Exchange transfusion

Last updated
Exchange transfusion
Other namesExsanguination transfusion, replacement transfusion, substitution transfusion
ICD-9 99.01
MeSH D005078
OPS-301 code 8-801
MedlinePlus 002923

An exchange transfusion is a blood transfusion in which the patient's blood or components of it are exchanged with (replaced by) other blood or blood products. [1] The patient's blood is removed and replaced by donated blood or blood components. This exchange transfusion can be performed manually or using a machine (apheresis). [2]

Contents

Most blood transfusions involve adding blood or blood products without removing any blood, these are also known as simple transfusions or top-up transfusions. [3] [4]

Exchange transfusion is used in the treatment of a number of diseases, including sickle-cell disease and hemolytic disease of the newborn. Partial exchange might be required for polycythemia.

Nearly all exchange transfusions are allogeneic (that is, the new blood or blood products come from another person or persons, via donated blood); autologous exchange transfusion is possible (using autologous blood banking), but there are not many situations in which a need for it arises, as most autologous transfusions involve no exchange.

Description

An exchange transfusion requires that the patient's blood can be removed and replaced. In most cases, this involves placing one or more thin tubes, called catheters, into a blood vessel. The exchange transfusion is done in cycles: each one usually lasts a few minutes. [1]

The patient’s blood is slowly withdrawn (usually about 5 to 20 mL at a time, depending on the patient’s size and the severity of illness), and a slightly larger amount of fresh, prewarmed blood or plasma flows into the patient's body. This cycle is repeated until the correct volume of blood has been replaced. [1]

After the exchange transfusion, catheters may be left in place in case the procedure needs to be repeated.

In diseases such as sickle cell anemia, blood is removed and replaced with donor blood. [5]

In conditions such as neonatal polycythemia, a specific amount of the child’s blood is removed and replaced with normal saline, plasma (the clear liquid portion of blood), or an albumin solution. This decreases the total number of red blood cells in the body and makes it easier for blood to flow through the body. [5]

Medical Uses

Sickle Cell Disease

Transfusion therapy is used as an emergency procedure to treat life-threatening complications of sickle-cell disease as well as an elective procedure to stop these complications occurring. [3] [4]

Treatment of life-threatening complications

The commonest emergency reason is to treat an acute chest syndrome. [6]

Prevention

  • Prior to surgery in people with sickle cell anemia (HbSS) who already have a hemoglobin above 85g/L, or who require a prolonged operation with general anesthetic, or who need high-risk surgery [3] [4] [6] [7]
  • To optimise hemoglobin S levels, for example to prevent a stroke occurring in a child. [5] [6] The target is usually to maintain a hemoglobin S level below 30% to prevent complications occurring. [5] [6]

The most common routine reason is to prevent a stroke occurring or re-occurring. [6]

Hemolytic Disease of the Newborn

Exchange transfusion to treat hemolytic disease of the newborn is now uncommon since the introduction of Anti-D prophylaxis in pregnancy. However, it can occur due to the development of other antibodies such as anti-c, anti-E, and ABO. [5]

Polycythemia

Polycythemia, a condition in which the number of red cells in the blood is too high, is usually diagnosed when the hematocrit is above 65%. [8] [9] Polycythemia can occur in neonates for multiple different reasons including: babies born after 42 weeks gestation (post-term), babies born to diabetic mothers, twin to twin transfusion, intrauterine growth restriction, and babies with genetic abnormalities. [8] Polycythemia can make the blood thicker than normal and therefore lead to complications. Partial exchange transfusion has been used as a treatment to prevent complications, and has been shown to improve cerebral blood flow, [10] but there is no evidence that it prevents long-term complications. [8]

Severe malaria

Exchange transfusion has been used for the treatment of severe malaria in the past. [11] [12] However, in 2013 the CDC examined the limited evidence available and found no evidence that exchange transfusion has any beneficial effects (decreased mortality) in people with very high parasite loads (> 10%). [12] Also, although uncommon, exchange transfusion can cause complications (low blood pressure (hypotension), abnormal heart rhythms (ventricular fibrillation) and breathing problems (acute respiratory distress syndrome)). [12] Based on this evidence, the CDC no longer recommend the use of exchange transfusion in the treatment of malaria. [12]

Risks

General risks are the same as with any transfusion. Other possible complications include: [1]

Recovery

The person may need to be monitored for several days in the hospital after the transfusion, but the length of stay generally depends on the condition for which the exchange transfusion was performed. Sickle Cell Disease patients may be exchanged in an outpatient setting and can be sent home the very same day. [13]

History

The technique was originally developed by Alexander S. Wiener, soon after he co-discovered the Rh factor. [14]

See also

Related Research Articles

<span class="mw-page-title-main">Hemolysis</span> Rupturing of red blood cells and release of their contents

Hemolysis or haemolysis, also known by several other names, is the rupturing (lysis) of red blood cells (erythrocytes) and the release of their contents (cytoplasm) into surrounding fluid. Hemolysis may occur in vivo or in vitro.

