Exchange transfusion

Overview

• Technically, "exchange transfusion" can refer to any blood product, but typically Involves removing patient's RBCs and replacing with donor RBCs
  • When treating neonatal polycythemia, RBCs are replaced with normal saline, albumin, or plasma rather than donor RBCs
• In contrast to simple transfusion, avoids hyperviscosity and volume overload
• Erythrocytapheresis: involves separating out patients RBCs from other blood components extracorporeally in a centrifuge, then returning the rest of the patient's blood to them with the donor RBCs

Indications

• Severe complications of sickle cell disease
  • Stroke
  • Acute chest syndrome (reserved for severe cases)
  • Priapism (conflicting evidence for benefit)
  • Other complications requiring transfusion when Hb >10
• Toxicities
  • Sulfhemoglobinemia, severe
  • Methemoglobinemia in patients with G6PD or with methemoglobinemia due to nitrite treatment of cyanide
  • Severe hemolysis due to formic acid toxicity
• Severe hemolysis due to malaria or babesiosis
• Neonatal hyperbilirubinemia, extremely severe or unresponsive to phototherapy
• Neonatal polycythemia

Contraindications

• Hemodynamic instability, sepsis, or otherwise unable to tolerate fluid shifts
• Severe hypocalcemia (citrate anticoagulant can worsen hypocalcemia)

Equipment Needed

• Supplies for vascular access
• Packed RBCs for transfusion
• Apheresis centrifuge (and any associated supplies) if planning erythrocytapheresis

Procedure

• Exact steps dependent on whether blood will be exchanged via an apheresis machine and specific model
• Apheresis may require large-bore central venous catheter (e.g. HD line or pheresis catheter)
• If no apheresis machine available:
  • Place at least two peripheral IVs
  • Slowly remove 5-20mL of patient's blood
  • Replace phlebotomized blood with warmed RBCs (or saline/albumin/plasma) in equal or greater amounts
  • Repeat prior steps until desired amount transfused

Complications

• Hypovolemia, shock (if more blood removed than transfused)
• Acute transfusion reactions
  • Intravascular hemolytic transfusion reaction
  • Febrile nonhemolytic transfusion reaction
  • Allergic transfusion reaction
  • Transfusion-associated circulatory overload (TACO)
  • Transfusion-related acute lung injury (TRALI)
  • Transfusion-associated graft-versus-host disease
  • Fluid overload
  • Sepsis
• Delayed transfusion reactions
  • Extravascular hemolytic transfusion reaction
  • Graft-vs-host disease
  • Infection
• PE/DVT
• Hypokalemia, hyperkalemia, hypocalcemia, hypoglycemia

See Also

• Transfusion
• Sickle cell disease
• Plasmapheresis