Neonatal Exchange Transfusion Research Articles

Long-term neurodevelopmental outcome after intrauterine transfusion for the treatment of fetal hemolytic disease

Objective: The aim of the study was to assess the developmental outcome of neonatal survivors of hemolytic disease of the neonate treated with modern intrauterine transfusion techniques. Study Design: In this prospective, observational study, auditory evoked-response tests were performed in the nursery. Neurodevelopmental evaluation with the Gesell Developmental Schedules was performed between 9 and 18 months of corrected age to assess motor skills, language development, comprehension capacity, and social skills. The McCarthy Scales of Children’s Abilities were administered between 36 and 62 months. Results: Forty children who survived severe fetal hemolytic disease were followed up until 62 months old. Demographic data included gestational age at first intrauterine transfusion (26.4 ± 3.7 weeks), median number of intrauterine transfusions (4, range 1-8), lowest fetal hematocrit (20.2%± 7.8%), peak fetal bilirubin (7.1 ± 2.1 mg/dL), incidence of hydrops fetalis (45%),and mean gestational age at delivery (35.6 ± 2.2 weeks). One case of severe bilateral deafness and 1 case of right spastic hemiplegia were diagnosed. The Gesell Developmental Schedules score was assessed between 9 and 18 months of corrected age in 22 infants. The global developmental quotient was 101.9 ± 9.5 (mean for normal population is 100). Regression analysis revealed no correlation between the global developmental quotient and gestational age at the first intrauterine transfusion, gestational age at birth, or the severity of the fetal hemolytic disease (fetal hematocrit, fetal bilirubin, presence of hydrops fetalis, total number of intrauterine transfusions, duration of neonatal phototherapy, and number of neonatal exchange transfusions). Eleven of the 40 children were followed up until they were 62 months old, and the McCarthy Scales of Children’s Abilities were administered. The mean cognitive index was 107.6 ± 9.4 (90-109 is considered average). Conclusion: Despite severe fetal hemolytic disease, normal developmental outcome can be expected for children treated with intrauterine transfusions. (Am J Obstet Gynecol 1998;179:858-63.)

Current practice in neonatal exchange transfusions: a retrospective audit based at one transfusion centre.

As a result of the widespread use of phototherapy, the need for neonatal exchange transfusion has declined markedly over the last 25 years. However, in spite of this, we have discovered a marked disparity in the number of requests for units of blood suitable for exchange transfusion made by neonatal units of similar size. A retrospective audit was therefore performed to establish current practice. A questionnaire was sent to consultant neonatologists and an audit trail of all units of blood issued from our Transfusion Centre for exchange transfusion over an 18-month period was followed. A significant finding was the large amount of overordering of blood by neonatologists, resulting in units produced expensively to high specification being given to other patients. Only 42% of the blood issued for exchange transfusions was actually used for that purpose. Also, published guidelines are not being adhered to, particularly with respect to the specification of the blood products being used. Better communication between neonatologists, hospital haematologists and transfusion medicine specialists would help to ensure that infants requiring exchange transfusion are given the best product and that valuable resources are not wasted.

The first neonatal exchange transfusion for haemolytic disease of the newborn

The first neonatal exchange transfusion for haemolytic disease of the newborn

Trends in neonatal exchange transfusions at Yodogawa Christian Hospital.

A review was conducted to determine the trends in exchange transfusion (ET) of newborn infants at the Yodogawa Christian Hospital during the past 18 years. At that hospital in 1957, the first ET was performed on a term infant with severe hemolytic jaundice caused by rhesus factor (Rh) incompatibility. By 1989, ET had been performed in more than 1400 newborn infants. These cases of newborns who had had ET were retrospectively reviewed, with a focus on every 3 year period from 1974 to 1992. The total number of infants requiring ET noticeably decreased from 68 cases (14.0% of total admissions) in 1974 to 19 cases (6.1% of total admissions) in 1992. (chi 2, P < 0.001) There were three major significant changes in ET during those years. The first was a change in the subjects for ET. The incidence of ET for term infants showed a marked decrease, while the incidence of ET for preterm infants, especially for very low birthweight (VLBW) infants (< 1500 g), noticeably increased. The second was a change in indications for ET. There was a marked decrease in the need for ET as a result of hyperbilirubinemia, while the incidence of ET because of other etiologies, such as septicemia and/or disseminated intravascular coagulopathy, noticeably increased. The third was a change in the technical methods of ET. Now at the Yodogawa Christian Hospital, 100% of the infants are given ET with an automated peripheral two-site method, instead of the Diamond method. Although ET might still be a useful treatment for severe hyperbilirubinemia and other acute problems, the total number of ET noticeably decreased in accord with a decrease in the number of severe hyperbilirubinemia in term newborns. On the other hand, the incidence of ET in preterm infants increased relatively, accompanied by an increase in the survival of VLBW infants. The automated two-site method is the preferred technique for ET at the Yodogawa Christian Hospital, rather than the Diamond method. Further changes in ET might occur in accord with new alternative measures in future.

