Definition
An exchange blood transfusion is a medical treatment in which aphaeresis is used to remove one person’s RBCs or platelets and replace them with transfused blood products.
It is an introduction of whole blood in exchange for 75-85% of an infant’s circulatory blood that is repeatedly withdrawn in small amounts and replaced with equal amounts of donor blood.
Indications
- Sickle cell disease.
- Thrombocytopenic purpura.
- Hemolytic disease of the newborn.
- Polycythemia: neonates blood is removed and replaced with an NS solution or plasma or albumin.
- Severe newborn’s jaundice.
- Toxic effect of certain drugs.
- Severe disturbances in body chemistry.
Equipment Needed
- Open bed with radiant heat source (for neonate).
- Cardiopulmonary monitor.
- Pulse oximeter.
- Noninvasive BP monitor.
- Soft restraints.
- Fresh whole blood (screened).
- Blood warmer with appropriate tubing.
- Blood administration set.
- Sterile gown.
- Sterile gloves.
- Mask and cap.
- Exchange transfusion tray with form.
- Pretransfusion laboratory results.
- Glucometer.
- Laboratory specimen tubes with labels.
- Umbilical catheterization tray.
- Code cart.
- Sterile drapes/towels.
Preparation
- Explain the procedure to the parents, answering questions as necessary.
- Verify if informed consent for the procedure and any stated mandated requirements for blood administration have been obtained.
- Arrange for donor blood.
- Obtain preprocedural laboratory tests as ordered.
- Assess the babies history for clinical indications of need for exchange trans-fusion, history of previous transfusions and relevant laboratory data.
- Ensure that all emergency drugs should be calculated and posted for provision of immediate resuscitation, if necessary.
- Ensure that the baby has been NPO for 3-4 hours before procedure to prevent aspiration of stomach contents during the procedure.
- Verify IV fluid orders with healthcare prescriber and ensure separate IV access for fluid, dextrose maintenance, and glucose and medications.
Procedure
| Procedure | Rationale | |
| 1. | Perform hand hygiene, | Reduces transmission of microorganism |
| 2. | Gather the necessary supplies. | Promotes efficient management and provides an organized approach to the procedure. |
| 3. | Place the baby supine and secure arms/legs for procedure. Place on radiant warmer in servo control mode, or place the baby supine in bed, attach cardiopulmonary monitor and pulse oximeter, and apply noninvasive BP monitor with set time intervals of 3 minutes. | Prevent hypothermia that can result in apnea, increased cardiac and oxygen requirement, acidosis, and stress. The warmer allows for easier access to the baby. Monitoring provides for ongoing assessment of the baby. Securing of extremities prevents contamination of sterile field and dislodgement of catheter as the young infant moves. |
| 4. | Check blood products with 2 licensed personnel (eg. 2. RNS, RN/MD), verify crossmatch and babies identification number. | Ensure proper identification and crossmatching. |
| 5. | Set up blood tubing and warmers as per manufacture’s direction, Prime tubing. Temperature of blood should not exceed 98.6°F (37°C). | Ensure appropriate use of equipment. |
| 6. | Assist the neonatologist with sterile gown and gloves as necessary. All personnel in the area must wear mask. | Minimizes contamination of area. Reduces transmission of microorganisms. |
| 7. | Open sterile towel on bedside stand to establish sterile working area for neonatologist. | |
| 8. | Open exchange transfusion tray and remove transfusion record form. | |
| 9. | Document pretransfusion vital signs and laboratory results. | Provides baseline data. |
| 10. | Connect tubing from exchange transfusion tray: Attach blood warmer tubing to side port of stopcock. Attach second extension tubing to top port of stopcock and place another end in blood-discard bag. The neonatologist will connect the stopcock to the Babies IV access site. Release roller clamp. | Decreases chance of dislodgement and therefore contamination of personnel. The waste blood container should be below table level to allow gravity to assist with drainage. |
