NURSING PATIENT CARE POLICY & PROCEDURE
March 3, 2015
X Nursing Manual (Red)
Policy #: 1.54P
Title: Neonatal Blood Exchange Transfusion
To describe the steps involved and care of the neonate receiving an exchange transfusion for
the removal of antibody coated red blood cells with the corollary benefit of reducing
excessive unconjugated bilirubin.
A. Neonatal exchange transfusions will be done in an intensive care unit under direct
supervision of an attending provider.
B. Informed consent should be obtained prior to procedure.
A. Indications for Exchange Transfusion
1. This procedure is most commonly used to treat severe unconjugated
hyperbilirubinemia that is unresponsive to phototherapy or if signs/symptoms of
acute bilirubin encephalopathy exist (see related reference A)
2. Hemolytic disease of the newborn
A. Radiant Warmer
B. Temperature probe
C. Infant Restraints
D. Maximal barrier equipment-sterile gloves, mask, gown, hat
E. Exchange transfusion tray
F. Sterile drapes
G. Universal procedure tray (if umbilical lines need to be placed)
H. Umbilical catheters
I. Lab tubes
J. 10 mL syringes (2)
K. Three-way stopcocks (2)- (needed for isovolumetric technique)
A. Procedure Preparation
1. Provider responsibility
a. Obtain vascular access for exchange transfusion
b. Obtain informed consent for procedure
c. Place orders via “Exchange transfusion-neonatal” order set
i. Determine blood product volume, 80 mL/kg for single volume
blood exchange transfusion, and 160 mL/kg for double volume
ξ Transfusion Services will prepare reconstituted whole
blood for exchange transfusions unless instructed
ξ The calculated hematocrit of the reconstituted product
will appear on blood product bag
ii. Labs (see related reference B)
iii. NPO status - ideally patient is NPO for four hours prior to
exchange, during exchange, and four hours following exchange
d. Prepare tubing for exchange transfusion for either isovolumetric technique
or push-pull technique (see sections B and C)
e. Perform universal protocol prior to initiating exchange transfusion as
outlined in UWHC Administrative Policy, 8.48, Operative, Invasive, and
2. Registered nurse (RN) responsibility
a. Obtain additional IV access as needed for maintenance fluids and
b. Maintain phototherapy as able
c. Place nasogastric/orogastric tube if not in place already, aspirate and
discard stomach contents to reduce risk of aspiration or ischemic event
d. Obtain continuous skin temperature via servo controlled radiant warmer or
e. Immobilize infant’s extremities as needed
f. Obtain blood product from blood bank according to UWHC
Administrative Policy, 8.12, Blood and Blood Component Transfusion
(Requiring Pre-Transfusion Testing)
g. Gently mix blood product by slowly inverting the bag 5 to 10 times
h. Prime blood product using tubing with filter in exchange transfusion kit
i. Document universal protocol prior to initiating procedure
3. Maximal barrier precautions are required for all persons performing procedure
or in patient room during procedure. This includes mask, gown, hat, and sterile
B. Procedure using the Isovolumetric Technique (performed by neonatal providers) is used
when there are two vascular access points, one for removal of blood and one for infusing
replacement blood (see related reference C for picture of set-up)
1. Open exchange transfusion tray under sterile technique
2. Drop sterile 10 mL syringes and sterile stopcocks onto sterile field
3. Don sterile gloves
4. Assemble exchange tubing, using three way stopcocks (one for arterial set-up,
one for venous set-up)
a. Arterial Stopcock
i. Port 1- connect to arterial line
ii. Port 2- connect to extension tubing in exchange tray, then assure
end of extension tubing is placed in the “waste” blood bag, for
blood removed during exchange procedure
iii. Port 3 - Attach empty 10mL syringe
b. Venous stopcock
i. Port 1- connect to venous line
ii. Port 2- attach 10 mL empty syringe
iii. Port 3- connect to blood product tubing, once primed from blood
c. Draw initial labs as ordered from port 3 of arterial line
d. Perform exchange transfusion (2 providers required)
i. Provider 1- withdraw and discard blood from arterial line at a rate
ii. Provider 2- Infuse transfusion blood into venous line at a rate of 2-
iii. Each provider to call out volume of blood withdrawn and infused
during each cycle
C. Procedure using the Push-Pull Technique (performed by neontal provider)- Used when
there is only one access point for removal of blood and infusing replacement blood (see
related document C for picture of set-up)
1. Open exchange transfusion tray under sterile technique.
2. Connect 4-way stopcock to the appropriate tubings
a. White stopcock arm has 4th port, positioned vertically; this is the syringe
port for push/pull technique
i. Connect normal saline syringe to this port and flush each port by
positioning arm in line with port to be flushed, removing cap,
flushing, replacing cap. Repeat with each port. The arm of this
stopcock points to the “open” port.
