Child and[Insert

Adolescent Health
Document Title] Service
Neonatology

GUIDELINE

Exchange Transfusion
Scope (Staff): Nursing and Medical Staff
Scope (Area): NICU KEMH, NICU PCH, NETS WA

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procedures to reduce the likelihood of harm to children and young people.

This document should be read in conjunction with this disclaimer

Also consult
 For NICU PCH – Red Blood Cells Prescribing, Ordering and Administration
 For NICU KEMH – Blood Products (Neonates)
Contents
Aim ................................................................................................................................................. 2
Key Points........................................................................................ Error! Bookmark not defined.
Preparation of the Infant.................................................................................................................. 3
Calcuation of Volume for Exchange ................................................................................................ 4
Haemodilution for Polycythaemia .................................................................................................... 5
Procedure Techniques .................................................................................................................... 5
Isovolumetric Set-Up ........................................................................................................... 5
Isovolumetric Procedure ...................................................................................................... 7
Push-Pull Set-Up ................................................................................................................. 8
Push-Pull Procedure ........................................................................................................... 9
Blood Specimens .......................................................................................................................... 10
Documentation .............................................................................................................................. 10
Post Exchange Care ..................................................................................................................... 11
Potential Complications................................................................................................................. 11
Images .......................................................................................................................................... 12
References ................................................................................................................................... 16
 Exchange Transfusion

Aim
The primary goal of the procedure is to remove circulating antibody-coated red blood
cells and/or products of haemolysis, e.g. bilirubin, whilst maintaining a constant or
nearly constant blood volume.
Advocated for infants with:
 Hyperbilirubinaemia (Haemolysis secondary to Rhesus/ABO or other blood
group incompatibility, G6PD deficiency) to prevent kernicterus.
 Anaemia/Hydrops.
 Congenital leukaemia (as an alternative to plasmapheresis)
 Neonatal Hemochromatosis
 Polycythaemia (i.e. Partial Exchange)
 Hyperkalaemia.
 Drug Toxicity/Overdose.
 Disseminated Intravascular Coagulation.

Key Points
 An exchange transfusion for hyperbilirubinaemia should be considered a
medical emergency, and continuous intensive phototherapy (multiple lights)
should be commenced immediately. The Consultant Neonatologist on
service should be contacted without delay.
 Talk to the parents. Obtain and document consent.
o Provide consumer information ‘Blood Transfusion for your Baby’ to the
parents.
o Be aware of issues relating to religious beliefs.
o Parents may stay with their infant during an exchange transfusion at the
discretion of the medical staff involved.
 Communicate with Blood Bank early.
o For further information regarding types of donor blood to use, consult
For NICU PCH – PCH Transfusion Medicine Protocols
For NICU KEMH – KEMH Transfusion Medicine Protocols
 Securing timely vascular access is imperative. Well placed umbilical arterial and
venous catheters are the ideal standard, however, if vascular access is
problematic engage senior help early and do not delay the procedure.
o Note that arterial lines (umbilical or peripheral) should only be used for
withdrawal of infant blood, not for injection of donor blood.

