By

Pravin Prakash .P
 A neonatal exchange transfusion involves
removing aliquots of patient blood and
replacing with donor blood in order to
remove abnormal blood components and
circulating toxins whilst maintaining
adequate circulating blood volume.
 Example
 to remove antibodies and excess bilirubin in
isoimmune disease,
 Example
 to remove antibodies and excess bilirubin in
isoimmune disease,
INDICATIONS
 Alloimmune haemolytic disease of the newborn
 Remove circulating bilirubin to reduce levels and prevent
kernicterus
 Replace antibody-coated red cells with antigen-negative
red cells
 Severe hyperbilirubinaemia secondary to alloimmune
haemolytic disease of the newborn is the most common
reason for exchange transfusion in the neonatal intensive
care unit.
 A total serum bilirubin level at or above the exchange
transfusion level should be considered a medical
emergency and intensive phototherapy (multiple light)
should be commenced immediately. The Consultant
Neonatologist on service should be contacted without
delay.
 Significant unconjugated hyperbilirubinaemia
with risk of kernicterus due to any cause
when intensive phototherapy is unsuccessful
 Severe anaemia (where there is normal or
increased circulating blood volume)
 Antibodies in maternal autoimmune disease
 Polycythaemia (to reduce haematocrit,
usually accomplished with partial exchange
transfusion using normal
TECHNIQUE
 Exchange transfusions are performed
using either one catheter or two catheter
push-pull method.
 The exchange equipment is set up by
nursing staff, but the specialist responsible
for the exchange must check the set-up
prior to commencing the exchange. This
set-up is a joint responsibility between
medical and nursing staff, but the specialist
doing the exchange has overall
responsibility for the procedure.
1. Two Catheter Push-pull
Technique
 Blood is removed from the artery while
infusing fresh blood through a vein at the
same rate.

In Out

Umbilical vein Peripheral artery

or Umbilical vein Umbilical artery

or Peripheral vein Peripheral artery2

or Peripheral vein Umbilical artery

2. One Catheter Push-pull Technique
 This can be done through an umbilical venous
catheter. Exceptionally, an umbilical artery
catheter can be used.
 Ideally, the tip of the UVC should be in the
IVC/right atrium (at or just above the
diaphragm) but can be used if it is in the portal
sinus. For ‘high’ UVC placement, position
should be checked by an X-ray. This is not
always necessary for a low position. A low
positioned catheter is usually removed after
each exchange.
 Withdraw blood over 2 minutes, infuse slightly
faster.
Volume
 N.B: Blood Volume = 70-90 ml/kg for
term and 85-110 ml/kg for preterm
infants
 One blood volume removes 65% of
baby’s red cells.
 Two blood volumes removes 88%
 Thereafter the gain is small.
<1000gms Use 5ml aliquots

