Exchange Transfusion Procedure

Pre-Procedure Preparation

The American Academy of Pediatrics recommends sending blood for immediate type and crossmatch when total serum bilirubin is at or approaching exchange level 2, 3
The American Academy of Pediatrics suggests using modified whole blood (red cells and plasma) crossmatched against the mother and compatible with the infant 1, 2, 3
For patients with sickle cell disease requiring operative shunting, consider simple transfusion of packed red blood cells to raise hemoglobin to 9-10 g/dL prior to general anesthesia 4, 5

Measure serum albumin level and calculate bilirubin/albumin (B/A) ratio to use in conjunction with total serum bilirubin level 6, 1
Assess for signs of acute bilirubin encephalopathy which mandate immediate exchange even if total serum bilirubin is falling 6
Repeat total serum bilirubin measurement every 2-3 hours if level is above exchange threshold 1, 2

Exchange is recommended when total serum bilirubin rises to threshold levels despite intensive phototherapy during birth hospitalization 1, 2, 3
For readmitted infants with total serum bilirubin above exchange level, consider exchange if total serum bilirubin remains above indicated levels after 6 hours of intensive phototherapy 1, 2, 3
Immediate exchange is mandatory for any jaundiced infant manifesting intermediate to advanced acute bilirubin encephalopathy, regardless of whether total serum bilirubin is falling 6

The bilirubin/albumin ratios that should trigger consideration of exchange transfusion alongside total serum bilirubin levels are:

Maintain hemoglobin below 10 g/dL in sickle cell disease patients to prevent hyperviscosity and associated complications 7
Do not increase hemoglobin by more than 4 g/dL in a single transfusion episode 7
For patients with hemoglobin >9-10 g/dL requiring exchange, target post-transfusion levels of 10-11 g/dL 7

Exchange transfusion should NOT be used as primary treatment for acute ischemic priapism in sickle cell patients 4, 5
Delaying intracavernosal phenylephrine and corporal aspiration to perform exchange transfusion is not warranted 4, 5
Exceeding hemoglobin threshold of 10 g/dL increases risk of vaso-occlusive complications, stroke, venous thromboembolism, and hyperviscosity syndrome 7