| ID | 360 |
|---|---|
| Name | EXCHANGE TRANSFUSION |
| Cause | |
| Signs Symptoms | |
| Diagnosis | |
| Investigations | |
| Management | Exchange transfusion is done commonly in hemolytic disease of the newborn due to Rh & ABO incompatibility. Exchange transfusion should be done in the specialized centres or hospitals under the supervision of experienced physicians or pediatricians. Indications: 1. Rh or ABO incompatibility leading to- a. A cord Hb level < 10 gm/dl b. A cord bilirubin level > 85/umol (5mg/dl) c. Development of more than mild Jaundice in the first 24 hours of birth, d. Rising of bilirubin level 10 mg/dl in 24 hours, e. S. bilirubin level = 20mg% f. If reticulocyte count is > 10-15% g. If the RBC of newborn show positive (+ve) direct coomb’s test, h. Clinical signs of severe hemolytic anemia e.g. icterus, pallor, hepatosplenomegaly, petechie, oedema, etc. i. Early signs of bilirubin encephalopathy (kernicterus). 2. Neonatal jaundice (physiological jaundice)- if unconjugated S. bilirubin rises to 20mg/dl or more in term & 15-18mg/dl in preterm babies. 3. Other rare indications are- a. Severe nonhemolytic anemia b. Disseminated intravascular coagulation (DIG). c. Septicemia (to eliminate toxins). d. Respiratory distress syndrome (RDS). e. Sclerema. f. Drug poisoning e.g salicylate. etc. Aim of exchange transfusion- 1. To correct anemia (& thus to prevent heart failure). 2. To reduce hyperbilirubinemia (phototherapy also helps). 3. To remove damaged & anti-body-coated RBCs from circulation. 4. To remove free or unfixed antibodies from circulation. (Practically there is very less amount of free antibody in the baby’s circulation, in case of ABO incompatibility; so the indirect coomb’s test is usually negative incase of baby). Choice of blood: Blood for exchange transfusion should be as fresh as possible (should not be more than 4 days old). Acid-citrate dextrose (ACD) or Heparin may be used as anticoagulant. The goal should be an exchange of approximately double of the blood volume of the infant (i.e 2 x 85ml/kg). This replaces 87% of the infant’s blood volume with new blood. Blood should be gradually warmed to & maintained at a temperature between 22-37°F throughout the exchange procedure. Whole blood should be used rather than packed cells, as the former has sufficient albumin in serum to bind unconjugated bilirubin. 1. In case of Rh incompatibility- donor’s blood should be Rh negative, type “O” & compatible with the mother’s serum. But it is also preferable that the ABO type as that of the infants if the mother has the same ABO type & compatible with the mother’s serum (& also baby’s serum) by indirect coomb’s test. 2. Incase of ABO incompatibility- donor’s blood should be of the same ABO type as that of the mother (i.e usually “O” type). Rh group should match the infants (if baby is Rh-ve). Therefore blood should be cross matched with maternal blood (& also with baby’s blood). 3. Incase of physiological jaundice- donor’s blood should be cross matched directly with the patients blood i.e blood of the same ABO & Rh group. 4. In other cause of exchange transfusion- same as physiological jaundice (i.e same ABO & Rh group). Selection of blood for E. T: Mothers group Babies group Blood for E.T. O O A O B A O B O A AB A or O B O A O B AB B or O A AorO AB B BorO AB A,AB,0 Procedures of E. T: 1. The whole procedure should be done in isolation room with strict aseptic precautions. An experienced doctor should conduct the procedure and an assistant is needed to help, monitor & tally the volume of blood exchanged. Warmth of the baby should be maintained properly, and hourly feeding should be ensured. Umbilical catheterisation is needed to be done first; the procedure has been detailed previously. 2. Two 3-way stop-cocks are attached end-to-end to make 4 ways: one way is connected with the distal end of the umbilical catheter, the another (opposite) way is connected with a 20 ml sterile disposable syringe; of the remaining two side ways, the distal one (from the operator) is connected with the donor blood set, and the proximal one is connected with a saline set leading down to an empty l000cc saline bag being tied with the leg of the cot; into which patient’s blood is expelled out & discared. Operator should make one round before starting the exchange to check the valves of stop-cocks and to confirm their functioning. 