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 Exchange Transfusion

o Evaluate the requirements for dedicated IV lines for other medications, e.g.
non-interrupted infusions/ compatibilities for inotropic support or sedation.
 There are two techniques for this procedure the isovolumetric and push-pull
techniques.
 Ensure blood warmer is set to 37 °C.
 Administration of intravenous calcium is not routinely recommended. Donor
blood citrate may reduce circulating ionised calcium, with potential to induce
tachycardia, peaked T waves, prolonged Q-Tc interval, and cause irritability,
vomiting, and apnoea.
o If symptomatic or ionised calcium <1.0 mmol/L administer 1-2 mL of
Calcium Gluconate 10% solution (1 mL 10% Calcium Gluconate/Kg) via
slow infusion and observe ECG. Clear line with NaCl 0.9% before
continuing with transfusion.
 Although the haematocrit of packed red cells (PRC) from the blood bank is in
the range of 0.5 to 0.6, removal of whole blood from the baby and replacing it
with PRC may result in hyperviscosity and coagulopathy. For this reason, fresh
frozen plasma (FFP) should also be ordered with the PRC. FFP should never
be added to the bag of PRC, but rather administered in a separate syringe. See
below.
 BloodSTAR (Blood System for Tracking Authorisations and Reviews) is a new
ICT system developed by the National Blood Authority with standardisation in
the Criteria for the clinical use of intravenous immunoglobulin in
Australia, funded by all governments through the national blood arrangements.
Whilst the second edition criteria (2012) remains in usage, IVIG may be
approved as listed under exceptional circumstances, for infants cared for at
KEMH following discussion with the Consultant Haematologist. With the release
of the third edition criteria in 2017, the use of IVIG for treatment of haemolytic
disease is not recommended.
 A checked resuscitation trolley must be nearby. If the infant’s condition
deteriorates acutely for any reason, the procedure must be suspended
immediately pending involvement of the consultant on call.
 If the exchange has to be stopped for any reason, always leave anti-
coagulated-donated blood in the line. Always leave the infant's blood volume in
balance - i.e. volume removed = volume replaced.
 Perform bedside administration check and monitor and record observations as
per policy.

Preparation of the Infant

 Nurse infant on radiant warmer or isolette with servo-controlled
thermoregulation.

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 Exchange Transfusion

 Continuous cardio-respiratory monitoring and, pulse oximetry to remain in situ

and observations recorded every 15 minutes, including NIBP.
 Maintain continuous intensified phototherapy throughout the procedure and
afterwards. Use of transparent sterile drapes facilitates this as well as the
capacity to visualise the baby throughout.
 Insert umbilical venous and arterial catheters in accordance with policy, without
delay.
o An alternative is to secure peripheral venous and arterial access. Additional
peripheral venous access may be required in an unstable patient requiring
dedicated infusion lines.
 The infant should be NBM and a gastric tube inserted. Gastric contents should
be aspirated, and the tube left in situ to open drainage. The infant may vomit
(especially if ionised calcium low).
 The patient should not usually require pharmacological sedation; take steps to
provide simple comfort measures, e.g. non-nutritive sucking, small quantities of
oral sucrose.
 Place urine bag (infants > 30 weeks gestation) or cotton balls to collect and
monitor urine output. This also assists with maintaining a clean, dry
environment.

Calculation of Volume for Exchange

The volume of blood for exchange is dependent on the reason for the exchange and
calculated using an estimate of the neonate’s circulating blood volume:
 Term infants: 80 mL/kg
 Preterm infants: 100 mL/kg
Upon ordering PRC units, consider the need for an additional 50 mL volume required
to prime the circuit.

Double volume exchange recommended for haemolytic disease of the newborn

 2 x circulating blood volume [for example, for a term infant weighing 3 kg: 2 x
estimated blood volume (80 mL) x weight (3 kg) = total 480 mL].
 The average volume per pack of PRC is 250 mL. Generally, 2 units of PRC are
sufficient for a term baby.
 Replaces approximately 85% of the blood volume
 This will cause an approximate reduction of 50% of the pre-exchange bilirubin
level (but can be expected to rebound 4 hours post-transfusion to approximately
two-thirds of pre-exchange level).
 Order FFP as above. Each unit contains on average 70ml; generally, 1 unit of
FFP will suffice for most exchange transfusions for a term baby.

