Approved by: Exchange Transfusion Gail Cameron Director, Maternal, Neonatal & Child Health Programs Neonatal Nursery Policy & Procedures Manual : Next Review March 2016 Dr. Ensenat Medical Director, Neonatology Dr. Peliowski Medical Director, Neonatology Purpose Applicability Policy Statement Principles To provide guidance for exchange transfusion to help ensure patient safety. All Covenant Health Intermediate Care Nursery staff. With advances in prenatal and postnatal care there has been a marked decline in the frequency of exchange transfusions. Despite the decrease in frequency of exchange transfusions they remain an important treatment for the neonatal population. Before an exchange transfusion is started please ensure: A consent form has been signed by parent(s)/guardian(s). Infant has stomach contents removed if recently fed. Infant is positioned on a radiant warmer with cardio-respiratory monitoring, blood pressure monitoring, and ISC monitoring in place. Infant has intravenous access in addition to umbilical access. Discuss the need with physician/neonatal nurse practitioner (NNP). Phototherapy lights are turned off and exchange equipment is ready Ensure blood is ordered, usually [(80-120 ml/kg X 2)+100 ml to prime tubing]. The clinician should order irradiated reconstituted whole blood in fresh frozen plasma (45-55% Hct.). Please refer to the Blood and Blood Product Administration policy for further information. Exchange transfusions may be done via arterial/venous or venous/venous access routes. If UAC/UVC are not in situ, please refer to Umbilical Line Insertion procedure before commencing the exchange transfusion. NOTE single lumen catheter(s) should be placed whenever possible as a double-lumen is smaller and make the exchange transfusion more difficult. Arterial/Venous Route Equipment Blood Warmer Pediatric/Neonate Blood Warmer Insert 60 ml syringe 2-3 way stopcocks 2-20 ml syringes 2 DEHP free extension tubing lines Blood Filter Set Sterile Bag for blood disposal Blood Transfusion Record
Page 2 of 7 Procedure ACTION RATIONALE 1. Perform hand hygiene. 2. Place infant on a warmer. Very small preterm infants may be in an incubator provided a sterile field can be maintained and lines are easily accessible. 3. Ensure continuous heart rate and saturation monitoring. 4. The physician/neonatal nurse practitioner (NNP) and nurse set up and prime blood lines to UVC and waste setup to UAC using clean no-touch technique (See Fig. 1). Please refer to the Blood/Fluid Warmer policy for setting up the blood/fluid warmer. 5. The initial blood drawn from the UAC is sent for testing (electrolytes, calcium, bilirubin, glucose and any other test ordered by the physician/nnp). 6. Utilize the blood transfusion record once the exchange transfusion begins (see attached). Record the blood drawn off and replaced with every 10-20 ml. Observe and record heart rate and rhythm, blood pressure, colour and behaviour every 5 minutes. 7. Blood is drawn from the UAC at the same rate that blood is infused by the syringe pump to the UVC. A double volume exchange transfusion should take 1-2 hours, so the rate of infusion/withdrawal is calculated accordingly (usually around 5mL/kg every 2-4 minutes). The 60 ml syringe will need to be filled numerous times to complete the exchange transfusion. Ensure to gently agitate the blood bag before aspirating to prevent sedimentation of red cells. 8. The last 10-20 ml of blood withdrawn from the infant is used for postexchange testing (hemoglobin, platelets, electrolytes, bilirubin, calcium, glucose and any other test ordered by the physician/nnp). Monitor beneficial or deleterious effects of the procedure. Air embolism may occur if the lines are not primed carefully. Hypoglycemia may occur therefore, serum glucose is checked before the procedure and each hour for 2-4 hours after the transfusion. To ensure same volume withdrawn is returned to the infant. Rapid withdrawal or injection of blood may cause cardiovascular instability. The time should be extended if the patient is hemodynamically unstable. Cardiac arrhythmia may occur with rapid injection of blood. Gently agitating the blood bag prevents relatively anemic blood toward the end of the exchange. Assess the infant s status post-exchange without drawing additional blood. Calcium chelation may cause thrombocytopenia and hypocalcaemia.
