This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Slide 1
Slide 2
Exchange transfusion Dr. Mahmood Noori Shadkam MD-MPH
Neonatologist Associated Professor of Pediatrics, Yazd University
of Medical Sciences 1393
Slide 3
History of Exchange The technique first was reported by
Wallerstein in 1946 as a useful method to treat severely affected
erythroblastotic newborns in whom repeated transfusion of
appropriately compatible rh_negative blood was ineffective He used
a 60_minute simultaneous withdrawal and transfusion method that
required two sites of vascular access. Wallerstein H:Treatment of
severe erythroblastosis by simultaneous removal and replacement of
the blood of the newborn infant,Science 103:583,1946
Slide 4
History of Exchange Diamond and associates in 1951 contributed
significantly to the safety and ease of the procedure and included
the alternate withdrawal and infusion of blood through a single
polyethylene tube in the umbilical vein. Diamond LK,et
al:Erythroblastosis fetalis.VII Treatmentwith exchange
transfusion,N Engl J Med 224:39,1951
Slide 5
Slide 6
1- Intensive phototherapy has failed to reduce Bilirubin levels
to a safe range. 2- The risk of Kernicterus exceeds the risk of the
procedure. 3- Correction of sever anemia and Hyperbilirubinemia in
Erythroblastosis Fetalis. additional factors supporting a decision
for early exchange transfusion. Cord Hemoglobin value of 10g/dl or
less Cord Bilirubin concentration of 5mg/dl or more. Previous
Kernicterus or severe Erythroblastosis in a sibling Reticulocyte
counts>%15 Prematurity
Slide 7
4- Polycythemia 5- Severe anemia with congestive cardiac
failure or hypervolemia. 6- DIC 7- Congenital leukemia 8-Metabolic
toxins Hyper ammonemia Organic acidemia Lead poisoning 9- Drug
overdose or Toxicity 10-Removal of antibodies and abnormal protein
11- Neonatal sepsis or Malaria
Slide 8
principal indications Hyperbilirubinemia and Hemolytic disease
Exchange transfusion aids in: 1. Removing antibody-coated RBCs 2.
Removes toxic bilirubin 3. To restore oxygen_carrying capacity by
providing Ag_Neg RBC 4. To provide additional free Albumin
Slide 9
Indications Sepsis Neonatal sepsis may be associated with shock
caused by bacterial endotoxins Exchange may help remove bacteria,
toxins, fibrin split products, and accumulated lactic acid It may
also provide immunoglobulins, complement, and coagulating
factors
Slide 10
Sepsis Benefits of exchange transfusion in neonatal sepsis : 1.
Increase immunoglobulins [ IgM &IgA ] 2. Removal of bacterial
and toxins 3. Increase of neutrophils 4. Improve perfusion and
oxygenation Exchange transfusion for this indication remains
controversial
Slide 11
Indications Polycythemia It is usually best to give a partial
exchange transfusion using normal saline. Plasma protein fraction
or 5% albumin in saline may also be used normal saline is preferred
because it reduces both the polycythemia and the hyperviscosity of
the infant's circulating blood volume.
Slide 12
Indications (Polycythemia). Partial exchange transfusion (PET)
has been used to treat both symptomatic and asymptomatic patients.
At present, no data support the use of PET in asymptomatic infants;
the potential benefit in symptomatic infants depends on the
symptoms. Studies of long-term neurodevelopmental status do not
show any clear long-term benefits for PET Sarkar S, Rosenkrantz TS,
Semin Fetal Neonatal Med. 2008 Aug;13(4):248-55
Slide 13
Indications Disseminated intravascular coagulation (DIC) The
benefits of exchange in DIC : 1. Replace of coagulation factor and
platelets 2. Replace of antithrombin III and protein C 3. To remove
Fibrin degradation products 4. To remove toxic products 5. To
remove damage RBC 6. To correct anemia 7. To supply deficiency host
defense proteins
Slide 14
Indication Severe anemia Severe anemia causing cardiac failure,
as in hydrops fetalis, is best treated with a partial exchange
transfusion using packed RBCs. thus the formula is : RBCs in CPDA-1
usually have a Hct that approximates 70%
Slide 15
Remove of toxin 1. Drug : ( theophylline, vancomicin and other
antibiotics overdose ) 2. Drug and chemicals given to the mother
near the time of delivery 3. Ammonia and potassium 4. Renal failure
5. .