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 Exchange Transfusion

Haemodilution for polycythaemia (‘partial exchange transfusion’

using normal saline):
Polycythaemia and hyperviscosity can occur in situations of chronic fetal hypoxia, e.g.
IUGR, twin-to-twin transfusion. Although neonatal hyperviscosity has been implicated
as a cause of long-term neurodevelopmental delay, the use of haemodilution for the
treatment of polycythaemia is controversial. There is no evidence of long-term benefit,
and the procedure has been associated with an increased risk of NEC.
There is minimal difference in efficacy using plasma, albumin or crystalloid products;
therefore, normal saline is recommended to minimise the risk associated with blood
product exposure (BCSH2016).
Wt (kg) x (Blood volume/kg) x (Hct of patient- Desired Hct)
Volume exchanged (mL) =
Hct of patient

Exchange Transfusion Procedural Techniques

An exchange transfusion is a sterile aseptic procedure and can be carried out using
either of two techniques. The likelihood of an uncomplicated exchange is increased if
care is taken to have good arterial and venous access, and to have all equipment
checked and ready prior to commencing.
Recommended duration of the transfusion using either method is a minimum of 2
hours, with the entire procedure including set-up should generally be completed within
3 hours.
The ‘ISOVOLUMETRIC METHOD’ is the slow removal of aliquots (5-10 mL usually)
from an artery (central or peripheral) and simultaneous continuous infusion of packed
red cells into a vein (central or peripheral). This method minimises the risk of wide
fluctuations of blood volume and pressure.
The ‘PUSH-PULL METHOD’ via an umbilical venous catheter, with the serial
withdrawal and injection of small aliquots (5-20 mL), via separate lumens. This is the
traditional method, not often used now except when arterial access is a problem. A
suggested rate is 30 aliquots over 2 hours, allowing 4 minutes each cycle.

Set-Up for Isovolumetric Method

Infusion IN (via UVC/PIVC)
KEMH PCH
1. Alaris blood giving set Ref 72980E Alaris VP giving set REF 70895
with dual bag insertion spikes

2. Alaris exchange transfusion pump Alaris VP plus exchange transfusion

(allows for higher rates of infusions pump (allows for higher rates of infusions
required) required)

3. Biegler Blood warmer 585 with Hotline fluid warmer

appropriate coil – set to 37 °C.

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 Exchange Transfusion

KEMH PCH
4. Long blood warming extension tube Hot line fluid warming set Ref-L70NI
for coiling

5. 2nd extension tube to connect to Ascena syringe pump ,blood giving set
UVC/PIV reaching the patient. with extension if co-administering FFP

6. Ascena syringe pump, syringe and

extension tubing if co-administering
FFP.

Aspirating OUT (via UAC/PAL)

 2 x 3-way taps in sequence as per diagram.
 Short extension tube if PAL used.
 10 mL or 30 mL Luer-lock syringe for blood withdrawal depending on aliquot
size
 Drainage bag and connection 74.5220.007 (KEMH) / DUB2000 (PCH)
 Heparinised arterial line set or heparinised saline syringe

Additional Equipment
 Exchange Transfusion Record MR460.
 Resuscitation trolley nearby.
 Calcium Gluconate 10% ampoules.
 Blood specimen tubes/sampling syringes.
 Ensure packed red cells prescribed and rates of infusion checked. ( e.g. double
volume exchange in a term infant weighing 3 kg: 2 x estimated blood volume
(80 mL) x weight (3 kg) = total 480 mL / 120 mins = rate 240 mL/Hr (therefore
withdrawal rate of blood from patient 4 mL/min).

