Exchange transfusion

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]

Exchange transfusion
Other namesExsanguination transfusion, replacement transfusion, substitution transfusion
ICD-999.01
MeSHD005078
OPS-301 code8-801
MedlinePlus002923

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The patient’s blood is slowly withdrawn (usually about 5 to 20 mL at a time, depending on the patient’s size and the severity of illness), and a slightly larger amount of fresh, prewarmed blood or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]

  • Blood clots
  • Changes in blood chemistry (high or low potassium, low calcium, low glucose, change in acid-base balance in the blood)
  • Heart and lung problems
  • Infection (greatly decreased risk due to careful screening of blood)
  • Shock due to inadequate replacement of blood

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

References
  1. "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. 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. "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. "Manual exchange blood transfusion protocol". www.gosh.nhs.uk. Retrieved 2019-01-04.
  6. 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. 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. "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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