Exchange Blood Transfusion
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Transcript of Exchange Blood Transfusion
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EXCHANGE BLOOD
TRANSFUSION
BY
DR H.C. ANYABOLU
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EXCHANGE BLOOD TRANSFUSION
Dr. Anyabolu
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Brief History
Definitions Indication
Equipment
The Procedure Monitoring
Post Exchange Care
Complications Controversies
Recent Trends
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BRIEF HISTORYHart (1925)Superior Sagittal
Sinus (out) andSapherious Vein (in).
Werner & Wexlar (1946)Radial
Artery( out )andSaphenous
Vein (in)
Diamond (1946)Umbilical Vein
(out and in)Sanchez (1960) Umbilical Venous cut
down
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INDICATIONS1. In severe hyperbilirubinema
* In hemolytic disease at birth if
PCV 5mg/dl or reticulocyte> 15%
* Rate of bilirubin rise >
0.5mg/dl/hr or >5mg/dl/day.* Kernicterus, irrespective of
serum bilirubin level
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* In preterm LBW babies, rule
of 10
* Lower values of bilirubin in
the presence of complication
eg. hypoalbuminema,
asphyxia, acidosis, hypoxia,hypothermia, sepsis, IVH,
hypoglycaemia.
* Serum bilirubin close toexchange value for > 36hrs.
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2. Severe anaemia (PCV
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8. Vasocclusive Cases in SCD* Priapism in Maiduguri (Ahmed
SG et al 2002)
After 6unitscompletedetumescence
- 95% Hbs 30.3% Hbs
* Prevents the 1st stroke and
also recurrence e.g. The 9yrgirl from Ilesha (Senbanjo et al
2005)
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9. Hyperparasitemia in Malaria* Especially with early end
organ failure
* Whole blood or reconstituted
red cells* Single, 1.5% or double
volume
* 70% 2% in parasites
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10.Babeiosis, Trypanosomiasis11.Pertussis(Romans MJ et al
2004)12.Kwashiorkor with severeanaemia in CCF.
13.Immunological Diseases- TSI in neonatal
thyrotoxicosis
- SLE (Olowu 2006)
- Myasthenia gravis
- Gullain Barre Syndrome
(Baranwal et al 2006)
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14.Inborn Error of MetabolismNeonatal hyperammonemia
15.Acute Hepatic Failure
16.LeukaemiaLeucostasis withhyperviscosity
17.PoisoningsSalicylate,sedatives, theophylline, snake
envenomation.
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EQUIPMENT1. Mask/sterile gown/gloves2. Umbilical catheter/cannula (2)/
IV set/ arterial line with
Transducerchoice depend onwhich method.
3. Dressing pack
4. Sterile green drape
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5. Haematology/Biochemistry
bottles and request form
6. Blood waste bag
7. Heparin flush solution
8. Blood giving set9. Cardiorespiratory monitor
10.Resuscitation apparatus
11.Pacifier
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PROCEDUREConsent
Blood/Blood Product
Type Depends on thecondition
Choices include wholeblood, packed red cells,reconstituted PRBC + FFP
Group Depends on thecondition (Rh dix, ABOdix)
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Haemocrit at least 40%
Genotype important in SCDx
G6PD status important in G6PD
defc.
AgeMost studies < 48hrs old (fresh)- Fresh, unbanked in DIC
Microbial ScreeningHIV, Hepatitis,
malariaSyphilis, CMV -
irradiation
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AnticoagulantsHeparin most
preferred (no
acidosis, electrolytederangement,
hypocalcemia.
Drawbacks
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SettingFree from Human Traffic- Well lighted
- Ambient temperature
250C - 300C (may need
incubator or radiant
heater)
AsepsisStrict- Patient on sterile drapes
- Personnel on sterile
gowns, gloves and masks
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Personnel1 Doctor and 1 nursewith another competent doctor
within shouting distance
GI Preparation NPO for 34 hrs- Stomach should
be aspirated
before and during,
in very sick babies
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Patient RestraintCrucifix
- Formica boardPriming25% albumin 1g/kg 1 -
2hrs before the
procedure(controversial)- Heparin solution flush
2000units + 250mls of
saline
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Vascular AccessNeonates,umbilical vein
Older children, femoral vein
Others: * great saphenous vein
* umbilical artery
* radial artery
* superficial temporal
arterySite in Umbilical Vein- not >7cm
Peripheralaccess
(indications)
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Volume ExchangedSingle volume- Double volume
- Partial Exchange
N/B * Blood volume: Neonates 80
100ml/kg others 6070mls/kg
Aliquots20mls in well termbabies less in sick babies
- 5mls/kg in preterm
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DurationMinimum 45mins but notmore than 90mins.Ideally, every 100mls
exchange = 15mins
Drugs - 10% calcium gluconate 1mlper 100ml of blood
(*controversial)
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MONITOR AND CHART Temperature, Heart Rate;
Respiration, Blood Pressure Portal venous pressure (not >
10mmH2O)
pH, PaO2
RBS (Dextrostix)
Colour cyanosis
Blood warmer at 35370C
Input and Output
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LAST BLOOD WITHDRAWN
PCV, B1B2, RBS, Ca2+, Na+, K+,
Mg2+,
B1B2 6hrs & 24hrs (rebound)
Blood Culture if indicated
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POST EXCHANGE CARE1. Monitor vital signs 1/2hrly x 2
hrly x 2 4hrly x 6 6hrly x 2
2. Observe catheter sites for
bleeding
3. Abd. Girth measurements
4. Observe stools for blood
5. N.P.O. for at least 3hours.
However must be on dextrose
containing fluid.
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6. Remove umbilical catheters with a
stitch in the vein. Cover with saline
soaked gauze. Send catheter tip form/c/s
7. Babies on antibiotics or
anticonvulsants should be re-
medicated8. Jaundiced babies should continue
phototherapy.
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9. Repeat portal venous pressure
10.Prophylactic antibiotics
individual merit
11.CARRY PARENTS ALONG.
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COMPLICATION
Metabolic .Acidosis
.Alkalosis (later)
. k+, Na , Glu, Ca2+,
Mg2+
. Hypo/Hyperthemia
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CARDIORESPIRATORY
- Volume overload
- Arrhythmia- Apnea
- Cardiac arrest
- Hypotension- Bradycardia
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GIT - Bowel perforation
- Inspissated bile syndrome
- NECVASCULARPortal vein thrombosis
and hypertension
- Umbilical vessel
perforation- Portal abscess
- Vasospasm
- IVH.
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COMPLICATION OF BLOOD PRODUCTS-Infection
-Thrombocytopenia-Air embolism
-Thromboembolism
-Anaemia (early & late)-GVH reaction
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Prevalence of complications
3% of neonates have transfusion
reaction usually mildSignificant morbidity5% ( in
recent times).
Deaths3 in 1000 procedures(highly dependent on premorbidstate).
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CONTROVERSIES
- Use of calcium gluconate
- Benefit in kernicterus
RECENT DEVELOPMENTS
Automationfaster, wastes
less blood, lesscirculatory
fluctuation, more
aseptic. Procedures are less frequent.
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