III. Indications: Exchange Transfusion for Hyperbilirubinemia in term infants (>36 weeks and >2 kg, or >35 weeks and >2.5 kg)

  1. See Severe Neonatal Hyperbilirubinemia Risk Factor
  2. Exchange Transfusion is indicated when a threshold is crossed based on an infants Hyperbilirubinemia risk factors
    1. High Risk Infant
      1. Gestational age >35 weeks AND <38 weeks AND Severe Neonatal Hyperbilirubinemia Risk Factor
    2. Intermediate Risk Infant
      1. Gestational age >38 weeks AND Severe Neonatal Hyperbilirubinemia Risk Factor OR
      2. Gestational age >35 weeks AND <38 weeks AND No Risk Factors
    3. Low Risk Infant
      1. Gestational age >38 weeks AND No Risk Factors
  3. Age 0 hours of life
    1. High risk Infant: Serum Bilirubin >12 mg/dl
    2. Intermediate risk Infant: Serum Bilirubin >13.8 mg/dl
    3. Low risk Infant: Serum Bilirubin >16 mg/dl
  4. Age 12 hours of life
    1. High risk Infant: Serum Bilirubin >13.5 mg/dl
    2. Intermediate risk Infant: Serum Bilirubin >15.1 mg/dl
    3. Low risk Infant: Serum Bilirubin >17.6 mg/dl
  5. Age 24 hours of life
    1. High risk Infant: Serum Bilirubin >15 mg/dl
    2. Intermediate risk Infant: Serum Bilirubin >16.5 mg/dl
    3. Low risk Infant: Serum Bilirubin >19 mg/dl
  6. Age 36 hours of life
    1. High risk Infant: Serum Bilirubin >16 mg/dl
    2. Intermediate risk Infant: Serum Bilirubin >18 mg/dl
    3. Low risk Infant: Serum Bilirubin >20.9 mg/dl
  7. Age 48 hours of life
    1. High risk Infant: Serum Bilirubin >17 mg/dl
    2. Intermediate risk Infant: Serum Bilirubin >19.1 mg/dl
    3. Low risk Infant: Serum Bilirubin >22.2 mg/dl
  8. Age 60 hours of life
    1. High risk Infant: Serum Bilirubin >18 mg/dl
    2. Intermediate risk Infant: Serum Bilirubin >20.1 mg/dl
    3. Low risk Infant: Serum Bilirubin >23 mg/dl
  9. Age 72 hours of life
    1. High risk Infant: Serum Bilirubin >18.5 mg/dl
    2. Intermediate risk Infant: Serum Bilirubin >21.3 mg/dl
    3. Low risk Infant: Serum Bilirubin >23.9 mg/dl
  10. Age 84 hours of life
    1. High risk Infant: Serum Bilirubin >18.8 mg/dl
    2. Intermediate risk Infant: Serum Bilirubin >22 mg/dl
    3. Low risk Infant: Serum Bilirubin >24.4 mg/dl
  11. Age >96 hours of life (up to 7 days old or 168 hours)
    1. High risk Infant: Serum Bilirubin >19 mg/dl
    2. Intermediate risk Infant: Serum Bilirubin >22.5 mg/dl
    3. Low risk Infant: Serum Bilirubin >24.9 mg/dl
  12. References
    1. AAP: Management of Hyperbilirubinemia in Infant > 35 weeks
      1. http://pediatrics.aappublications.org/content/114/1/297.full#F2

IV. Mechanism

  1. Extracts Antibody coated erythrocytes
  2. Extracts partially hemolyzed Red Blood Cells
  3. Replaces removed blood with uncoated donor RBCs

V. Technique

  1. Usually performed at neonatal tertiary centers
  2. Umbilical Venous Catheter placed at 7 cm or less
  3. Alternate aspiration and infusion
    1. Aspirate 20 cc of infant's blood
    2. Infuse 20 cc of donors blood
    3. Consider only 5-10 cc volumes in tenuous patients
  4. Exchange twice the infant's Blood Volume (2 x 85 ml/kg)

VI. Complications (5-10% of infants)

  1. Mortality: 0.3%
  2. Air embolism
  3. Transient Vasospasm
  4. Transient Bradycardia
  5. Thrombocytopenia
  6. Transfusion reaction
  7. Disseminated Intravascular Coagulation
  8. Electrolyte disturbance
    1. Hypoglycemia
    2. Hyperkalemia
    3. Hypernatremia
    4. Hypocalcemia
    5. Metabolic Acidosis
  9. Sepsis
  10. Blood borne pathogen
    1. Cytomegalovirus
    2. HIV Infection
    3. Hepatitis

VII. Precautions

  1. Obtain lab work prior to exchange transfusion
  2. Lab findings on post-exchange blood are not helpful
  3. Pre-exchange blood sample labs
    1. Complete Blood Count
    2. Peripheral Smear
    3. Reticulocyte Count
    4. Bilirubin
    5. Calcium
    6. Glucose
    7. Total protein
    8. Infant blood type
    9. Coombs Test

VIII. References

  1. Behrman (2000) Nelson Pediatrics, Saunders, p. 524
  2. (2000) Harriet Lane Handbook, Mosby, p. 431

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