1000-2000gm 10ml

>2000gm 3 15ml
PRE- PROCEDURE PREPARATION

 Preparation of the Infant

 Equipments
 Set-Up
Preparation of the Infant
 discuss the procedure with the parents/guardian
 obtain consent
 Advise AUM and Consultant Neonatologist on duty as soon as
decision to exchange is made
 Exclusively allocate at least one doctor and one nurse to care
of the infant throughout the procedure
 When an exchange transfusion is taking place the Consultant
Neonatologist on duty should be present on the unit to provide
support and to troubleshoot issues so that the Fellow or
Registrar can carry out the procedure without interruption
 Ensure resuscitation equipment and medications are easily
accessible
 Nurse infant under radiant warmer for accessibility
 Ensure infant is comfortable and settled – sedation and pain
relief are not usually required unless the infant is active and
likely to compromise line stability or sterile field
 Ensure full cardio-respiratory monitoring is initiated and
document full set of baseline observations (temperature,
respiratory and heart rate, blood pressure and oxygenation)
 Infant should be nil orally as soon as decision is made to
perform exchange transfusion.
 Pass oro/nasogastric tube and aspirate stomach contents.
Leave tube in-situ and on free drainage for duration of
procedure
 Before commencing exchange transfusion collect blood
samples for required baseline bloods and any specific testing
required. Tests may include (but not be limited to) blood
cultures, blood gas, serum bilirubin, blood glucose, FBC,
UEC, LFT, newborn screening test, haematological,
chromosome or metabolic studies
 Establish vascular access for
procedure if not already in-situ (see
RCH Clinical Practice Guideline
“Central Vascular Access Devices
Insertion and Management”)
depending on whether the procedure
will be performed via arterial and
venous access or via single venous
access
Equipments
 Plastic aprons or protective  Sodium chloride 0.9% and
gowns Water for Injection ampoules
 Protective eye wear  Emergency resuscitation
 Sterile gloves equipment including
 Blood warmer medications and fluids
 blood warming extension set  Calcium gluconate 10%
 Blood administration set  Sodium bicarbonate 8.4%
 Water feed set  Glucose 10%
 Urine drainage bag  Frusemide (20mg/2ml)
 Exchange transfusion recording  Pathology collection tubes as
sheet required
 Sterile drape  Alcohol swabs Sterile gauze
and
 3-way taps  Packed red blood cells
 Syringes assorted sizes as  Fresh frozen plasma (ordered
required but do not collect from Blood
 Blood gas syringes Bank until required)
 Drawing up needles
 Sleek tape
Set-Up
 performed slowly over approximately 2 hours to
avoid major fluctuations in blood pressure.
 Anticipate the need for increased oxygen
requirement during procedure (administer oxygen
via nasal cannula in self ventilating babies if
required).
 Set blood warmer at 41oC.
 Blood warming extension set should be threaded
onto the blood warming coil while it is not
primed. Start at the back of the device and wind
anti-clockwise towards the front 8 times (that is
80cm between blood warmer and patient). Line
must be completely inserted between the grooves
of the blood warming coil.
PROCEDURE
 All exchanges are to be conducted in NICU level 3
 There must be at least one doctor and one nurse exclusively
involved in the exchange throughout its progress.
 The nurse must be a level four nurse (or senior nurse), who
is trained and up to date with this procedure.
 The doctor must be present throughout the exchange. If
called away, the exchange is to be stopped and the lines
flushed with NaCl 0.9%.
 Meticulous care must be taken with volume balance, the rate
of the exchange, the vital signs and any signs of air in the
lines.
 IF THERE ARE ANY DOUBTS ABOUT THE SET-UP OR
THE METHOD OF DOING THE EXCHANGE
TRANSFUSION, THEY MUST BE IMMEDIATELY
REFERRED TO SENIOR MEDICAL OR NURSING STAFF
AND THE EXCHANGE INTERRUPTED UNTIL THEY ARE
ANSWERED SATISFACTORILY.
 Asepsis must be maintained throughout the procedure.
PROCEDURE IN CASE OF ADVERSE REACTION
AND/OR NEGATIVE OUTCOME
Steps Action

1 •At first sign of any adverse reaction - STOP the blood being infused.

2 •Initiate resuscitative measures as indicated.

3 •The IV cannulae/catheter may be re-used once flushed with 0.9% NaCl.

4 •All blood and infusion lines used in the Exchange Transfusion must be returned to the Blood
Bank for investigation.

5 •Document adverse reaction using the on-line reporting system (Risk Pro). Document the file
number in the medical notes.

6 •In the case of infant’s death resulting from an Exchange Transfusion:

• Inform the Duty Manager and Clinical Director of Newborn unit.
• Photograph the transfusion set up and bedspace, in as much detail as possible
• The Consultant/Registrar contacts the Police and Coroner. The Consultant/Registrar
must ask the Coroner’s permission before any lines can be removed.
• If lines and blood pack are removed they must be sent to Blood Bank for proper
analysis.
• Blood Bank must hold all blood samples, the units of blood and lines until the Police or
Coroner state otherwise. (Notify Blood Bank to ensure this happens)
• All clinical records for the baby are photocopied prior to being sent to the Coroner.
NB •Do not dispose of anything used in the Exchange Transfusion. It will be required by the Police
and the Coroner.
COMPLICATIONS
 The most commonly reported adverse
events during or soon after exchange
transfusion:
 Catheter related complications

 Potential complications related to exchange

transfusion
 air emboli; thrombosis; haemorrhage
 Haemodynamic (related to excess removal of
injection of blood): hypo or hypertension,
intraventricular haemorrhage (preterm)
 Hypo or hyperglycaemia
 Hypocalcaemia, hyperkalaemia, acidaemia
 Arrhythmias
 Bradycardia
 Neutropenia, dilutional coagulopathy
 Feed intolerance, necrotizing enterocolitis
 Septicaemia, blood born infection
 Hypo or hyperthermia
NURSES RESPONSIBILITY

 Exchange Transfusion
Safety/Nursing Care of the Baby
 Exchange Transfusion
Monitoring and Documentation
 Exchange Transfusion
Specimens - Donor, Pre-exchange,
During Exchange, and Post-
Exchange
Exchange Transfusion
Safety/Nursing Care of the Baby
Step Action
1 •Exchange transfusions must be performed in the Level Three section of
the Newborn Intensive Care Unit by either a Consultant or Registrar/NS-
ANP under Consultant’s authorisation.
2 •Resuscitation equipment and drugs must be checked and ready for use
including adrenaline 1:10,000.
3 •Ventilator must be set up ready for use at the bed space.

