1. Blood Exchange Transfusion

4. Timing of Follow-up

7. Treatment Recommendations
If the TSB does not fall or continues to rise despite intensive phototherapy, it is very likely that hemolysis is occurring.
The direct-reacting (or conjugated) bilirubin level should not be subtracted from the total

8. Treatment Recommendations
If the TSB is at a level at which exchange transfusion is recommended or>25 mg/dL (428 mol/L) Directly admit to ICU for intensive phototherapy
Exchange transfusions should be performed only by trained personnel in a NICU with full monitoring and resuscitation capabilities

9. Treatment Recommendations
In isoimmune hemolytic disease, administration of IVIG(0.5-1g/kg over 2 hours) is recommended if the TSB is rising despite PT or the TSB level is within 2 to 3 mg/dL of the exchange level
Reduce the need for exchange transfusions in Rh and ABO hemolytic disease
Evidence quality B

10. Treatment Recommendations
If albumin <3g/dL lower threshold
Immediate exchange transfusion is recommended in acute bilirubin encephalopathy
Obtaining a venous sample to “confirm” an elevated capillary TSB level is not recommended

11. Risk of Exchange Transfusion
Death associated with exchange transfusion has been reported in approximately 3 in 1000
Significant morbidity:
Apnea, bradycardia, cyanosis, vasospasm, thrombosis, necrotizing enterocolitis
Hypoxic-ischemic encephalopathy and acquired immunodeficiency syndrome

12. About Phototherapy
There is no standardized method for reporting phototherapy dosages in the clinical literature
Intensive PT: use of high levels of irradiance in the 430- to 490-nm band
Usually 30 μW/cm2 per nm or higher

13. When Should Phototherapy Be Stopped
For readmission:
When the serum bilirubin level < 13 to 14
Discharge from the hospital need not be delayed
For hemolytic diseases or is initiated early
Follow-up within 24 hours after discharge

14. Blood Exchange Transfusion
Goal: Remove circulating antibody coated red blood cells and hemolytic products
Provide fresh donor albumin with Bil binding site
Performed in 3/ live births
Indications: AAP 2004

15. Blood Exchange Transfusion

16. Blood Exchange Transfusion
Cross match with mother and/or infant
Fresh blood to avoid hyperkalemia
Reconstruct PRBC with FFP
If O-O- PRBC+ AB FFP
Irradiation to reduce GVHD
Warm by water bath

17. Single-Catheter Pull Push Technique
Umbilical venus catheter
Placing the infant on the warmer/incubator
Oral feeds are withheld
4 channels of connection
Usually 15- to 20-mL withdrawn or infused at a rate of 5 ml/kg/min.
Entire procedure: min, cycles
Calcium may be used in EKG changes
NPO

19. Double-Catheter Pull Push Technique
UA+ UV catheter
Blood withdrawn from UA
Simultaneously replace through UV

20. Peripheral Route Peripheral vessels may be used
↓infection, central vessel complications, time
Better temperature regulation
NPO not necessary
Occlusion and maintenance difficulty

21. Blood Volume to Design Term newborn’s blood volume: 80-90 ml/kg
SVBET: Exchange 63% of the infant’s blood
DVBET: Exchange 86% of the infant’s blood
Bil removed was 45% higher than the fall in serum bilirubin
mL/kg: Max. removal of bilirubin

22. Blood Volume to Design
20% Albumin 1g/kg 1 hr before lower Bil level after BET
Not justified
IVIG: g/kg over 2 hr in hemolytic Dz
Repeat in 12 hrs
Significant reduction in the need for BET

23. Adverse Events Cardiovascular collapse Necrotizing enterocolitis
Bacterial sepsis
Pulmonary hemorrhage
Incidence of mortality or serious permanent sequelae was< 1%
Procedure-related complications leading to death was 8%

29. Pre- and Post- BET Exam Before BET After BET Brain echo, CXR, KUB
CBC/DC, Ret
1hr Hb/Hct, Bil T/D, Sugar, Na, K, Ca, pH
PB smear and B/C
Sugar, BUN, GOT/GPT
4hr Bil T/D, Sugar
BilT/D, Na/K/Ca
12hr Bil T/D
Coomb’s test, UA
VDRL, G6PD, TORCH

30. Pre- and Post- BET Management
Before BET
After BET
UA/UV or peripheral line
Keep Phototherapy
Albumin 1g/kg
Vital signs:
Q30min x 4 Q1h x 2 Q2H x 2 Q4H
Fresh whole blood or
O PRBC+AB FFP (85ml/kgx2)

31. During BET 1ml Ca-gluconate/100ml blood exchanged
Vital signs for braycardia
First drawn blood send for test
Last cycle: only in
Recommend duration 1hr

32. Thanks For Attention