Exchange blood transfusion involves removing an infant's blood and replacing it with donor blood in small aliquots to treat conditions like jaundice. It was pioneered in the 1920s and involves cannulating the umbilical vein to withdraw the infant's blood while infusing donor blood. Indications include severe jaundice, Rh sensitization, and other conditions. The donor blood must be the right blood type and crossmatched to avoid incompatibility reactions. Partial or full volume exchanges can be done, and careful monitoring is needed due to risks like infection, electrolyte imbalances, and cardiac complications.

1. Exchange Blood Transfusion
Presenter
Dr. Puja CN Pathak

2. Content
• Definition
• Indication
• Choice of blood
• Collection of specimens
• Types of Exchange Blood Transfusion
• Procedure
• Exchange Blood Transfusion through other Routes
• Complications
• Summary
• References

3. What is EBT???
• Removing affected infant’s blood and simultaneously replacing with
aliquots of compatible donor blood .
• Aliquots of blood=small volumes of blood
• The use of ET (also known as exsanguination, venesection, or
substitution transfusion) was foremost reported by Dr AP Hart in
1925 in a severely jaundiced neonate with erythroblastosis fetalis.He
used the sagittal sinus for removing blood while infusing it through a
peripheral venous cut-down.
• Louis Diamond was the pioneer to utilize the umbilical vein for ET in
1946. He provided the complete technique and apparatus required
for performing ET

4. Indications:
At birth
Cord Hb <10 g/dl or Bilirubin >5mg/dl
Rh-isoimmunization
With unconjugated Sr.Bili -10mg/dl within 24 Hrs
Or
15mg/dl within 48 Hrs
Or
Rate of rise of Bili of >5mg/dl/hr
Indirect Sr.Bili 20mg/100ml or more during first 5 days of life in Term
Babies.
In preterm – at relatively lower Sr.Bili level ( when it exceeds
1mg/100g body weight) particularly when a/w perinatal asphyxia,
acidosis, hypothermia, hypoglycemia and respiratory distress.

5. Partial exchange transfusion for chronic anemia
Exchange transfusion with fresh heparinized blood for disseminated
intravascular coagulation
Life-threatening metabolic disorders
Acute Renal and Hepatic failure
Septicemia
Poisoning due to accidental injection of local anaesthetic into fetal
scalp during paracervical block,transplacental passage of
chlorpropamide and magnesium sulfate to the fetus.
Exchange transfusion with normal saline for symptomatic
polycythemia.

6. Choice of Blood
• In emergency situations – O Rh negative, without crossmatching
• In anticipated severely Rh-sensitised infant birth – O Rh negative blood
crossmatched against maternal serum
• For subsequent exchange transfusions- irrespective of ABO group of
infant,group O blood crossmatched against infant’s serum
*Rh-negative /infant with HDN due to Rh-isoimmunization – Rh-negative
• In less severe cases-Identify ABO group of both mother and baby.
If infant’s RBCs compatible with mother’s serum-blood of same ABO type as
the baby ,crossmatched against mother’s serum can be used for first
exchange transfusion
If incompatible- ABO type –specific blood crossmatched against infant’s
serum should be used
• In HDN due to ABO incompatibility-O Rh specific cells with a low titre of anti-
A and anti-B antibodies should be crossmatched with mother or O-Rh
specific RBCs can be suspended in AB plasma

7. • Fresh Citrate phosphate dextrose blood (not more than 3 days old) or
heparinized blood can be used for the procedure.
• Acid citrate dextrose blood – tends to produce hypocalcemia,
hyperkalemia and metabolic acidosis
• Heparinised blood – risk of hypoglcemia and rise in free fatty acids
leading to displacement of bilirubin from albumin binding sites
• CPD blood-relative safe and free from side effects
• Stored CPD blood must be prewarmed by immersing the bottle in a
waterbath @ 37oC.
• Albumin administration 1/2-1hr before exchange –more effective in
removal of bilirubin
• Some workers prefer addition of albumin into exchange blood itself.
Type of Blood:

8. Types of blood exchange transfusion
• Blood Volume estimates-
Term infant-80ml/kg
Preterm infant-100ml/kg
• Types
• Single Volume = 1 x circulating volume
• Double Volume = 2 x circulating volume
• Partial exchange = (actual Hct-Desired Hct) x Blood volume
actual Hct

9. How to decide Aliquots for transfusion
• <1500gms – 5ml
• 1500-2500 gms – 10ml
• 2500-3500 gms – 15ml
• >3500 gms – 20ml
• Umbilical vein Catheter size
• Pre-term (less than 1500 gm) catheter size: 3.5 french
• Term (over 1500 gm) catheter size: 5 french

