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  1. Unconjugated hyperbilirubinemia. Exchange transfusion (ET) is most commonly performed for infants with hyperbilirubinemia of any origin when the serum bilirubin level reaches or exceeds a level that puts the infant at risk for central nervous system toxicity (see Chapters 63 and 99). Double-volume ETs (DVETs) taking 50 to 70 minutes are usually recommended for removal and reduction of serum bilirubin. Efficiency of bilirubin removal is increased in slower paced exchanges to allow for time of extravascular and intravascular bilirubin equilibration. The American Academy of Pediatrics (AAP) has recommendations for indications of ET for unconjugated hyperbilirubinemia (see Figure 99–3).

  2. Hemolytic disease of the newborn (HDN) results from destruction of fetal red blood cells (RBCs) by passively acquired maternal antibodies. ET aids in removing antibody-coated RBCs and replaces them with uncoated donor RBCs that lack sensitizing antigen, thereby prolonging intravascular RBC survival. It also reduces a potentially toxic bilirubin concentration, the result of the antibody destruction of RBCs. Intravenous immunoglobulin administration has been shown to decrease the need for ET in infants with hemolytic disease of the newborn caused by Rhesus (Rh) or ABO incompatibility and is recommended by the AAP if the total serum bilirubin level is rising with intensive phototherapy or within 2 to 3 mg/dL of the exchange level. Recent Cochrane review (2018) feels further studies are needed before recommending the use of IVIG for the treatment of alloimmune HDN.

  3. Severe anemia (normovolemic or hypervolemic) causing congestive cardiac failure, as in hydrops fetalis, or chronic fetal–maternal or fetal–fetal posthemorrhagic anemia, which is best treated by partial ET (PET) using packed RBCs.

  4. Polycythemia/hyperviscosity syndrome is best treated by PET using normal saline. Normal saline is preferred because it reduces both the polycythemia and the hyperviscosity of the infant’s circulating blood volume. A Cochrane review (2010) states that “there are no proven clinically significant short or long term benefits of PET in polycythemic newborn infants who are clinically well or who have minor symptoms related to hyperviscosity. PET may increase the risk of NEC [necrotizing enterocolitis]. The true risks and benefits of PET are unclear.”

  5. Other less common indications

    1. Metabolic disorders causing severe acidosis or hyperammonemia (organic acidemia, hyperammonemia).

    2. Extreme thrombocytosis

    3. Congenital leukemia. ET is effective in improving hyperleukocytosis.

    4. Neonatal sepsis. Recent studies indicate that mortality rate was lower (36%) in infants with septic shock treated with ET than with standard of care treatment (51%). In infants <1000 g with severe sepsis, DVET was associated with a 21% decrease in mortality.

    5. Malaria

    6. Neonatal hemochromatosis

    7. Severe fluid or electrolyte imbalance (eg, hyperkalemia)

    8. Renal failure

    9. Drug overdose/toxicity

    10. Removal of abnormal proteins or antibodies


  1. Three types of ETs are commonly used: single-volume, double-volume, and partial exchange.

    1. Single-volume exchange blood transfusion refers to replacing 1 times the estimated blood volume at 60% of infant’s blood volume.

    2. Double-volume exchange blood transfusion refers to replacing 2 times the estimated blood volume at ...

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