EXCHANGE BLOOD TRANSFUSION

BY DR H.C. ANYABOLU

EXCHANGE BLOOD TRANSFUSION

Dr. Anyabolu

Brief History Definitions Indication Equipment The Procedure Monitoring Post Exchange Care Complications Controversies Recent Trends

BRIEF HISTORY Hart (1925) Superior Sagittal Sinus (out) and Sapherious Vein (in). Werner & Wexlar (1946) Radial Artery( out )and Saphenous Vein (in) Diamond (1946) Umbilical Vein (out and in) Sanchez (1960) Umbilical Venous cut down

DEFINITION: Simultaneous (isovolumetric type) or cyclical (discontinuous type) withdrawal of the recipients blood and

transfusion with the donors blood. When a

recipients blood is replaced with crystalloids or colloids, it is partial exchange. Synonyms: *Substitution transfusion

*Replacement transfusion
*Exsanguination transfusion

INDICATIONS 1. In severe hyperbilirubinema * In hemolytic disease at birth if PCV <45% with +ve DCT, serum bilirubin> 5mg/dl or reticulocyte > 15% * Rate of bilirubin rise > 0.5mg/dl/hr or >5mg/dl/day. * Kernicterus, irrespective of serum bilirubin level

* In preterm LBW babies, rule of 10 * Lower values of bilirubin in the presence of complication eg. hypoalbuminema, asphyxia, acidosis, hypoxia, hypothermia, sepsis, IVH, hypoglycaemia. * Serum bilirubin close to exchange value for > 36hrs.

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Severe anaemia (PCV <36) Septicaemia DIC Intractable hypoglycemia Profound hypothermia (<320C rectal) 7. Polycythemia (partial EBT/Dilution Transfusion can arrest progression of pathology. Okeniyi et al 2006)

8. Vasocclusive Cases in SCD * Priapism in Maiduguri (Ahmed SG et al 2002) After 6units complete detumescence - 95% Hbs 30.3% Hbs * Prevents the 1st stroke and also recurrence e.g. The 9yr girl from Ilesha (Senbanjo et al 2005)

9. Hyperparasitemia in Malaria * Especially with early end organ failure * Whole blood or reconstituted red cells * Single, 1.5% or double volume * 70% 2% in parasites

10.Babeiosis, Trypanosomiasis 11.Pertussis (Romans MJ et al 2004) 12.Kwashiorkor with severe anaemia in CCF. 13.Immunological Diseases - TSI in neonatal thyrotoxicosis - SLE (Olowu 2006) - Myasthenia gravis - Gullain Barre Syndrome (Baranwal et al 2006)

14.Inborn Error of Metabolism Neonatal hyperammonemia 15.Acute Hepatic Failure 16.Leukaemia Leucostasis with hyperviscosity 17.Poisonings Salicylate, sedatives, theophylline, snake envenomation.

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EQUIPMENT Mask/sterile gown/gloves Umbilical catheter/cannula (2)/ IV set/ arterial line with Transducer choice depend on which method. Dressing pack Sterile green drape

5. Haematology/Biochemistry bottles and request form 6. Blood waste bag 7. Heparin flush solution 8. Blood giving set 9. Cardiorespiratory monitor 10.Resuscitation apparatus 11.Pacifier

PROCEDURE
Consent Blood/Blood Product Type Depends on the condition Choices include whole blood, packed red cells, reconstituted PRBC + FFP Group Depends on the condition (Rh dix, ABO dix)

 Haemocrit at least 40% Genotype important in SCDx G6PD status important in G6PD defc. Age Most studies < 48hrs old (fresh) - Fresh, unbanked in DIC Microbial Screening HIV, Hepatitis, malaria Syphilis, CMV irradiation

Anticoagulants Heparin most preferred (no acidosis, electrolyte derangement, hypocalcemia. Drawbacks <24hrs NEFA Hypocoagulability - CPDA most widely available - ACD no longer used

Setting Free from Human Traffic - Well lighted - Ambient temperature 250C - 300C (may need incubator or radiant heater) Asepsis Strict - Patient on sterile drapes - Personnel on sterile gowns, gloves and masks

Personnel 1 Doctor and 1 nurse with another competent doctor within shouting distance GI Preparation NPO for 3 4 hrs - Stomach should be aspirated before and during, in very sick babies

Patient Restraint Crucifix - Formica board Priming 25% albumin 1g/kg 1 2hrs before the procedure(controversial) - Heparin solution flush 2000units + 250mls of saline

Vascular Access Neonates, umbilical vein Older children, femoral vein Others: * great saphenous vein * umbilical artery * radial artery * superficial temporal artery Site in Umbilical Vein- not >7cm

Peripheral access (indications)

Volume Exchanged Single volume - Double volume - Partial Exchange N/B * Blood volume: Neonates 80 100ml/kg others 60 70mls/kg Aliquots 20mls in well term babies less in sick babies - 5mls/kg in preterm

Duration Minimum 45mins but not more than 90mins. Ideally, every 100mls exchange = 15mins Drugs - 10% calcium gluconate 1ml per 100ml of blood (*controversial)

MONITOR AND CHART Temperature, Heart Rate; Respiration, Blood Pressure Portal venous pressure (not > 10mmH2O) pH, PaO2 RBS (Dextrostix) Colour cyanosis Blood warmer at 35 370C Input and Output

LAST BLOOD WITHDRAWN PCV, B1B2, RBS, Ca2+, Na+, K+, Mg2+, B1B2 6hrs & 24hrs (rebound) Blood Culture if indicated

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POST EXCHANGE CARE Monitor vital signs 1/2hrly x 2 hrly x 2 4hrly x 6 6hrly x 2 Observe catheter sites for bleeding Abd. Girth measurements Observe stools for blood N.P.O. for at least 3hours. However must be on dextrose containing fluid.

6. Remove umbilical catheters with a stitch in the vein. Cover with saline soaked gauze. Send catheter tip for m/c/s 7. Babies on antibiotics or anticonvulsants should be remedicated 8. Jaundiced babies should continue phototherapy.

9. Repeat portal venous pressure 10.Prophylactic antibiotics individual merit 11.CARRY PARENTS ALONG.

COMPLICATION Metabolic .Acidosis .Alkalosis (later) . k+, Na , Glu, Ca 2+, Mg2+ . Hypo/Hyperthemia

CARDIORESPIRATORY - Volume overload - Arrhythmia - Apnea - Cardiac arrest - Hypotension - Bradycardia

GIT - Bowel perforation - Inspissated bile syndrome - NEC VASCULAR Portal vein thrombosis and hypertension - Umbilical vessel perforation - Portal abscess - Vasospasm - IVH.

COMPLICATION OF BLOOD PRODUCTS -Infection -Thrombocytopenia -Air embolism -Thromboembolism -Anaemia (early & late) -GVH reaction

Prevalence of complications 3% of neonates have transfusion reaction usually mild Significant morbidity 5% ( in recent times). Deaths 3 in 1000 procedures (highly dependent on premorbid state).

CONTROVERSIES Use of calcium gluconate Benefit in kernicterus RECENT DEVELOPMENTS Automation faster, wastes less blood, less circulatory fluctuation, more aseptic. Procedures are less frequent.