• Prevent neurotoxicity induced by hyperbilirubinemia.
• Jaundice and intermediate to advanced stages of acute bilirubin
encephalopathy are present even if the serum bilirubin level does
not exactly fit the guidelines.
• Early phase: Severely jaundiced infants become lethargic,
hypotonic, and feed poorly.
• Intermediate phase: Moderate stupor; irritability; and hypertonia,
manifested by backward arching of the neck (retrocollis) and trunk
(opisthotonos); fever; and high-pitched cry that may alternate with
• Treat coagulopathy due to disseminated intravascular coagulation
and life-threatening metabolic disorders.
• Correct polycythemia using a partial exchange transfusion, meaning
that < 1 blood volume is removed and then replaced with normal
• Treat severe anemia associated with heart failure with partial
exchange transfusion, using packed red blood cells as the replacement
• Recommended after intensive phototherapy fails.
• Quantifying the risks of morbidity and mortality
accurately is difficult because exchange transfusions are now rarely
• Death has been reported in approximately 0.3% of all
procedures; although in otherwise well term and near-term infants
(> 35 weeks’ gestation), the risk is probably much lower.
• Significant morbidity occurs in as many as 5% of cases.
• The risks associated with the use of blood products must always
• Hypoxic-ischemic encephalopathy and AIDS have been reported in
otherwise healthy infants receiving exchange transfusions.
• In general, phototherapy is initiated at lower
TSB levels in an attempt to avoid exchange transfusion.
• Additional risk factors for neurotoxicity, such as prematurity,
sepsis, and acidosis, should be carefully considered when deciding
whether to proceed with an exchange transfusion.
• Intravenous gamma-globulin has been shown to reduce the need
for exchange transfusions in Rh and ABO hemolytic disease.
• Therefore, in isoimmune hemolytic disease, administration of
intravenous gamma-globulin (0.5–1 g/kg over 2 hours)
• The fluid volume required to administer the dose of gamma-globulin
is considerable and needs to be factored into its use for critically
• While there are multiple causes of hyperbilirubinemia,
severe disease is most commonly the result of isoimmune hemolytic
disease of the newborn secondary to Rh, ABO, or other antigen incompatibility.
• Perhaps the most difficult aspect of this procedure is determining
when the level of hyperbilirubinemia warrants its use.
• A clinical practice guideline was recently published by
the American Academy of Pediatrics Subcommittee on Hyperbilirubinemia.
• Recommended total serum bilirubin (TSB) levels for exchange transfusion are provided in this document and are based largely on keeping TSB levels below those at which kernicterus has been reported.
• Exchange transfusion is performed infrequently due to improved
prenatal prevention and management of hemolytic disease of the newborn.
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