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Chapter 70. Exchange Transfusion of the Newborn

Robin H. Steinhorn, MD

  • • 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 drowsiness.

    • 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 saline.

    • Treat severe anemia associated with heart failure with partial exchange transfusion, using packed red blood cells as the replacement solution.

    • Recommended after intensive phototherapy fails.

  • • Quantifying the risks of morbidity and mortality accurately is difficult because exchange transfusions are now rarely performed.

    • 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.

    • • Infection.

      • Complications of vascular catheters (vasospasm, thrombosis).

      • Apnea and bradycardia.

      • Necrotizing enterocolitis.

    • The risks associated with the use of blood products must always be considered.

    • 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) is recommended.

    • • If the TSB is rising despite intensive phototherapy.

      • If the TSB level is within 2–3 mg/dL of the exchange level.

    • The fluid volume required to administer the dose of gamma-globulin is considerable and needs to be factored into its use for critically ill newborns.

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• 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.

  • • The possible need for exchange ...

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