Technique

• There are a variety of techniques for exchange transfusion. That chosen will depend on the vascular access available and the choice of the specialist supervising the exchange.
• The exchange equipment is usually 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.  Isovolumetric Exchange

• Remove blood from an artery while infusing through a vein at the same rate.

2.  Push-pull

• This can be done through an umbilical venous catheter. ³  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. Aim to exchange 180 ml/kg over 1½ -2 hours.
• If using a 2-catheter push-pull method, withdraw the blood at the same time that blood is given.

3.  Infusion Method

• The choice of method is that of the specialist supervising.
• The choice of infusion method is a syringe or an infusion pump.
• Blood removal is by syringe. 
• With the isovolumetric method and syringes, the doctors/NS-ANPs involved infuse and withdraw at the same rate.
• REFER TO THE OTHER RELATED DOCUMENTS FOR LINKS TO THE DIAGRAMS OF THE SET-UPS.

Volume

• Usually use two blood volumes (180 ml/kg).
  • One blood volume removes 65% of baby’s red cells.
  • Two blood volumes removes 88%.
• Thereafter the gain is small. ³

Procedure

• There must be at least one doctor/NS-ANP and one nurse exclusively involved in the exchange throughout its progress. 
• Meticulous care must be taken throughout, especially with volume balance, the rate of the exchange, the vital signs and any signs of air in the lines. 
• A doctor/NS-ANP must be present throughout the exchange. He/she may leave the room briefly to get blood results, but if called away, the exchange is stopped and the lines flushed. 
• All exchanges are to be conducted in NICU Level 3.
• It may be necessary for another doctor/NS-ANP to cover the rest of the unit during the exchange.
  
• 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.

Partial Exchange Transfusion ³

• To correct severe anaemia without hypovolaemia or polycythaemia.

Polycythaemia

Anaemia

• Blood volume = 70-90 ml/kg for term and 85-110 ml/kg for preterm infants.

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References