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Exchange Transfusion in Newborns

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Exchange Transfusion in Newborns

  • Indications
  • Exchange Transfusion for Hyperbilirubinemia in term infants (>36 weeks and >2 kg, or >35 weeks and >2.5 kg)
  1. See Severe Neonatal Hyperbilirubinemia Risk Factor
  2. Exchange Transfusion is indicated when a threshold is crossed based on an infants Hyperbilirubinemia risk factors
    1. High Risk Infant
      1. Gestational age >35 weeks AND <38 weeks AND Severe Neonatal Hyperbilirubinemia Risk Factor
    2. Intermediate Risk Infant
      1. Gestational age >38 weeks AND Severe Neonatal Hyperbilirubinemia Risk Factor OR
      2. Gestational age >35 weeks AND <38 weeks AND No Risk Factors
    3. Low Risk Infant
      1. Gestational age >38 weeks AND No Risk Factors
  3. Age 0 hours of life
    1. High risk Infant: Serum Bilirubin >12 mg/dl
    2. Intermediate risk Infant: Serum Bilirubin >13.8 mg/dl
    3. Low risk Infant: Serum Bilirubin >16 mg/dl
  4. Age 12 hours of life
    1. High risk Infant: Serum Bilirubin >13.5 mg/dl
    2. Intermediate risk Infant: Serum Bilirubin >15.1 mg/dl
    3. Low risk Infant: Serum Bilirubin >17.6 mg/dl
  5. Age 24 hours of life
    1. High risk Infant: Serum Bilirubin >15 mg/dl
    2. Intermediate risk Infant: Serum Bilirubin >16.5 mg/dl
    3. Low risk Infant: Serum Bilirubin >19 mg/dl
  6. Age 36 hours of life
    1. High risk Infant: Serum Bilirubin >16 mg/dl
    2. Intermediate risk Infant: Serum Bilirubin >18 mg/dl
    3. Low risk Infant: Serum Bilirubin >20.9 mg/dl
  7. Age 48 hours of life
    1. High risk Infant: Serum Bilirubin >17 mg/dl
    2. Intermediate risk Infant: Serum Bilirubin >19.1 mg/dl
    3. Low risk Infant: Serum Bilirubin >22.2 mg/dl
  8. Age 60 hours of life
    1. High risk Infant: Serum Bilirubin >18 mg/dl
    2. Intermediate risk Infant: Serum Bilirubin >20.1 mg/dl
    3. Low risk Infant: Serum Bilirubin >23 mg/dl
  9. Age 72 hours of life
    1. High risk Infant: Serum Bilirubin >18.5 mg/dl
    2. Intermediate risk Infant: Serum Bilirubin >21.3 mg/dl
    3. Low risk Infant: Serum Bilirubin >23.9 mg/dl
  10. Age 84 hours of life
    1. High risk Infant: Serum Bilirubin >18.8 mg/dl
    2. Intermediate risk Infant: Serum Bilirubin >22 mg/dl
    3. Low risk Infant: Serum Bilirubin >24.4 mg/dl
  11. Age >96 hours of life (up to 7 days old or 168 hours)
    1. High risk Infant: Serum Bilirubin >19 mg/dl
    2. Intermediate risk Infant: Serum Bilirubin >22.5 mg/dl
    3. Low risk Infant: Serum Bilirubin >24.9 mg/dl
  12. References
    1. AAP: Management of Hyperbilirubinemia in Infant > 35 weeks
      1. http://pediatrics.aappublications.org/content/114/1/297.full#F2
  • Mechanism
  1. Extracts Antibody coated erythrocytes
  2. Extracts partially hemolyzed Red Blood Cells
  3. Replaces removed blood with uncoated donor RBCs
  • Technique
  1. Usually performed at neonatal tertiary centers
  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)
  • Complications (5-10% of infants)
  • 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
  • References
  1. Behrman (2000) Nelson Pediatrics, Saunders, p. 524
  2. (2000) Harriet Lane Handbook, Mosby, p. 431