3. In the push-pull method, blood is removed in aliquots that are tolerated by the infant. This-usually is 5ml for infants under 1500gms, 10ml for infants 1500 to 2500gms, 15ml for infants 2500 to 3500gms, & 20ml for infants over 3500gms. The volume of blood as advised is withdrawn first from the patient slowly & steadily over 2 minutes, it is then expelled out through the proximal sideway outlet, by keeping the inlet closed. Then same amount of donor’s blood is drawn from the suspended bag through the distal sideway outlet by keeping the proximal outlet key closed, and the whole amount is transfused slowly over 3 minutes. Thus it should take 5 minutes to complete one cycle. In this way the total amount of donor’s blood is exchanged. The rate of exchange and aliquots size have little effect on the efficacy of bilirubin removal, but smaller aliquot and a slower rate causes less stress on CVS. The recommended time for the exchange transfusion is about 1 hour.17 4. As ill infants usually have a metabolic acidosis which can readily be aggravated by donor’s citrated blood with a low pH(6-7), it has become a common practice to inject 1ml (Immol) of 8.4 percent sodium bicarbonate after each 100ml of blood exchanged, especially during the first exhange transfusion. As the citrate is catabolised, there is a later tendency towards metabolic alkalosis; & so sodium bicarbonate should not be given during subsequent exchange(s). 5. It is a common practice to inject 1ml of 10% calcium gluconate with each 100ml of blood exchanged. Recently it has been suggested that after the whole procedure is over, patient should be assessed; if he or she is found to have features of hypocalcemia, then it should be corrected immediately by 3-5ml of 10% ca-gluconate IV. 6. At the end of the procedure 10 ml of blood or more is to be drawn out to make a negative balance; this sample may be sent for estimation of post-exchange serum bilirubin level. The catheter may be left in-situ when further excha-nge is expected, in that case 5% dextrose in aqua at a rate of 1 drop/min should be continued (using a solu-set), if there is no need for further exchange, the umbilical catheter is withdrawn and a dry dressing is applied. 7. After exchange transfusion, phototherapy is continued and bilirubin levels are measured every 4 hours.39 8. An intake-output chart should be maintained. Heart rate, respiration rate, temperature, color etc are to be recorded on a chart during the whole procedure. Possible hazards of exhange trasfusion: Acute hazards: 1. Febrile reactions, allergic reaction. 2. Cardiac- dysrhythmias, arrest, hypovolemia, failure from hypervolemia. 3. Electrolyte & metabolic- hyperkalemia, hypocalcemia, hyperglycemia, hypoglycemia, acidosis followed by alkalosis (citrate intoxication) 4. Hemorrhage- from cord, internal e. g. pulmonary, cerebral. 5. Embolic- blood clot, air. 6. Hepatic cirrhosis- portal and splenic vein thrombosis. 7. Hypothermia 8. Infection- bacteremia, serum hepatitis, CMV infection, necrotising enterocolitis, hepatitis, malaria. 9. Others- colonic perforation, peritonitis. Late complications: 1. Anemia 2. cholestasis 3. Inspissated bile syndrome (more) 4. Portal vein thrombosis 5. Necrotising enterocolitis. Note: 1. After the exchange transfusion is over the bilirubin level must be determined at frequent intervals (every 4-8 hours), and 2nd or more exchange transfusions should be carried out when indicated. 2. Ordinary transfusions of compatible Rh-negative blood may be necessary to correct anemia Cboost’ transfusion, 20ml/kg) when Hb level falls below 9gm/100ml at any stage of the disease up to 6-8 weeks of age, when the infant’s own blood forming mechanism may be expected to take over. |
| Introduction | |
| History | |
| Etiology | |
| Clinical Features | |
| Preventions | |
| Treatment | |
| Complications | |
| Prognosis | |
| Types | |
| Classification | |
| Observation | |
| Pathology |
© Pakistan Drug Directory. All Rights Reserved.
Designed By: Pakistan Drug Directory Team