<span class="mw-page-title-main">Hemoglobinopathy</span> Medical condition

Hemoglobinopathy is the medical term for a group of inherited blood disorders and diseases that primarily affect red blood cells. They are single-gene disorders and, in most cases, they are inherited as autosomal co-dominant traits.

<span class="mw-page-title-main">Anemia</span> Medical condition

Anemia or anaemia is a blood disorder in which the blood has a reduced ability to carry oxygen due to a lower than normal number of red blood cells, or a reduction in the amount of haemoglobin. When anemia comes on slowly, the symptoms are often vague, such as tiredness, weakness, shortness of breath, headaches, and a reduced ability to exercise. When anemia is acute, symptoms may include confusion, feeling like one is going to pass out, loss of consciousness, and increased thirst. Anemia must be significant before a person becomes noticeably pale. Additional symptoms may occur depending on the underlying cause. Preoperative anemia can increase the risk of needing a blood transfusion following surgery. Anemia can be temporary or long term and can range from mild to severe.

<span class="mw-page-title-main">Kernicterus</span> Medical condition

Kernicterus is a bilirubin-induced brain dysfunction. The term was coined in 1904 by Schmorl. Bilirubin is a naturally occurring substance in the body of humans and many other animals, but it is neurotoxic when its concentration in the blood is too high, a condition known as hyperbilirubinemia. Hyperbilirubinemia may cause bilirubin to accumulate in the grey matter of the central nervous system, potentially causing irreversible neurological damage. Depending on the level of exposure, the effects range from clinically unnoticeable to severe brain damage and even death.

<span class="mw-page-title-main">Polycythemia</span> Medical condition

Polycythemia is a disease state in which the hematocrit and/or hemoglobin concentration are elevated in peripheral blood.

<span class="mw-page-title-main">Hemolytic–uremic syndrome</span> Group of blood disorders related to bacterial infection

Hemolytic–uremic syndrome (HUS) is a group of blood disorders characterized by low red blood cells, acute kidney failure, and low platelets. Initial symptoms typically include bloody diarrhea, fever, vomiting, and weakness. Kidney problems and low platelets then occur as the diarrhea progresses. Children are more commonly affected, but most children recover without permanent damage to their health, although some children may have serious and sometimes life-threatening complications. Adults, especially the elderly, may present a more complicated presentation. Complications may include neurological problems and heart failure.

<span class="mw-page-title-main">Hemolytic disease of the newborn</span> Fetal and neonatal alloimmune blood condition

Hemolytic disease of the newborn, also known as hemolytic disease of the fetus and newborn, HDN, HDFN, or erythroblastosis foetalis, is an alloimmune condition that develops in a fetus at or around birth, when the IgG molecules produced by the mother pass through the placenta. Among these antibodies are some which attack antigens on the red blood cells in the fetal circulation, breaking down and destroying the cells. The fetus can develop reticulocytosis and anemia. The intensity of this fetal disease ranges from mild to very severe, and fetal death from heart failure can occur. When the disease is moderate or severe, many erythroblasts are present in the fetal blood, earning these forms of the disease the name erythroblastosis fetalis.

<span class="mw-page-title-main">Neonatal jaundice</span> Medical condition

Neonatal jaundice is a yellowish discoloration of the white part of the eyes and skin in a newborn baby due to high bilirubin levels. Other symptoms may include excess sleepiness or poor feeding. Complications may include seizures, cerebral palsy, or kernicterus.

Autoimmune hemolytic anemia (AIHA) occurs when antibodies directed against the person's own red blood cells (RBCs) cause them to burst (lyse), leading to an insufficient number of oxygen-carrying red blood cells in the circulation. The lifetime of the RBCs is reduced from the normal 100–120 days to just a few days in serious cases. The intracellular components of the RBCs are released into the circulating blood and into tissues, leading to some of the characteristic symptoms of this condition. The antibodies are usually directed against high-incidence antigens, therefore they also commonly act on allogenic RBCs. AIHA is a relatively rare condition, with an incidence of 5-10 cases per 1 million persons per year in the warm-antibody type and 0.45 to 1.9 cases per 1 million persons per year in the cold antibody type. Autoimmune hemolysis might be a precursor of later onset systemic lupus erythematosus.

