Newborn Services Clinical Guideline

Newborn Services Clinical Guideline

Note: The electronic version of this guideline is the version currently in use.
Any printed version can not be assumed to be current. Printed copies of this document are valid for Sunday, June 27, 2010.
The general disclaimer regarding use of Newborn Services Guidelines and Protocols applies to this guideline.

Exchange Transfusion	Reviewed by K. Brokenshire, M. Battin & Pita Birch
	December 2009

Technique		Procedure
Other Related Documents		References

Technique

1.            Exchange transfusions are performed using a one catheter or two catheter push-pull method.

2. 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

1.            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

1.            This can be done through an umbilical venous catheter. Exceptionally, an umbilical artery catheter can be used.

2. 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.
3. 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

1.            One blood volume removes 65% of baby’s red cells.

2. Two blood volumes removes 88%
3. Thereafter the gain is small.

<1000gms	Use 5ml aliquots
1000-2000gm	10ml
>2000gm 3	15ml

Procedure

1.            There must be at least one doctor/NS-ANP and one nurse exclusively involved in the exchange throughout its progress. 

2. The 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. 
3. It may be necessary for another doctor/NS-ANP to cover the rest of the unit during the exchange.
4. 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. 
5. All exchanges are to be conducted in NICU Level 3.
6. The nurse must be at least a level four nurse, who is trained and up to date with the procedure, if there are not two nurses who are trained and up to date on shift, one who is should be called in (placed on call)
7. 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.

References

1	Thayyil S, Milligan D. Single versus double volume exchange transfusion in jaundiced newborn infants. Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD004592. DOI: 10.1002/14651858.CD004592.pub2
2	Chen HN, Lee ML, Tsao LY. Exchange transfusion using peripheral vessels is safe and effective in newborn infants. Pediatrics. 2008 Oct;122(4):e905-10.
3	Iowa_Neonatology_Fellows. Exchange Transfusion. In: Bell EF, Segar JL, editors. Iowa Neonatology Handbook. Iowa City, Iowa: http://www.uihealthcare.com/depts/med/pediatrics/iowaneonatologyhandbook/procedures/exchangetransfusion.html; 2008.
4	Benders MJ, Meinesz JH, Dorrepaal CA, Steendijk P, van Bel F, van de Bor M. Effect of exchange transfusion on brain perfusion and electrocortical brain activity in newborn lambs. Biol Neonate. 1999;75(2):130-6.
5	Robitaille N, Nuyt A-M, Panagopoulos A, Hume HA. Exchange Transfusion in the Infant. In: Hillyer CD, Strauss RG, Luban NLC, editors. Handbook of Pediatric Transfusion Medicine. San Diego, California: Elsevier Academic Press; 2004. p. 159-66.