ORIENTATION: 2005 Exchange Transfusion

Exchange Transfusion Exchange transfusion is indicated with the presence of hemolytic disease when bili rubin levels meet those associated with Kernicterus despite use of photo therapy. Exchange transfusion may be necessary to protect the CNS status of the jaundiced infant. Most exchanges are done for ABO blood group incompatibility problems.

Exchange Transfusion Double volume Exchange Transfusion Purpose-to remove the infant’s bilirubin and antibody-coated red blood cells from circulation by removing the infant’s blood volume and replacing the volume with blood or another volume expander

Partial Exchange Transfusions Goals Relieves congestive failure and helps improve CNS function Corrects hypoglycemia Reduces cyanosis Improve renal function Desired decrease in HCT less than 60%

Exchange Transfusion Indications for double volume exchange transfusion Bili level Greater than 20-25 mg/dl in an uncompromised term infant Greater than 18 mg/dl in a high-risk term infant 10 to 18 mg/dl in the preterm infant depending on gestational age and conditions 10 to 12 mg/dl in a preterm or stressed infant when acidosis and/or hypoxia is present Diagnosis and condition How quickly level is rising Gestational age Actual age (in hours and days) Presence of significant hemolytic disease Increase in bilirubin despite phototherapy

Exchange Transfusion Nursing Care and Procedure Infant should be NPO UVC and UAC/peripheral a-line placement; central or peripheral venous access can be used Treatment of hypoglycemia, acidosis, temperature control, fluid and electrolyte imbalances prior to exchange transfusion Administration of albumin for low albumin levels before and during exchange if needed; is contraindicated with severe anemia, hydrops, and CHF

Exchange Transfusion Nursing Care and Procedure-(continued) HR/RR monitor, frequent B/P’s, place infant under RW; take vital signs and B/P before and after procedure; monitor vital signs q 5 minutes and prn during procedure Have oxygen and suction available Remember the A, B, C’s Maintain sterility Pre-exchange vital signs-TPR & B/P for baseline vital signs Extra line of access for emergencies

Exchange Transfusion Pre-exchange labs on infant Type and cross Renal Bili levels (conjugated and unconjugated) Calcium Glucose CBC with diff Coombs test Possibly blood cultures Blood gas

Exchange Transfusion Blood to be transfused should also be tested for CBC Bilirubin Calcium Physician and/or nurse practitioner must discuss plans of care concerning exchange transfusions and must obtain informed consent from parent or guardian CAN DO (emergency code sheet) sheet must have current weight (dry or actual) 3 rounds of emergency medications at bedside, including 10% calcium gluconate

Exchange Transfusion Equipment needed Blood Warmer, preheated to 36.5-37 degrees Celsius Blood Administration Sets Blood Warming Coils Multiple syringes Stopcocks Exchange Transfusion Tray, if available

Exchange Transfusion Nursing Care Assist physician/practitioner with procedure Keep accurate tally of blood withdrawn and fluids infused Assess infant for Adverse or anaphylactic blood transfusion reactions S/S of congestive heart failure, fluid depletion or overload, respiratory distress, and cardiac deterioration or arrest S/S of hypocalcemia Signs of complications Adjust med schedules, especially meds that must maintained at certain drug levels; check drug levels Keep parents updated of any significant events during exchange

Exchange Transfusion Post-exchange Resume phototherapy if needed Vital signs-q 15 minutes X 2, then q 30 minutes X 2, Monitor temperature closely for the next 24 hours Obtain labs within one hour of exchange, with f/u bili levels every 4 hours until stabilized Keep parents updated; encourage family interaction as infant tolerates Maintain adequate hydration Assess need for repeated exchanges