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 Exchange Transfusion

Procedure
Blood Infused IN:
KEMH PCH
1. Blood warming extension set should be Pour sterile water into the reservoir of
threaded onto the blood warming coil hotline warmer.
while it is not primed. Start at the back
of the device and wind anti-clockwise
towards the front 8 times (that is 80cm
between blood warmer and patient).
Line must be completely inserted
between the grooves of the blood
warming coil. Refer to image 1.
2. Connect the blood administration set to Plug the Twin-Tube Connector on the
the blood warming coil and clamp off the hotline infusion set into the socket of
lines. hotline warmer and turn the power on.
Refer image 1b.
3. Insert the administration set spike into Remove the end cap and inspect the
PRC units (both if 2 required). Refer to patient end of the warming set for leaks to
image 2. confirm the integrity of the intravenous
pathway.
4. Release the clamp and prime the Prime the Alaris VP giving set with blood
extension lines through to the end, and connect it to HOTLINE Fluid warming
clamp and connect to the 3-way tap of set.
UVC or PIV, maintaining asepsis.
5. Prime the entire circuit with blood and
connect the distal end of the HOTLINE
Fluid warming set to the patient’s
intravenous access site. Refer image 2b
6. Record baseline observations (infant temperature, heart rate, respiratory rate, blood
pressure, oxygen requirement, oxygen saturations, neurological status) prior to
commencement of the procedure.
7. Commence infusion of PRC at the prescribed rate (recommended over 2 hours).
8. The pack containing the blood being infused should be gently agitated every 5
minutes during the transfusion. This will prevent the settling of red blood cells.
9. Once 90 mL of PRC has been infused, stop the PRC infusion, and administer 10ml of
FFP instead. Then continue the PRC and repeat this process every 90 mL until the
exchange transfusion is complete. I.e., replace 100 mL of baby’s blood with 90 mL of
PRC and 10 mL of FFP.

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 Exchange Transfusion

Blood Withdrawn OUT (Refer to image 3)

1. Size of aliquot depends on the size of the infant and cardiovascular stability;
recommend aliquots of 5mls for infants <1500 g; 10-15 mL above 1500 g, at a
pre-determined rate (4 mL/min in the example above).
2. Slowly aspirate aliquot, maintaining steady gentle flow. Turn 3-way tap OFF to
infant and send “First out” specimens to the laboratory. In all other sequences
turn 3-way tap ON to waste bag to discard blood.
3. Do not use excessive suction or too rapid withdrawal as potential to induce
Negative pressure within the vessel causing injury and altered tissue perfusion
to the liver, GIT and renal beds, increasing the risk of complications such as
NEC. Rapid changes in blood volume may cause hypotension, cardiac
arrhythmias, hypoxia and metabolic instability.
4. Repeat sequentially, ensuring the balance of infusion and withdrawn blood.
Nurse assisting with the procedure to maintain documentation on Exchange
Transfusion Record MR460 of aliquots and cumulative totals exchanged, to be
announced every 100 mL. Continue patient observations every 15 min,
recorded on MR460.
5. Complete the exchange transfusion and collect ‘last out’ specimens for testing
as indicated.

Set-Up for Push-Pull Method (Double Lumen UVC)

Infusion IN (via primary lumen UVC)
Refer to images 5, 6 and 7
 Alaris blood giving set Ref 72980E with dual bag insertion spikes
 Biegler Blood warmer 585 with appropriate coil – set to 37 °C.
 Long blood warming extension set for coiling
 2nd extension set to connect to UVC/PIV reaching the patient
 2 x 3-way taps, 30 mL Luer-lock syringe for measuring and administering
aliquots
 Saline-filled syringe or flush
 Ascena syringe pump, syringe and extension tubing if co-administering FFP.
Aspirating OUT (via secondary lumen UVC)
Refer to image images 5, 8 and 9
 2 x 3-way taps.
 10 mL or 30 mL Luer-lock syringe for blood withdrawal depending on aliquot
size
 Drainage bag and connection 74.5220.007

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 Exchange Transfusion

 Saline-filled syringe or flush.

Additional Equipment
 Exchange Transfusion Record MR460.
 Resuscitation trolley nearby.
 Calcium Gluconate 10% ampoules.
 Blood specimen tubes/sampling syringes.
 Ensure packed red cells prescribed and rates of infusion checked. ( e.g. double
volume exchange in a term infant weighing 3 kg: 2 x estimated blood volume
(80 mL) x weight (3 kg) = total 480 mL / 30 aliquots = 16 mL every 4 mins.)