10. Collection of specimens
• Exchange transfusion provides an opportunity for large quantities of
blood being available for various investigations.
• Donor Blood- Hb,haematocrit,potassium & pH
• Baby’s blood at beginning-Hb, haematocrit, bilirubin, glucose,
potassium,pH and various investigations for cause of jaundice
• Post-exchange- Hb,haematocrit, bilirubin, glucose, calcium,potassium
and pH The total affluent should also be collected for bilirubin
estimation in order to calculate the total bilirubin removed.
• Bacteriological specimens-Umbilical swab for culture at the beginning
of procedure and blood for culture at the end.At the time of removal
of the catheter,its tip should be sent for culture.

11. Procedure
• Performed either in nursery /NICU
• Baby must be kept warm
• Stomach contents should be aspirated
• Baby is fastened on a well padded crucifix splint
• Vitals are monitored continuously.
• Exchange transfusion chart should be prepared
• After full aseptic precautions, umbilical vein should be cannulated
• Some prefer umbilical artery instead
• Umbilical catheter is attached to two Three-way taps so that their leads are
connected to the umbilical catheter,syringe,donor blood and a sterile container
for waste
• The blood is withdrawn with gentle suction and donor’s blood is injected slowly
in aliquots depending on size of baby.
• After every 100ml exchange,venous pressure should be checked ,especially more
frequently in hydropic infant
• https://www.youtube.com/watch?v=ywFFyzjqbJQ&t=33s

12. • https://www.youtube.com/watch?v=ywFFyzjqbJQ&t=33s

13. Precautions
• Blood should be prewarmed in a water bath @ 37oC.
• Should never be heated under hot water tap
• During procedure the bottle of donor blood –gently agitated, time to time to
keep the cells and plasma mixed.
• Jammed syringes and blocked 3-way connectors should be rinsed with
heparinized saline (10 units of heparin/ml)
• Accurate record of baby’s condition and IN/OUT volume should be
maintained.
• Whenever an untoward sign appears –procedure must be withheld till baby
improves
• When ACD or CPD blood is being transfused ,1ml calcium gluconate should
be injected slowly after every 50ml of exchange.
• Catheter should be rinsed with heparinised saline before and after the
injection of CG to avoid clotting

14. • During the injection HR must be watched closely for any bradycardia
• If CG is poorly tolerated, it should be abandoned and baby started on
oral CG after procedure.
• After completion of procedure the catheter should be filled with
heparinized normal saline and umbilical stump sprayed with an
antibiotic powder.
• The prophylactic use of antibiotics is not recommended though they
are often given in centers where asepsis is at suspect.

15. Exchange Blood Transfusion through other
routes
• Avoid umbilical route in presence of umbilical sepsis
• When cord has fallen or umbilical vessel can’t be cannulated, cut
down should be performed by making an incision in the midline
above the umbilicus
• The umbilical vein lies rather deep in a trough.When umbilical vein
cut down also fails,saphenous vein below the inguinal ligament
should be exposed by cut down to cannulate femoral vein.Blood can
be injected from this site with ease ,withdrawal however is almost
impossible
• In such circumstances,radial artery should be cannulated for
adequate withdrawal of blood,while blood can be injected through
the cut-down at the saphenous vein.

16. Complications
• Bacterial sepsis, candidemia,perforation of vein and
extravasation,thrombophlebitis, thrombosis,embolism
• Risk of malaria,syphilis, CMV, HIV and hepatitis B and C
• Over-loading of circulation with cardiac failure or shock following
excessive deficit
• Hypocalcemia, hyperkalemia, acidosis and sudden cardiac arrest or
arrhythmia may occur during exchange transfusion with ACD
blood.Acidosis may be f/b mild alkalosis as the citrate is being
metabolized.
• Hypoglycemia and bleeding manifestations may occur following
exchange transfusion with heparinized blood
• Oxygen toxicity may occur at a relatively lower arterial oxygen
tension because adult Hb (transfused blood) readily releases oxygen
to tissues by virtue of its poor affinity to bind oxygen

17. Article:

18. References
• https://www.ncbi.nlm.nih.gov/books/NBK549869/
• Meherban Singh;Care of Newborn;Revised eighth edition;January
2015
• https://pubmed.ncbi.nlm.nih.gov/23834341/
• AIIMS Protocol in Neonatology-2018

19. Thank You