Exchange blood transfusion in Pediatrics

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It is an introduction of whole blood in exchange for 75-85% of an infant’s circulatory blood that is repeatedly withdrawn in small amounts and replaced with equal amounts of donor blood.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: child’s 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 for Exchange Blood Transfusion

• Open bed with radiant heat source for infant)
• Bed in ICU (for child)
• 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 child’s 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 infant/child 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

• Perform hand hygiene
• Gather the necessary supplies
• Place the infant supine on radiant warmer in servo control mode, or place the child supine in bed, attach cardiopulmonary monitor and pulse oximeter, and apply noninvasive BP monitor with set time intervals of 3 minutes. For the infant secure arms/legs for procedure
• Check blood products with 2 licensed personnel (e.g., 2 RNs, RN/MD), verify crossmatch and child’s identification number
• Set up blood tubing and warmers as per manufacture’s direction. Prime tubing. Temperature of blood should not exceed 98.6°F (37°C)
• Assist the paediatrician with sterile gown and gloves as necessary. All personnel in the area must wear mask
•  Open sterile towel on bedside stand to establish sterile working area for pediatrician.
• Open exchange transfusion tray and remove transfusion record form.
• Document pretransfusion vital signs and laboratory results.
• 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 other end in the blood discard bag.
• The pediatrician will connect the stopcock to the child’s IV access site
• Release roller clamp
• Monitor vital signs closely during procedure every 15 minutes. Document temperature, pulse, respiration, blood pressure, oxygen saturation, and blood aliquots in and out, maintaining ongoing total balance.
• The pediatrician is responsible for performing aspirations/infusion of blood aliquots, maintaining aseptic technique.
• Open stopcock to the child, withdraw desired amount of blood, continue monitoring child, and record blood amounts
• Assess vital signs to determine infant’s 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 child; infuse blood into child and record “blood in” amount. Repeat above step as needed. Perform procedure over 1-4 hours
• Obtain laboratory work during the procedure as ordered; monitor blood glucose every 15 minutes or as ordered if there are signs of hypoglycemia.
• During the procedure, gently invert blood bag every 15 minutes.
• Assist to obtain postprocedural tests as ordered.
• Upon completion of procedure, clamp blood tubing and disconnect from catheter. Flush IV line with normal saline and reconnect the ordered IV solution.
• Dispose of equipment and waste in appropriate receptacle. Remove gloves and perform hand hygiene.

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 the infant 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 infant is fed slowly and repositioned after each feeding.
• Fluid intake and output are measured, and ongoing care is provided as for all high-risk infants.

REFERENCES

1. 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
2. Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
3. Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwer’s, ISBN-13:978-9388313285
4. Marcia London, Ruth Bindler, Principles of Paediatric Nursing: Caring for Children, 8th Edition, 2023, Pearson Publications, ISBN-13: 9780136859840
5. Naveen Bajaj, Rajesh Kumar, Manual of Newborn Nursing, 2nd Edition, 2023, Jaypee Publishers, ISBN:978-9354659294
6. 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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