/dl
- Age 72 hours: >=26.0 mg/dl
- Age 96 hours: >=27.0 mg/dl
-
Gestational age 36 weeks - Thresholds
- Age 24 hours: >=21.0 mg/dl
- Age 48 hours: >=22.0 mg/dl
- Age 72 hours: >=24.0 mg/dl
- Age 96 hours: >=25.5 mg/dl
- References
IV. Indications: AAP 2022 - Exchange Transfusion in HIGH risk TERM infants (>36 weeks and >2 kg, or >35 weeks and >2.5 kg)
- Background
- Use BiliTool or PediTools calculators for exact indication thresholds (thresholds here are rough estimates summarizing guidelines)
- Thresholds updated in AAP 2022 are considerably higher than prior thresholds for initiating exchange transfusion
- High risk factors for neurotoxicity include Hemolysis (e.g. g6PD, Hemolytic Disease of the Newborn), Sepsis, instability, albumin <3 g/dl
- Escalate care to NICU when Total Bilirubin is within 2 mg/dl of exchange transfusion threshold
-
Gestational age 38 to 40 weeks - Thresholds
- Age 24 hours: >=17.5 mg/dl
- Age 48 hours: >=20.0 mg/dl
- Age 72 hours: >=22.0 mg/dl
- Age 96 hours: >=23.5 mg/dl
-
Gestational age 36 weeks - Thresholds
- Age 24 hours: >=16.5 mg/dl
- Age 48 hours: >=19.0 mg/dl
- Age 72 hours: >=21.0 mg/dl
- Age 96 hours: >=22.0 mg/dl
- References
V. Mechanism
- Extracts Antibody coated erythrocytes
- Extracts partially hemolyzed Red Blood Cells
- Replaces removed blood with uncoated donor RBCs
VI. Technique
- Usually performed at neonatal tertiary centers (NICU)
- Umbilical Venous Catheter placed at 7 cm or less
- Alternate aspiration and infusion
- Aspirate 20 cc of infant's blood
- Infuse 20 cc of donors blood
- Consider only 5-10 cc volumes in tenuous patients
- Exchange twice the infant's Blood Volume (2 x 85 ml/kg)
VII. Complications (5-10% of infants)
- Mortality: 0.3% (up to 1 to 3% of infants with Hemolysis)
- Air Embolism
- Transient Vasospasm
- Transient Bradycardia
- Thrombocytopenia
- Transfusion Reaction
- Disseminated Intravascular Coagulation
- Necrotizing Enterocolitis
- Electrolyte disturbance
- Sepsis
- Blood borne pathogen
- Cytomegalovirus
- HIV Infection
- Hepatitis
VIII. Precautions
- Obtain lab work prior to exchange transfusion
- Lab findings on post-exchange blood are not helpful
- Pre-exchange blood sample labs
IX. References
- Behrman (2000) Nelson Pediatrics, Saunders, p. 524
- (2000) Harriet Lane Handbook, Mosby, p. 431