b. Female adapter A (positioned at a 90 degree angle from the male port and
other female adapter port): Connect waste tubing to this port, and then
connect other end of waste tubing to the waste bag.
c. Female adapter B (positioned in line with the male port): Attach primed
blood product tubing to female adapter B.
d. Prior to connecting male adapter to central venous or arterial catheter,
aspirate blood product into syringe to remove any excess air, move
stopcock arm clockwise to waste bag and discard waste.
e. Connect primed male adapter to central venous or arterial catheter.
3. To begin exchange
a. Position stopcock arm pointing toward venous or arterial catheter,
withdraw aliquot (usually 5-10 mL) of blood from baby over 2-4 minutes.
b. Turn stopcock arm clockwise toward waste port. Discard wasted blood
into waste blood bag.
c. Turn stopcock arm clockwise toward blood product, withdraw aliquot
(usually 5-10 mL) of blood.
d. Turn stopcock arm clockwise toward venous or arterial line and infuse
e. Repeat process until exchange complete.
f. Provider to call out volume of blood withdrawn and infused during each
D. Patient Monitoring
1. Vital Signs
a. Every 15 minutes during exchange transfusion
b. Once 30 minutes following exchange transfusion
c. Then resume routine vital sign monitoring
2. Labs per provider order (see related document)
3. Monitor for potential complications during and after procedure. The
complications include but are not limited to the following:
a. Lab abnormalities
iv. Metabolic acidosis
b. Necrotizing enterocolitis
c. Disseminated intravascular coagulation (DIC)/ Hemorrhage
d. Intracranial hemorrhage
e. Blood pressure abnormalities-hypo/hypertension
g. Air embolism
j. Respiratory distress
E. Exchange Transfusion Completion/Discontinuation
1. Upon completion/discontinuation of exchange transfusion, dispose of waste
blood down drain, place empty waste bag in red biohazard waste container.
1. Provider to document procedure note following exchange transfusion
2. RN to document in electronic health record the following items
a. Initiation of exchange transfusion
b. Vital signs
c. Volume of blood withdrawn and volume of blood infused
d. Completion of exchange transfusion
e. Babies tolerance of procedure and any additional assessments or
VI. UWHC CROSS REFERENCE
A. Hospital Administrative Policy, 4.17, Informed Consent
B. Hospital Administrative policy, 8.12, Blood and Blood Component Transfusion
(Requiring Pre-Transfusion Testing).
C. Hospital Administrative Policy 8.48, Operative, Invasive, and other Procedures.
D. Related Reference A - Guidelines for Exchange Transfusion in Infants 35 or More Weeks
E. Related Reference B - Exchange Transfusion Labs
F. Related Reference C - Neonatal Exchange Transfusion Set-up
A. American Academy of Pediatrics (2004). Management of hyperbilirubinemia in the
newborn infant 35 or more weeks of gestation. Pediatrics, 114(1), 297-316.
B. Bhutani, V. K. Committee on the Fetus and Newborn, American Academy of Pediatrics
(2011). Phototherapy to prevent severe neonatal hyperbilirubinemia in the newborn infant
35 or more weeks gestation. Pediatrics, 128:e1046.
C. Johnson L., Bhutani, V. K. (2011). The clinical syndrome of bilirubin-induced neurologic
dysfunction. Seminars in Perinatology, 35:101.
D. Murki, S., & Kumar, P. (2011). Blood exchange transfusion for infants with severe
neonatal hyperbilirubinemia. Seminars in Perinatology, 35(3), 175-184.
E. Verklan, T. M. & Walden, M. (2014). Core Curriculum for Neonatal Intensive Care
Nursing. St. Louis, MO: Saunders Elsevier.
VIII. REVIEWED BY
Department of Neonatology Clinical Guidelines Group
NICU Clinical Nurse Specialist
Nursing Patient Care Policy and Procedure Committee, February 2015
Beth Houlahan, MSN, RN, CENP
Senior Vice President Patient Care Services, Chief Nursing Officer