Slide 16
Indications Severe fluid or electrolyte imbalance eg,
hyperkalemia or hypernatremia .. Isovolumetric exchanges are
recommended to prevent Severe electrolyte imbalance with each
aliquot of blood exchanged.
Slide 17
Indication Metabolic disorders causing severe acidosis
Peritoneal dialysis may also be useful for treating some
progressive metabolic disorders Partial exchange transfusion are
usually acceptable
Slide 18
Kernicterus: * Bilirubin deposits typically in basal ganglia,
hippocampus, substantia nigra, etc.
Slide 19
Clinical Symptoms: Acute Bilirubin Encephalopathy/Kernicterus:
Irritability, jitteriness, increased high-pitched crying Lethargy
and poor feeding Back arching Apnea Seizures Long-term:
Choreoathetoid CP, upward gaze palsy, SN hearing loss, dental
dysplasia
Slide 20
Slide 21
For infants at low risk (38 weeks GA and without risk factors),
exchange transfusion is indicated for the following TB values. 24
hours of age: >19 mg/dL (325 micromol/L) 48 hours of age: >22
mg/dL (376 micromol/L) 72 hours of age: >24 mg/dL (410
micromol/L) Any age greater than 72 hours: 25 mg/dL (428
micromol/L)
Slide 22
For infants at medium risk (38 weeks GA with risk factors or 35
to 37 6/7 weeks GA without risk factors), exchange transfusion is
indicated for the following TB values. 24 hours of age: >16.5
mg/dL (282 micromol/L) 48 hours of age: >19 mg/dL (325
micromol/L) 72 hours of age: >21 mg/dL (359 micromol/L)
Slide 23
For infants at high risk (35 to 37 6/7 weeks GA with risk
factors), exchange transfusion is indicated for the following TB
values. 24 hours of age: >15 mg/dL (257 micromol/L) 48 hours of
age: >17 mg/dL (291 micromol/L) 72 hours of age: >18.5 mg/dL
(316 micromol/L)
Slide 24
Slide 25
Bilirubin/albumin ratio The bilirubin/albumin (B/A) ratio can
be used as an additional factor in determining the need for
exchange transfusion; it should not be used alone but in
conjunction with TB values
Slide 26
Slide 27
Slide 28
Slide 29
For infants 38 weeks gestation, consider exchange transfusion
when TB (mg/dL)/albumin (g/dL)ratio is >8.0 For infants 35 to 37
6/7 weeks and well or 38 weeks with high risk (eg, isoimmune
hemolytic disease or G6PD deficiency), consider exchange
transfusion when TB (mg/dL)/albumin (g/dL) ratio is >7.2 For
infants 35 to 37 6/7 weeks with high risk (eg, isoimmune hemolytic
disease or G6PD deficiency), consider exchange transfusion when TB
(mg/dL)/albumin (g/dL) ratio is >6.8
Slide 30
Treatment: Bilirubin/Albumin Ratio Risk Category B/A Ratio at
Which Exchange Transfusion Should be Considered Infants 38 0/7 wk
8.0 Infants 35 0/736 6/7 wk and well or 38 0/7 wk if higher risk or
isoimmune hemolytic disease or G6PD deficiency 7.2 Infants 35 0/737
6/7 wk if higher risk or isoimmune hemolytic disease or G6PD
deficiency 6.8
Slide 31
Bilirubin/Albumin Ratio It is an option to measure the serum
albumin level and consider an albumin level of less than 3.0 g/dL
as one risk factor for lowering the threshold for phototherapy
use
Slide 32
Additional Albumin This is the rationale for the recommendation
to administer 25% albumin either 1 hour before an exchange ( 1 gr /
kg ) No evidence shows that this practice is of practical value in
neonates with normal albumin levels. Side effects of this practice
( CHF, ..)