| 11. | Monitor vital signs closely during procedure every 15 minutes. Document temperature, pulse, spiration, blood pressure, oxygen saturation, and blood aliquots in and out, maintaining ongoing mal balance. | Ensure prompt detection of vital signs instability, which may occur because of too large amount of infusion or rapid speed of withdrawal. Ensures detection of heart failure due to fluid depletion or overload. |
| 12. | The neonatologist is responsible for performing aspirations/infusion of blood aliquots, maintaining septic technique. Open stopcock to the baby, withdraw desired amount of blood, continue monitoring the baby, and record blood amounts. Assess vital signs to determine babies’ tolerance to amount and rate of withdrawal. Rotate stopcock to waste/discard tubing, expel contents of syringe. Rotate stopcock to warm blood tubing, fill with same increment as withdrawal amount. Rotate stopcock to baby; infuse blood into the baby and record “blood in” amount. Repeat above step as needed. Perform procedure over 1-4 hours. | Equal amounts of blood in and out in maintaining homeostasis. This process completes one cycle of the exchange process. |
| 13. | Obtain laboratory work during the procedure as ordered, monitor blood glucose every 15 minutes or as ordered if there are signs of hypoglycemia. | Continuous monitoring is needed due to effects of anticoagulants and other additives used in blood products. |
| 14. | During the procedure, gently invert blood bag every 15 minutes. | Keep cells and plasma mixed. |
| 15. | Assist to obtain postprocedural tests as ordered. | Validates the effectiveness of the exchange as well as the need for any adjustment of fluids. |
| 16. | Upon completion of procedure, clamp blood tubing and disconnect from catheter. Flush IV line with normal saline and reconnect the ordered IV solution. | Maintain the line patency. |
| 17. | Dispose of equipment and waste in appropriate receptacle. Remove gloves and perform hand hygiene. | Standard precautions reduce transmission of microorganism. |
Nursing Considerations
- 160 mL/kg (double the normal volume of 80 mL/kg) blood is used for exchange blood transfusion.
- The donor blood is checked to make certain that it is not >48 hours old.
- If fresh whole blood is not used, stored blood is mixed in amounts as ordered with frozen plasma or human plasma protein fraction.
- Unless contraindicated the infant’s parents may be present.
- The integrity of all blood tubing connection is inspected periodically.
- Notify the physician when each 160 mL of blood has been exchanged.
- The patient’s blood is slowly withdrawn (usually 5-10 mL at a time, depending on patient’s size and severity of illness).
Post procedure Care
- Monitor for complications.
- Maintain neutral thermal environment.
- Handle baby minimally and gently for next 24 hours.
- Monitor cardiac and respiratory rates every 15 minutes for 4 hours, then every 30 minutes for 24 hours, and hourly for 48 hours or as ordered.
- The axillary temperature is checked every 1-3 hours for 48 hours.
- The cord is observed for bleeding every 5-15 minutes for 1-2 hours after the procedure.
- Feeding by gavage or bottle with soft nipple with a large enough hole to ensure that adequate intake is initiated 4-6 hours after the transfusion is ordered.
- The baby is fed slowly and repositioned after each feeding.
- Fluid intake and output are measured and ongoing care is provided as for all high-risk neonates.
Complication
- Thrombocytopenia.
- Hypocalcaemia.
- Metabolic acidosis.
- Hypoglycemia.
- Catheter malfunction.
- Apnea.
- Bradycardia.
- Hypotension.
- Hyperkalemia.
- Hypomagnesaemia.
- Hypertension.
- Respiratory distress.
- Vessel thrombosis.
- Seizures.
- Sepsis.
- Renal failure.
- Omphalitis (neonate).
- Necrotizing enterocolitis (neonate).
- Jitteriness.
- Cyanosis.
- Bleeding from the cord.
- Metabolic alkalosis.
REFERENCES
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwer’s, ISBN-13:978-9388313285
- Marcia London, Ruth Bindler, Principles of Paediatric Nursing: Caring for Children, 8th Edition, 2023, Pearson Publications, ISBN-13: 9780136859840
- Naveen Bajaj, Rajesh Kumar, Manual of Newborn Nursing, 2nd Edition, 2023, Jaypee Publishers, ISBN:978-9354659294
- Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/
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