Page 3 of 7 9. When the exchange is complete the catheters may be removed if no longer needed. 10. The infant should remain NPO for at least 12 hours. Necrotizing enterocolitis may occur from ischemia of the bowel. 11. Verify with physician/nnp the frequency and type of post-exchange bloodwork needed. Catheter removal depends on the infants condition and likelihood of another transfusion. Blood flow to the intestine may be disrupted profoundly during the exchange transfusion as a result of back pressure created in the portal venous system during the injection of blood. Diagram Arterial/Venous Route
Page 4 of 7 Venous/Venous Route Equipment Blood Warmer Pediatric/Neonate Blood Warmer Insert 20 ml syringe Double 3 way stopcock 2-20 ml syringes 2 DEHP free extension tubing lines Blood Filter Set Sterile Bag for blood disposal Exchange Transfusion Record Procedure ACTION RATIONALE 1. Perform hand hygiene. 2. Place infant on a warmer. Very small preterm infants may be in an incubator provided a sterile field can be maintained and lines are easily accessible. 3. Ensure continuous heart rate and saturation monitoring. 4. The physician/neonatal nurse practitioner (NNP) and nurse set up and prime blood lines to UVC using clean no-touch technique (See Fig. 2). Please refer to the Blood/Fluid Warmer policy for setting up the blood/fluid warmer. 5. The initial blood drawn from the UVC is sent for testing (electrolytes, calcium, bilirubin, glucose and any other test ordered by the physician/nnp). 6. Utilize the blood transfusion record once the exchange transfusion begins (attached). Record the blood drawn off and replaced with every set of exchanges. Observe and record heart rate and rhythm, blood pressure, colour and behaviour every 5 minutes. 7. Utilizing the double three way stop cock, blood is drawn from and infused back into the UVC at identical volumes (See Fig. 3). Depending on the infant s size and condition this volume is from 7-20 ml. This process continues until twice the infant s volume is exchanged. The procedure should take 1-2 hours, so the rate of infusion/withdrawal is calculated accordingly. Ensure to gently agitate the blood bag before aspirating to prevent sedimentation of red cells. Monitor beneficial or deleterious effects of the procedure. Air embolism may occur if the lines are not primed carefully. Hypoglycemia may occur therefore, serum glucose is checked before the procedure and each hour for 2-4 hours after the transfusion. To ensure same volume withdrawn is returned to the infant. Rapid withdrawal or injection of blood may cause cardiovascular instability. The time should be extended if the patient is hemodynamically unstable. Cardiac arrhythmia may occur with rapid injection of blood. Gently agitating the blood bag prevents relatively anemic blood toward the end of the exchange.
Page 5 of 7 8. The last 10-20 ml of blood withdrawn from the infant is used for post-exchange testing (hemoglobin, platelets, electrolytes, bilirubin, calcium, glucose and any other test ordered by the physician/nnp). 9. When the exchange is complete the catheters may be removed if no longer needed. 10. The infant should remain NPO for at least 12 hours. Necrotizing enterocolitis may occur from ischemia of the bowel. 11. Verify with physician/nnp the frequency and type of post-exchange bloodwork needed. Assess the infant s status post-exchange without drawing additional blood. Calcium chelation may cause thrombocytopenia and hypocalcaemia. Catheter removal depends on the infants condition and likelihood of another transfusion. Blood flow to the intestine may be disrupted profoundly during the exchange transfusion as a result of back pressure created in the portal venous system during the injection of blood. Diagram Venous/Venous Route
Page 6 of 7 Documentation The procedure should be documented on the patient s chart. The name of the clinician who completed the procedure and the volumes removed and infused should be included. Postexchange Care After all exchange transfusions the following postecxchange care should occur: Monitor vital signs (including blood pressure) every hour for six hours. If within normal limits, return to routine vital signs monitoring as ordered. Complete postexchange blood work as ordered. Blood glucose levels should be monitored closely for the first 24 hours. Once clinically stable an order for feeding can be obtained. Watch for signs of feeding intolerance (i.e. abdominal distension, absent bowel sounds, vomiting, and blood in stool). Related Documents Adapted with permission from Stollery Children s Policy and Procedure Manual: http://www.intranet2.capitalhealth.ca/nicu/pages/policiesprocedures/policiesprocedures_n ew.htm Exchange Transfusion, January 2008 Blood and Blood Product Administration Blood/Fluid Warmer Exchange Transfusion Record References MacDonald, MG, Ramasethu, J, & Rais-Bahrami, K. (2012). Exchange Transfusion In: MG MacDonald, J Ramasethu and K Rais-Bahrami (Eds). Atlas of Procedures in Neonatology (5 th ed. pp. 315-322). Philadelphia: Lippincott Williams & Wilkins. Revisions November 2005
Page 7 of 7 Signing Original Signed GAIL CAMERON DIRECTOR MATERNAL, NEONATAL & CHILD HEALTH PROGRAMS COVENANT HEALTH GREY NUNS & MISERCORDIA HOSPITALS Original Signed DR. SANTIAGO ENSENAT MEDICAL DIRECTOR NEONATAL PROGRAM COVENANT HEALTH GREY NUNS HOSPITAL April 15, 2013 DATE April 16, 2013 DATE Original Signed June 10, 2013 DR. ABRHAM PELIOWSKI MEDICAL DIRECTOR NEONATAL PROGRAM COVENANT HEALTH MISERICORDIA HOSPITAL DATE
EXCHANGE TRANSFUSION RECORD Blood Serial Number: Group: RH Factor: Checked by: Time In (volume/total) Out (volume/total) Vital Signs (HR, BP,Colour,Behaviour) Medication Comments