Slide 33
Slide 34
1- When alternatives such as simple transfusion or phototherapy
would be just as effective with less risk. 2- When patient is
unstable and the risk of the procedure out weights the possible
benefit. In Infant with sever anemia, with cardiac failure or hyper
volemia, partial ET may be useful 10 stabilize the patients
conditions before a complete or double-volume ET is performed.
Slide 35
Slide 36
1-the infants stomach should be emptied before transfusion to
prevent aspiration 2-body temperature should be maintained and
vital signs monitored. 3- with strict aseptic technique,the
umbilical vein is cannulated with a polyvinyl catheter to a
distance no greater than 7 cm in a fulll-term infant 4-the exchange
should be carried out over 45-60minute. 5-aspiration of 20ml of
infant blood alternating with infusion of 20ml of donor blood.
6-smaller aliquots(5-10ml)may be indicated for sick and premature
infants. 7- the goal should be an isovolumetric exchange of
approximately two blood volumes of the infant (285 ml/kg)
Slide 37
Slide 38
Slide 39
Slide 40
Treatment of Indirect Hyperbilirubinemia: Exchange Transfusion:
Double-volume exchange 2 x blood volume = 2 x 80 cc/kg = 160 cc/kg
Takes about 1-1.5 hours Exchange at rate of ~5cc/kg/3 min Volume
withdrawn/infused based on weight
Slide 41
Slide 42
1- if the blood is obtained before delivery,it should be taken
from a type o,RH-negative donor with a low titer of anti-A and
anti-B antibodies and should be determined compatible with the
mothers serum by the indirect coombs test. 2- after delivery,blood
should be obtained from an RH-negative donor whose cells are
compatible with both the infants and the mothers sera. 3-when
possible,type o donor cells are generally used,but cells of the
infants ABO blood type may be used when the mother has the same
type. 4- A complete cross match,including an indirect coombs
test,should be performed before the 2nd and subsequent
transfusions.
Slide 43
Slide 44
1-be as fresh as possible 2- be gradually warmed 3- maintained
at a temperature between 35 and 37 c throughout the exchange
transfusion. 4- be kept well mixed by gentle squeezing or agitation
of the bag to avoid sedimentaition 5-whole blood or packed
leukoreduced and irradiated RBCS reconstituted with fresh frozen
plasma to an HCT of 40% should be used.
Slide 45
Types of exchange Three types of exchange transfusion are
commonly used: 1 - 2-volume exchange 2 - Partial exchange ( For
treatment polycythemia or anemia ) 3 - intrauterine exchanges
Slide 46
Two volume exchange A one volume exchange transfusion results
in removal of 70% to 75% of the neonates RBC . A two volume
exchange replaces 90% The optimal volume for an exchange
transfusion is twice the infants blood volume
Slide 47
Simple 2-volume exchange transfusion blood volume in a
full-term newborn ( 80 mL/kg) The blood volume of LBW and ELBW
(which may be up to 95 mL/kg) should be taken into account when
calculating exchange volumes.
Slide 48
Slide 49
+ : A= 2 85 wt = B= A = RBC 2 C= B = RBC 0.7 0.7 D=A - C = FFP
45 50
Slide 50
Establish the volume of each aliquot 20 ml > 3 Kg > 3 Kg
15 ml 2 - 3 Kg 10 ml 1 2 Kg 5 ml 850 gr _1Kg
Slide 51
Slide 52
Slide 53
Slide 54
Late complication 1-Anemia 2-Cholestasis 3-Inspissated bile
syndrome 4-Portal vein thrombosis 5-Portal hypertension