exchange blood transfusion

7/27/2019 Exchange Blood Transfusion

1/38

EXCHANGE BLOOD

TRANSFUSION

BY

DR H.C. ANYABOLU


2/38

EXCHANGE BLOOD TRANSFUSION

Dr. Anyabolu


3/38

Brief History

Definitions Indication

Equipment

The Procedure Monitoring

Post Exchange Care

Complications Controversies

Recent Trends


4/38

BRIEF HISTORYHart (1925)Superior Sagittal

Sinus (out) andSapherious Vein (in).

Werner & Wexlar (1946)Radial

Artery( out )andSaphenous

Vein (in)

Diamond (1946)Umbilical Vein

(out and in)Sanchez (1960) Umbilical Venous cut

down


5/38


6/38

INDICATIONS1. In severe hyperbilirubinema

* In hemolytic disease at birth if

PCV 5mg/dl or reticulocyte> 15%

* Rate of bilirubin rise >

0.5mg/dl/hr or >5mg/dl/day.* Kernicterus, irrespective of

serum bilirubin level


7/38

* In preterm LBW babies, rule

of 10

* Lower values of bilirubin in

the presence of complication

eg. hypoalbuminema,

asphyxia, acidosis, hypoxia,hypothermia, sepsis, IVH,

hypoglycaemia.

* Serum bilirubin close toexchange value for > 36hrs.


8/38

2. Severe anaemia (PCV


9/38

8. Vasocclusive Cases in SCD* Priapism in Maiduguri (Ahmed

SG et al 2002)

After 6unitscompletedetumescence

- 95% Hbs 30.3% Hbs

* Prevents the 1st stroke and

also recurrence e.g. The 9yrgirl from Ilesha (Senbanjo et al

2005)


10/38

9. Hyperparasitemia in Malaria* Especially with early end

organ failure

* Whole blood or reconstituted

red cells* Single, 1.5% or double

volume

* 70% 2% in parasites


11/38

10.Babeiosis, Trypanosomiasis11.Pertussis(Romans MJ et al

2004)12.Kwashiorkor with severeanaemia in CCF.

13.Immunological Diseases- TSI in neonatal

thyrotoxicosis

- SLE (Olowu 2006)

- Myasthenia gravis

- Gullain Barre Syndrome

(Baranwal et al 2006)


12/38

14.Inborn Error of MetabolismNeonatal hyperammonemia

15.Acute Hepatic Failure

16.LeukaemiaLeucostasis withhyperviscosity

17.PoisoningsSalicylate,sedatives, theophylline, snake

envenomation.


13/38


14/38


15/38

EQUIPMENT1. Mask/sterile gown/gloves2. Umbilical catheter/cannula (2)/

IV set/ arterial line with

Transducerchoice depend onwhich method.

3. Dressing pack

4. Sterile green drape


16/38

5. Haematology/Biochemistry

bottles and request form

6. Blood waste bag

7. Heparin flush solution

8. Blood giving set9. Cardiorespiratory monitor

10.Resuscitation apparatus

11.Pacifier


17/38

PROCEDUREConsent

Blood/Blood Product

Type Depends on thecondition

Choices include wholeblood, packed red cells,reconstituted PRBC + FFP

Group Depends on thecondition (Rh dix, ABOdix)


18/38

Haemocrit at least 40%

Genotype important in SCDx

G6PD status important in G6PD

defc.

AgeMost studies < 48hrs old (fresh)- Fresh, unbanked in DIC

Microbial ScreeningHIV, Hepatitis,

malariaSyphilis, CMV -

irradiation


19/38

AnticoagulantsHeparin most

preferred (no

acidosis, electrolytederangement,

hypocalcemia.

Drawbacks


20/38

SettingFree from Human Traffic- Well lighted

- Ambient temperature

250C - 300C (may need

incubator or radiant

heater)

AsepsisStrict- Patient on sterile drapes

- Personnel on sterile

gowns, gloves and masks


21/38

Personnel1 Doctor and 1 nursewith another competent doctor

within shouting distance

GI Preparation NPO for 34 hrs- Stomach should

be aspirated

before and during,

in very sick babies


22/38

Patient RestraintCrucifix

- Formica boardPriming25% albumin 1g/kg 1 -

2hrs before the

procedure(controversial)- Heparin solution flush

2000units + 250mls of

saline


23/38

Vascular AccessNeonates,umbilical vein

Older children, femoral vein

Others: * great saphenous vein

* umbilical artery

* radial artery

* superficial temporal

arterySite in Umbilical Vein- not >7cm

Peripheralaccess

(indications)


24/38


25/38

Volume ExchangedSingle volume- Double volume

- Partial Exchange

N/B * Blood volume: Neonates 80

100ml/kg others 6070mls/kg

Aliquots20mls in well termbabies less in sick babies

- 5mls/kg in preterm


26/38

DurationMinimum 45mins but notmore than 90mins.Ideally, every 100mls

exchange = 15mins

Drugs - 10% calcium gluconate 1mlper 100ml of blood

(*controversial)


27/38

MONITOR AND CHART Temperature, Heart Rate;

Respiration, Blood Pressure Portal venous pressure (not >

10mmH2O)

pH, PaO2

RBS (Dextrostix)

Colour cyanosis

Blood warmer at 35370C

Input and Output


28/38

LAST BLOOD WITHDRAWN

PCV, B1B2, RBS, Ca2+, Na+, K+,

Mg2+,

B1B2 6hrs & 24hrs (rebound)

Blood Culture if indicated


29/38

POST EXCHANGE CARE1. Monitor vital signs 1/2hrly x 2

hrly x 2 4hrly x 6 6hrly x 2

2. Observe catheter sites for

bleeding

3. Abd. Girth measurements

4. Observe stools for blood

5. N.P.O. for at least 3hours.

However must be on dextrose

containing fluid.


30/38

6. Remove umbilical catheters with a

stitch in the vein. Cover with saline

soaked gauze. Send catheter tip form/c/s

7. Babies on antibiotics or

anticonvulsants should be re-

medicated8. Jaundiced babies should continue

phototherapy.


31/38

9. Repeat portal venous pressure

10.Prophylactic antibiotics

individual merit

11.CARRY PARENTS ALONG.


32/38

COMPLICATION

Metabolic .Acidosis

.Alkalosis (later)

. k+, Na , Glu, Ca2+,

Mg2+

. Hypo/Hyperthemia


33/38

CARDIORESPIRATORY

- Volume overload

- Arrhythmia- Apnea

- Cardiac arrest

- Hypotension- Bradycardia


34/38

GIT - Bowel perforation

- Inspissated bile syndrome

- NECVASCULARPortal vein thrombosis

and hypertension

- Umbilical vessel

perforation- Portal abscess

- Vasospasm

- IVH.


35/38

COMPLICATION OF BLOOD PRODUCTS-Infection

-Thrombocytopenia-Air embolism

-Thromboembolism

-Anaemia (early & late)-GVH reaction


36/38

Prevalence of complications

3% of neonates have transfusion

reaction usually mildSignificant morbidity5% ( in

recent times).

Deaths3 in 1000 procedures(highly dependent on premorbidstate).


37/38

CONTROVERSIES

- Use of calcium gluconate

- Benefit in kernicterus

RECENT DEVELOPMENTS

Automationfaster, wastes

less blood, lesscirculatory

fluctuation, more

aseptic. Procedures are less frequent.


38/38

exchange blood transfusion

Documents