4 •Blood and IV fluids must be prescribed by medical staff on appropriate

charts.
5 •Consent must be obtained by the Doctor from the parent(s) prior to
commencement of the exchange transfusion.
6 •Nurse the baby on a radiant heat table.
•If the exchange is being done for hyperbilirubinaemia, ensure optimal
exposure to phototherapy and biliblanket is maintained
7 •The infants cardiorespiratory status and oxygen saturation must be
monitored continuously. Non-invasive blood pressures are to be taken
every 15minutes.
Step Action

8 •Baby remains NBM throughout the exchange. Aspirate stomach

contents prior to commencement of procedure and leave the gastric
tube on free drainage. This eliminates the risk of aspiration.

9 •During the exchange ensure volume in/volume out balance does not
exceed
• 5ml < 1000g baby
• 10mls > 1000g baby
• 15ml > 2000g baby

10 •If the exchange transfusion is stopped for any reason for longer than 2-
3 minutes, disconnect blood line from the baby, remove blood line from
heating sheath, remove line from under radiant heater1.

11 •Observe carefully throughout the procedure that there is no air in the

lines.
Exchange Transfusion
Monitoring and Documentation
Steps Action
1 •Record baseline observations prior to commencing exchange
transfusion.
• Axilla/rectal temperature
• Heart rate
• Respiratory rate
• Blood pressure
• Oxygen saturation and colour
2 •Continuously monitor and record at 15 minute intervals on the
record of Exchange Transfusion sheet(CR5730), the following
observations:
• Skin temperature
• Heart rate
• Respiratory rate
• Oxygen saturation
• Blood Pressure (non-invasive)
Exchange Transfusion
Monitoring and Documentation
Steps Action

3 •Record axilla/rectal temperature recorded 15 minutes after each

donor pack is commenced, and then every 30 minutes during the
transfusion.

4 •Observe for any changes in neurological status - drowsiness,

irritability.
5 •Record blood in/blood out on the Record of Exchange
Transfusion sheet (CR5730).
• Keep a running total.

6 •Record blood results on the Exchange Transfusion Results Sheet

(CR5729)
7 •Maintain continuous electronic monitoring of vital signs for at
least two hours post transfusion (or longer if baby’s condition is
not stable).
 Exchange Transfusion
Specimens - Donor, Pre-exchange, During
Exchange, and Post-Exchange
Step Action
s
1 •Donor Blood Specimens:
• Mix blood well.
• Specimen is to be taken from each unit as
soon as it arrives.
• Collect 0.3ml into a blood gas syringe and
record haemoglobin and K+.
• Blood should not be used if potassium result
is:
>15mmol/L in well babies
>10mmol/L in small sick babies
 Exchange Transfusion
Specimens - Donor, Pre-exchange, During
Exchange, and Post-Exchange
Steps Action
2 •Pre-Exchange Patient Specimens:
• Arterial blood gas, Na, K, Ca and glucose levels.
• FBC and differential.
• Urea, Creatinine, Bilirubin (total and direct).
• Guthrie (unless previously done)
• Coagulation screen should be collected if more
than one exchange is performed ( 0.8ml into
buffered citrate micro-container obtained from lab).

3 •During Exchange Specimen:

• Blood gas, electrolytes and glucose are tested as
ordered.
 Exchange Transfusion
Specimens - Donor, Pre-exchange, During
Exchange, and Post-Exchange
Steps Action

4 •Post-Exchange Patient Specimens: (take from the last

few ml of the exchange out volume)
• Arterial blood gas, Na, K, Ca, Glucose.
• FBC and differentials
• Urea, Bilirubin (total and direct).
• Coagulation screen should be performed if more
than one exchange.
SUMMARY
 NEONATAL EXCHANGE
TRANSFUSION, its indication,
techniques commonly used,
preprocedure preparation, procedure,
complications and nurses
responsibilities.
Thank you