Chapter 70. Exchange Transfusion of the Newborn

• 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.

• The possible need for exchange transfusion should be discussed with the family at the onset ...