Procedure
1. Steps 1-5 as per isovolumetric set up for PRC infusion.
2. Connect to the two 3-way taps in sequence to each lumen (the second tap
allows for saline flush as required).
3. Connect the PRC infusion and ‘giving’ syringe to the proximal lumen tap, and
the aspirating syringe and drainage tube/bag to the distal lumen tap – refer to
image 5.
4. Withdraw the first aliquot with a slow, steady pre-determined rate, e.g. 16 mL
every 4 mins. Announce “XX mL OUT”; nurse records, send “First out”
specimens to the laboratory. Refer to image 8.
5. Fill giving syringe accurately from blood pack via proximal tap – image 6.
6. Turn 3-way tap ON to infant and infuse at the same rate. Announce “XX mL IN”;
nurse records. If infant hypovolaemic may start with small aliquot ‘In’ first. Refer
to image 7.
7. For all subsequent withdrawals turn 3-way tap ON to waste bag for collection –
image 9.
8. ‘Ins’ and ‘Outs’ are repeated sequentially, with a record of cumulative totals to
be announced every 100 mL by assisting nurse.
9. After 90 mL of PRC have been infused, administer 10 mL FFP next instead of
PRC. Then continue administering PRC until the next 90ml has been
administered, after which 10 mL FFP is administered again. Continue this
process until the exchange transfusion is completed. I.e., replace 100ml of
baby’s blood with 90 mL of PRC and 10 mL of FFP.
10. The pack containing the blood being infused should be gently agitated every 5
minutes during the transfusion. This will prevent the settling of red blood cells.
11. Finish in exact balance (or in positive balance if advisable). Collect ‘last out’
specimens for testing as indicated.

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 Exchange Transfusion

Blood Specimens
Initial or “First Out”.
 FBC & film
 Blood Group, Direct Coomb's test
 Urea and electrolytes, calcium, SBR, total and conjugated
 Blood gas with PGL
 Coagulation profile
 Newborn screening test
 Hold samples for other tests as indicated, e.g. G6PD deficiency, viral infection,
hereditary spherocytosis, metabolic studies.

Halfway Specimens
 SBR
 Blood gas with PGL
 FBC/Coagulation screen if warranted

End or “Last Out” specimens

 SBR, Urea & Electrolytes, calcium, magnesium, phosphate
 FBC and Crossmatch for possible subsequent exchange
 Coagulation studies
 Blood gas with PGL

Post Exchange
Measure serum bilirubin within 2 hours of performing the exchange transfusion, and
frequency thereafter is dependent on the indication for the exchange, the anticipated
rate of rise of bilirubin and the most recent results.

Documentation
Document the procedure in the medical record and using the Exchange Transfusion
Record (MR460) recording time of commencement, aliquot volumes and the total
volume exchanged, blood specimens’ analysed, infant observations and completion of
the procedure.
Routine observations every 15 min during the procedure: infant temperature, heart
rate, respiratory rate, blood pressure, oxygen requirement, oxygen saturations, blood
warmer temperature, the general condition of the infant
Document any patient instability, complications of the exchange transfusion and any
further management required, e.g. medications.

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 Exchange Transfusion

Post Exchange Care

Continuously monitor vital signs and record 30 minutely for the first 4 hours post-
procedure. Routine observations as per NICU observation chart should be continued
for 24 hours.
Phototherapy needs to be continued post exchange and reviewed with the results of
the SBR 2 hours post-procedure. Further SBR levels at approximately 6 hourly
intervals.
Observe the infant’s behaviour and catheter sites for bleeding or signs of infection.
PGL, as indicated by initial and post exchange results.
Keep infant NBM for at least 4 hours post exchange transfusion, or longer at the
direction of the medical officer. As exchange transfusion carries a potential risk of
necrotising enterocolitis (especially in the preterm infant) monitor the appearance of
the abdomen and the presence of bowel sounds. Observe for signs of feed intolerance
when feeding is recommenced
Document how the infant tolerated the procedure and ensure the parents are
informed.

