RT Book, Section
A1 Gomella, Tricia Lacy
A1 Eyal, Fabien G.
A1 Bany-Mohammed, Fayez
SR Print(0)
ID 1168356364
T1 Exchange Transfusion
T2 Gomella's Neonatology: Management, Procedures, On-Call Problems, Diseases, and Drugs, 8e
YR 2020
FD 2020
PB McGraw-Hill Education
PP New York, NY
SN 9781259644818
LK accesspediatrics.mhmedical.com/content.aspx?aid=1168356364
RD 2023/03/25
AB 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).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.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.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.”Other  less  common  indicationsMetabolic  disorders  causing  severe  acidosis  or  hyperammonemia  (organic  acidemia,  hyperammonemia).Extreme  thrombocytosisCongenital  leukemia.  ET  is  effective  in  improving  hyperleukocytosis.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.MalariaNeonatal  hemochromatosisSevere  fluid  or  electrolyte  imbalance  (eg,  hyperkalemia)Renal  failureDrug  overdose/toxicityRemoval  of  abnormal  proteins  or  antibodies