Chapter 44 ■ Exchange Transfusions 321
Exchange Transfusion by Isovolumetric
Technique (Central or Peripheral Lines)
1. Scrub as for major procedure.
2. Select two sites for line placement, and insert (See page
(2) Peripheral IV that is at least 23 gauge
(2) Peripheral, usually radial if infant’s size permits
3. Connect arterial line to three-way stopcock.
a. Use short, connecting IV tubing to extend peripheral line.
b. Attach additional connecting tubing to stopcock
and place into sterile waste container.
c. Attach empty 3- to 10-mL syringe to stopcock, for
An additional stopcock may also be placed on
this port so that a syringe of heparinized saline (5 U/
mL) may be attached for use as needed. Be cautious
4. Connect venous line to single, three-way stopcock,
which in turn connects to empty 5- to 10-mL syringe
5. Start exchange-transfusion record.
6. Withdraw and discard blood from arterial side at rate of
2 to 3 mL/kg/min, and infuse at same rate into venous
side. Keep flow as steady as possible, and volumetrically
equal for infusion and removal.
7. Intermittently, flush arterial line with heparinized
The heparin solution remaining in tubing will be
removed with next withdrawal, thus reducing significantly
the total heparin dose actually received by the patient.
8. Follow steps as for push–pull technique until exchange
9. Total duration for isovolumetric ET: 45 to 60 minutes,
may be longer in sick, unstable infant.
H. Postexchange for All Techniques
1. Continue to monitor vital signs closely for at least 4 to
2. Rewrite orders: Adjust any drug dosages as needed to
compensate for removal by exchange.
3. Keep infant NPO for at least 4 hours. Restart feeds if
clinically stable. Monitor abdominal girth and bowel
sounds every 3 to 4 hours for next 24 hours if exchange
has been performed using umbilical vascular lines.
Observe for signs of feeding intolerance.
4. Monitor serum glucose levels every 2 to 4 hours for
5. Repeat blood gases as often as clinically indicated.
6. Measure serum ionized calcium levels and platelet
counts in sick infants immediately after the ET and
further as clinically indicated. A double-volume ET
Equilibration of intra- and extravascular bilirubin and
continued breakdown of sensitized and newly formed
red cells by persisting maternal antibody results in a
rebound of bilirubin levels following initial ET and
may necessitate repeated ET in severe HDN.
in sick infants. There may be some uncertainty in
ascribing adverse events to the ET in infants who are
2. Many of the adverse events are hematologic or biochemical laboratory abnormalities which may be
asymptomatic. The most common adverse effects noted
during or soon after the ET, usually in infants who are
c. Thrombocytopenia (<50,000 in 10% of healthy infants,
up to 67% in infants <32 weeks’gestational age)
3. Complications reported from ET are related to the
blood transfusion and to complications of vascular
access (see Chapters 29, 30, and 43).
4. Potential complications include
a. Metabolic: Hypocalcemia, hypo- or hyperglycemia,
b. Cardiorespiratory: Apnea, bradycardia, hypotension,
c. Hematologic: Thrombocytopenia, dilutional coagulopathy, neutropenia, disseminated intravascular
d. Vascular catheter related: Vasospasm, thrombosis,
e. Gastrointestinal: Feeding intolerance, ischemic
injury, necrotizing enterocolitis
f. Infection: Omphalitis, septicemia
1. Steiner LA, Bizzarro MJ, Ehrenkrantz RA, et al. A decline in the
frequency of neonatal exchange transfusions and its effect on
exchange transfusion related morbidity and mortality. Pediatrics.
2. Johnson L, Bhutani VK, Karp K, et al. Clinical report from the
pilot USA Kernicterus Registry (1992 to 2004). J Perinatol. 2009;
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