Potential Complications
The most commonly reported adverse events during or soon after exchange
transfusion:
 Catheter-related complications; air emboli; thrombosis; haemorrhage
 Haemodynamic (related to excess removal of injection of blood): hypo or
hypertension, intraventricular haemorrhage (preterm)
 Hypo or hyperglycaemia (often transient)
 Hypocalcaemia, hyperkalaemia, mild metabolic acidosis
 Thrombocytopenia
Potential complications related to exchange transfusion:
 Arrhythmias
 Bradycardia
 Neutropenia, dilutional coagulopathy
 Feed intolerance, necrotising enterocolitis
 Septicaemia, blood-born infection
 Hypo or hyperthermia

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 Exchange Transfusion

Images
Fluid / Blood warmers
Used at KEMH Used at PCH

Image 1a Image 1b

Temperature set at 37 °C.

Blood warming extension set should be HotLine blood warmer
threaded onto the blood warming coil while it Follow instructions with blood warmer.
is not primed. NOTE: Requires flow rates of 50-2,000
Start at the back of the device and wind anti- mL/hours.
clockwise towards the front 8 times (that is Remember to add an extension set if the flow
80 cm between blood warmer and patient). rate is less than 50ml/h to prevent overheating
Line must be completely inserted between the infusion given.
the grooves of the blood warming coil.

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 Exchange Transfusion

Isovolumetric Technique
Isovolumetric set-up KEMH Isovolumetric set-up PCH

Image 2a Image 2b

Isovolumetric set-up
Image 3

Isovolumetric – two 3-way taps attached to

arterial line.
Note: the waste bag is attached to the distal 3-
way tap.

Waste extension attached to

distal 3-way tap

3-way tap on to baby off to waste

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 Exchange Transfusion

Isovolumetric set-up
Image 4

UVC – Blood in UAC – Blood out.

Use distal 3-way

tap to infuse FFP

Push-pull Technique
Image 5
Double lumen UVC

Blood in Saline flush

10mL syringe
10mL syringe

Blood out
Saline flush
To waste
Remove flush syringe to
infuse FFP

Push-pull technique – Blood in

Double lumen UVC (primary lumen)
3-way tap turned off to baby, on to unit of
packed red blood cells.

Image 6

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 Exchange Transfusion

Image 7 Push-pull technique – Blood in

3-way tap turned off to unit of packed red
blood cells and open to baby.

Image 8 Push-pull technique – Blood out

Double lumen UVC (secondary lumen)
3-way tap turned on to baby, off to waste

Image 9 Push-pull technique – Blood out

3-way tap turned off to baby, open to waste

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 Exchange Transfusion

Related CAHS internal policies, procedures and guidelines

WNHS
 Blood Products (Neonates)
PCH
 Red Blood Cells (RBC) Prescribing, Ordering and Administration

References

1. American Academy of Pediatrics Subcommittee on Hyperbilirubinemia. Management of

hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics.
2004;114(1):297–316
2. British Committee for Standards in Haematology (BCSH) (2016). Guidelines on transfusion
for fetuses, neonates and older children.
3. National Blood Authority Australia. Patient Blood Management Guidelines; Neonatal and
Paediatrics p113-114. https://www.blood.gov.au/bloodstar accessed 20/12/2016

Useful resources (including related forms)

Parent Information: Blood Transfusion for your baby

This document can be made available in

alternative formats on request.

Document Owner: Neonatology

Reviewer / Team: Neonatal Coordinating Group
th
Date First Issued: July 2006 Last Reviewed: 15 February 2021
th
Amendment Dates: 7 September 2021 Next Review Date: 15th February 2024
Approved by: Neonatal Coordinating Group Date: th
24 March 2021
Endorsed by: Neonatal Coordinating Group Date:
Standards
Applicable: NSQHS Standards:
Child Safe Standards: 1,10
Printed or personally saved electronic copies of this document are considered uncontrolled

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