<span class="mw-page-title-main">Sickle cell trait</span> Medical condition

Sickle cell trait describes a condition in which a person has one abnormal allele of the hemoglobin beta gene, but does not display the severe symptoms of sickle cell disease that occur in a person who has two copies of that allele. Those who are heterozygous for the sickle cell allele produce both normal and abnormal hemoglobin.

Hemolytic disease of the newborn (anti-Rhc) can range from a mild to a severe disease. It is the third most common cause of severe HDN. Rh disease is the most common and hemolytic disease of the newborn (anti-Kell) is the second most common cause of severe HDN. It occurs more commonly in women who are Rh D negative.

<span class="mw-page-title-main">Packed red blood cells</span> Red blood cells separated for blood transfusion

Packed red blood cells, also known as packed cells, are red blood cells that have been separated for blood transfusion. The packed cells are typically used in anemia that is either causing symptoms or when the hemoglobin is less than usually 70–80 g/L. In adults, one unit brings up hemoglobin levels by about 10 g/L. Repeated transfusions may be required in people receiving cancer chemotherapy or who have hemoglobin disorders. Cross-matching is typically required before the blood is given. It is given by injection into a vein.

Hemolytic disease of the newborn (anti-RhE) is caused by the anti-RhE antibody of the Rh blood group system. The anti-RhE antibody can be naturally occurring, or arise following immune sensitization after a blood transfusion or pregnancy.

A vaso-occlusive crisis is a common painful complication of sickle cell anemia in adolescents and adults. It is a form of sickle cell crisis. Sickle cell anemia – most common in those of African, Hispanic, and Mediterranean origin – leads to sickle cell crisis when the circulation of blood vessels is obstructed by sickled red blood cells, causing ischemic injuries. The most common complaint is of pain, and recurrent episodes may cause irreversible organ damage. One of the most severe forms is the acute chest syndrome which occurs as a result of infarction of the lung parenchyma. This can rapidly result in death. Other types of vaso-occlusive crisis in sickle cell anemia include dactylitis, priapism, abdominal pain, and jaundice.
1) Full blood count to check for Hemoglobin levels and
2) Rapid diagnostic test (RDT) for Malaria to be able to rule out malaria in the patient

Hematologic diseases are disorders which primarily affect the blood & blood-forming organs. Hematologic diseases include rare genetic disorders, anemia, HIV, sickle cell disease & complications from chemotherapy or transfusions.

<span class="mw-page-title-main">Sickle cell disease</span> Group of genetic blood disorders

Sickle cell disease (SCD) is a group of blood disorders typically inherited from a person's parents. The most common type is known as sickle cell anaemia. It results in an abnormality in the oxygen-carrying protein haemoglobin found in red blood cells. This leads to a rigid, sickle-like shape under certain circumstances. Problems in sickle cell disease typically begin around 5 to 6 months of age. A number of health problems may develop, such as attacks of pain, anemia, swelling in the hands and feet, bacterial infections and stroke. Long-term pain may develop as people get older. The average life expectancy in the developed world is 40 to 60 years.

Sickle cell nephropathy is a type of nephropathy associated with sickle cell disease which causes kidney complications as a result of sickling of red blood cells in the small blood vessels. The hypertonic and relatively hypoxic environment of the renal medulla, coupled with the slow blood flow in the vasa recta, favors sickling of red blood cells, with resultant local infarction. Functional tubule defects in patients with sickle cell disease are likely the result of partial ischemic injury to the renal tubules.

A delayed hemolytic transfusion reaction (DHTR) is a type of transfusion reaction. According to the Centers for Disease Control's (CDC) National Healthcare Safety Network's (NHSN) Hemovigilance Module, it is defined as:

Red blood cells (erythrocytes) from donors contain normal hemoglobin (HbA), and transfusion of normal red blood cells into people with sickle cell disease reduces the percentage of red cells in the circulation containing the abnormal hemoglobin (HbS). Although transfusion of donor red blood cells can ameliorate and even prevent complications of sickle cell disease in certain circumstances, transfusion therapy is not universally beneficial in sickle cell disease.

