Exchange Transfusion in Newborns

Aka: Exchange Transfusion in Newborns, Exchange Transfusion for Severe Neonatal Hyperbilirubinemia

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II. Indications

  1. Severe Hyperbilirubinemia refractory to Phototherapy
  2. Hemolytic Disease of the Newborn (or other Hemolysis, e.g. G6PD Deficiency)
  3. 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)

  1. Background
    1. Use BiliTool or PediTools calculators for exact indication thresholds (thresholds here are rough estimates summarizing guidelines)
    2. Thresholds updated in AAP 2022 are considerably higher than prior thresholds for initiating exchange transfusion
    3. Escalate care to NICU when Total Bilirubin is within 2 mg/dl of exchange transfusion threshold
  2. Gestational age 38 to 40 weeks - Thresholds
    1. Age 24 hours: >=21.5 mg/dl
    2. Age 48 hours: >=24.0 mg/dl
    3. Age 72 hours: >=26.0 mg/dl
    4. Age 96 hours: >=27.0 mg/dl
  3. Gestational age 36 weeks - Thresholds
    1. Age 24 hours: >=21.0 mg/dl
    2. Age 48 hours: >=22.0 mg/dl
    3. Age 72 hours: >=24.0 mg/dl
    4. Age 96 hours: >=25.5 mg/dl
  4. References
    1. Kemper (2022) Pediatrics 150(3): e2022058859 [PubMed]

IV. Indications: AAP 2022 - Exchange Transfusion in HIGH risk TERM infants (>36 weeks and >2 kg, or >35 weeks and >2.5 kg)

  1. Background
    1. Use BiliTool or PediTools calculators for exact indication thresholds (thresholds here are rough estimates summarizing guidelines)
    2. Thresholds updated in AAP 2022 are considerably higher than prior thresholds for initiating exchange transfusion
    3. High risk factors for neurotoxicity include Hemolysis (e.g. g6PD, Hemolytic Disease of the Newborn), Sepsis, instability, albumin <3 g/dl
    4. Escalate care to NICU when Total Bilirubin is within 2 mg/dl of exchange transfusion threshold
  2. Gestational age 38 to 40 weeks - Thresholds
    1. Age 24 hours: >=17.5 mg/dl
    2. Age 48 hours: >=20.0 mg/dl
    3. Age 72 hours: >=22.0 mg/dl
    4. Age 96 hours: >=23.5 mg/dl
  3. Gestational age 36 weeks - Thresholds
    1. Age 24 hours: >=16.5 mg/dl
    2. Age 48 hours: >=19.0 mg/dl
    3. Age 72 hours: >=21.0 mg/dl
    4. Age 96 hours: >=22.0 mg/dl
  4. References
    1. Kemper (2022) Pediatrics 150(3): e2022058859 [PubMed]

V. Mechanism

  1. Extracts Antibody coated erythrocytes
  2. Extracts partially hemolyzed Red Blood Cells
  3. Replaces removed blood with uncoated donor RBCs

VI. Technique

  1. Usually performed at neonatal tertiary centers (NICU)
  2. Umbilical Venous Catheter placed at 7 cm or less
  3. Alternate aspiration and infusion
    1. Aspirate 20 cc of infant's blood
    2. Infuse 20 cc of donors blood
    3. Consider only 5-10 cc volumes in tenuous patients
  4. Exchange twice the infant's Blood Volume (2 x 85 ml/kg)

VII. Complications (5-10% of infants)

  1. Mortality: 0.3% (up to 1 to 3% of infants with Hemolysis)
  2. Air Embolism
  3. Transient Vasospasm
  4. Transient Bradycardia
  5. Thrombocytopenia
  6. Transfusion Reaction
  7. Disseminated Intravascular Coagulation
  8. Necrotizing Enterocolitis
  9. Electrolyte disturbance
    1. Hypoglycemia
    2. Hyperkalemia
    3. Hypernatremia
    4. Hypocalcemia
    5. Metabolic Acidosis
  10. Sepsis
  11. Blood borne pathogen
    1. Cytomegalovirus
    2. HIV Infection
    3. Hepatitis

VIII. Precautions

  1. Obtain lab work prior to exchange transfusion
  2. Lab findings on post-exchange blood are not helpful
  3. Pre-exchange blood sample labs
    1. Complete Blood Count
    2. Peripheral Smear
    3. Reticulocyte Count
    4. Bilirubin
    5. Calcium
    6. Glucose
    7. Total Protein
    8. Infant Blood Type
    9. Coombs Test

IX. References

  1. Behrman (2000) Nelson Pediatrics, Saunders, p. 524
  2. (2000) Harriet Lane Handbook, Mosby, p. 431

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