exchange transfusion in the newborn
exchange transfusion in the newborn
Etymology: L, ex + cambire, to change
the introduction of whole blood in exchange for 75% to 85% of an infant's circulating blood that is repeatedly withdrawn in small amounts and replaced with equal amounts of donor blood. The procedure is performed to improve the oxygen-carrying capacity of the blood in the treatment of erythroblastosis fetalis by removing Rh and ABO antibodies, sensitized erythrocytes that produce hemolysis, and accumulated bilirubin.
method A radiant heat warmer, a pacifier, and cardiac and respiratory monitors are prepared, and resuscitative equipment and drugs, including oxygen, a mask, a bag, suction apparatus, glucose, calcium, and sodium bicarbonate, are made readily available. The results of laboratory studies of the infant's bilirubin, hemoglobin, and calcium levels; hematocrit; blood culture; random blood glucose test; and the donor blood culture are checked. The donor blood is checked to make certain that it is not more than 48 hours old. If fresh whole blood is not used, stored blood is mixed in amounts as ordered with frozen plasma or human plasma protein fraction (Plasmanate). Before exchange transfusion nothing is administered by mouth for 3 to 4 hours or the contents of the infant's stomach are aspirated. The baby's extremities are restrained; the blood is warmed as ordered, and the physician is assisted with the insertion of an umbilical venous line, if one is not in place. The physician may administer albumin with the donor blood. The procedure may be carried out under phototherapy lights. Unless contraindicated, the infant's parents may be present. During the procedure the young patient is observed for bradycardia with less than 100 beats a minute, cyanosis, hypothermia, vomiting, aspiration, apnea, an air embolus, abdominal distension, or cardiac arrest. The respiratory and cardiac rates are checked every 5 minutes; the axillary temperature is checked every 15 to 30 minutes. The integrity of all blood tubing connections is inspected periodically. The amount of blood withdrawn and infused is recorded, and the physician is notified when each 100 mL of blood has been exchanged. A repetition of laboratory studies is requested as ordered for the last amount of blood removed from the infant. After the procedure the infant is observed for signs of tachycardia or bradycardia, tachypnea or bradypnea, hypothermia, lethargy, jitteriness, increasing jaundice, cyanosis, edema, dark urine, bleeding from the cord, convulsions, or complications, such as hemorrhage, hypocalcemia, heart failure, hypoglycemia, sepsis, acidosis, hyperkalemia, thrombus formation, or shock. The infant is maintained in a neutral thermal environment and is handled gently and minimally for the next 2 to 4 hours. The cardiac and respiratory rates are monitored every 15 minutes for 4 hours, then every 30 to 60 minutes for 24 to 48 hours or as ordered. The axillary temperature is checked every 1 to 3 hours for 48 hours, and the cord is observed for bleeding every 5 to 15 minutes for 1 to 2 hours after the procedure. Feeding by gavage or a bottle with a soft nipple with a large enough hole to ensure adequate intake is initiated 4 to 6 hours after the transfusion, as ordered. The infant is fed slowly and repositioned after each feeding. Fluid intake and output are measured, and ongoing care is provided as for all high-risk infants.
interventions The nurse prepares the equipment and infant for the exchange transfusion, assists the physician in the insertion of the umbilical venous line, and monitors the baby during and after the procedure.
outcome criteria An exchange transfusion is usually administered only to a high-risk infant, but the procedure often effectively counteracts the hemolytic anemia and hyperbilirubinemia associated with erythroblastosis neonatorum.