Hemolytic jaundice, also known as prehepatic jaundice, is a type of jaundice arising from hemolysis or excessive destruction of red blood cells, when the byproduct bilirubin is not excreted by the hepatic cells quickly enough. Unless the patient is concurrently affected by hepatic dysfunctions or is experiencing hepatocellular damage, the liver does not contribute to this type of jaundice.

References

  1. 1 2 3 4 "Exchange transfusion". Nlm.nih.gov. MedlinePlus.
  2. ↑ "Spectra Optia for automatic red blood cell exchange in patients with sickle cell disease | Guidance and guidelines | NICE". www.nice.org.uk. Retrieved 2019-01-04.
  3. 1 2 3 4 5 Davis, Bernard A.; Allard, Shubha; Qureshi, Amrana; Porter, John B.; Pancham, Shivan; Win, Nay; Cho, Gavin; Ryan, Kate (2017). "Guidelines on red cell transfusion in sickle cell disease. Part I: principles and laboratory aspects". British Journal of Haematology. 176 (2): 179–191. doi:10.1111/bjh.14346. ISSN   1365-2141. PMID   28092109. S2CID   3462324.
  4. 1 2 3 4 5 6 "Evidence-Based Management of Sickle Cell Disease: Expert Panel Report, 2014 | National Heart, Lung, and Blood Institute (NHLBI)". www.nhlbi.nih.gov. Retrieved 2019-01-04.
  5. 1 2 3 4 5 6 "Manual exchange blood transfusion protocol". www.gosh.nhs.uk. Retrieved 2019-01-04.
  6. 1 2 3 4 5 6 7 Davis, Bernard A.; Allard, Shubha; Qureshi, Amrana; Porter, John B.; Pancham, Shivan; Win, Nay; Cho, Gavin; Ryan, Kate (2017). "Guidelines on red cell transfusion in sickle cell disease Part II: indications for transfusion" (PDF). British Journal of Haematology. 176 (2): 192–209. doi:10.1111/bjh.14383. ISSN   1365-2141. PMID   27858994. S2CID   3534824.
  7. ↑ Estcourt, Lise J; Fortin, Patricia M; Trivella, Marialena; Hopewell, Sally (2016-04-06). "Preoperative blood transfusions for sickle cell disease". Cochrane Database of Systematic Reviews. 4: CD003149. doi:10.1002/14651858.cd003149.pub3. ISSN   1465-1858. PMC   4854326 . PMID   27049331.
  8. 1 2 3 Özek, Eren; Soll, Roger; Schimmel, Michael S (2010-01-20). "Partial exchange transfusion to prevent neurodevelopmental disability in infants with polycythemia". Cochrane Database of Systematic Reviews (1): CD005089. doi:10.1002/14651858.cd005089.pub2. ISSN   1465-1858. PMID   20091569.
  9. ↑ Paul, Vinod K.; Deorari, Ashok; Agarwal, Ramesh; Sankar, M. Jeeva (2010-10-01). "Management of Polycythemia in Neonates". The Indian Journal of Pediatrics. 77 (10): 1117–1121. doi:10.1007/s12098-010-0177-z. ISSN   0973-7693. PMID   20725868. S2CID   20174315.
  10. ↑ Bada, H. S.; Korones, S. B.; Kolni, H. W.; Fitch, C. W.; Ford, D. L.; Magill, H. L.; Anderson, G. D.; Wong, S. P. (1986). "Partial plasma exchange transfusion improves cerebral hemodynamics in symptomatic neonatal polycythemia". The American Journal of the Medical Sciences. 291 (3): 157–163. doi:10.1097/00000441-198603000-00003. ISSN   0002-9629. PMID   3953635. S2CID   35878878.
  11. ↑ Dongare, H. C.; Khatib, K. I. (2016). "JCDR - Exchange blood transfusion, Malaria, Plasmodium falciparum". Journal of Clinical and Diagnostic Research. 10 (2): OD05–6. doi:10.7860/jcdr/2016/16341.7190. PMC   4800569 . PMID   27042503.
  12. 1 2 3 4 "CDC - Malaria - Exchange Transfusion for Treatment of Severe Malaria No Longer Recommended". www.cdc.gov. United States Centers for Disease Control and Prevention. 28 June 2017. Retrieved 2019-01-04.
  13. ↑ "Scheduled Outpatient Red Blood Cell Exchange Program Reduces Admission and Complications in Sickle Cell Disease". ashpublications.org.
  14. ↑ "Alexander Wiener biography". Bbguy.org. Archived from the original on 2014-08-12. Retrieved 2014-07-28.
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