The management of hemolytic disease in the fetus and newborn

Rh hemolytic disease (HDN) is the prototype of maternal alloimmunization and fetal hemolytic disease. There are other antigens capable of causing alloimmunization and hemolytic disease such as c, Kell, and Fya. Rh immunization is usually caused by a prior Rh positive fetal maternal transplacental hemorrhage, which occurs in at least 75% of pregnancies. Unless treated, hemolytic disease will result in kernicterus or fetal hydrops in 25% of cases, respectively. Neonatal exchange transfusion has eradicated kernicterus. Measures available to predict severity of fetal hemolytic disease are maternal antibody titers, prior history of hemolytic disease, in vitro cell-mediated maternal antibody functional assays, amniotic fluid spectrophotometry, ultrasound fetal assessment, and fetal blood sampling. The Rh or Kell antigen status of the fetus may be determined by amniotic fluid PCR testing. The management of the severely affected fetus consists of early delivery, with or without fetal transfusions, depending on the gestation of the fetus. With the use of these diagnostic and treatment measures, perinatal mortality from hemolytic disease of the fetus and newborn has been reduced in Manitoba, population one million, from 100 per year in the early 1940s to 1 every 3 years in the mid 1990s.

The First Neonatal Exchange Transfusion for Haemolytic Disease of the Newborn by Dr. Alfred Hart of Toronto

The First Neonatal Exchange Transfusion for Haemolytic Disease of the Newborn by Dr. Alfred Hart of Toronto

Variation in blood component irradiation practice: implications for prevention of transfusion-associated graft-versus-host disease

RAFT-VERSUS-HOST DISEASE (GVHD) is comG monly observed after allogeneic bone marrow transplantation (BMT), but transfusion-associated (TA) GVHD is only rarely reported. Although early reports of TAGVHD were recognized in immunocompromised hosts, more recent cases have been documented in immunocompetent transfusion recipients. The increasing awareness of this serious complication of transfusion prompted a national survey of transfusion medicine practices to identify patients at risk for TA-GVHD and assess methods for its prevention. HISTORICAL PERSPECTIVE The reported cases of TA-GVHD have recently been summarized.' To date, it has been documented after transfusion of unirradiated blood components to at least 87 patients: in patients with severe combined immunodeficiency, thymic hypoplasia, and Wiskott Aldrich syndrome2.'*; premature newborns and those with erythroblastosis fetali~'~-*~; patients with hematologic malignancies including Hodgkin's and non-Hodgkin's lymphomas, acute myelocytic and lymphoblastic leukemias, chronic lymphocytic leukemia, and aplastic patients with solid tumors including neuroblastomas, glioblastoma, rhabdomyosarcoma, cervical carcinoma, small cell lung cancer, and germ cell tum08'-'~; patients after cardiac surgery and cholecystectomp-60; and in an apparently healthy 22-year-old woman.6' This syndrome has developed after neonatal exchange and intrauterine transfusions; and after transfusion of whole blood, fresh (nonfrozen) plasma, red blood cells, and platelets. Leukocytes harvested from normal donors and from donors with chronic myelocytic leukemia transfused to patients with hematologic malignancies have also been implicated in TA-GVHD. TA-GVHD results in an overall mortality of 84% at a median of 21 (8 to 1,050) days after transfusion.'

Combined Intravascular-Intraperitoneal Transfusions in Hydropic Twins due to Rh (D) Alloimmunization

Fetal hydrops due to Rh (D) alloimmunization can be reversed by ultrasound-guided intravascular transfusions with improvement in perinatal morbidity and mortality. We report a case of in utero intravascular transfusion in hydropic twins which reversed all the hydropic findings within 3 days. A simple intraperitoneal transfusion was performed in each twin 2 weeks later, and only one neonatal exchange transfusion was required for the ultimate survival of both twins.

Prevention of Rh isoimmunization and treatment of the compromised fetus.

Intrauterine intravascular transfusion for the treatment of severe erythroblastosis fetalis has resulted in a number of benefits: (a) Direct access to the fetal vasculature allows an accurate assessment and prompt correction of anemia, albeit temporary. In contrast, intraperitoneally transfused blood may be absorbed erratically, especially in the face of ascites. (b) Intravascular treatments can be performed, in general, as early as 17 weeks of gestation, earlier than intraperitoneal approaches permit. (c) Reversal of hydrops along with the correction of anemia and hypoproteinemia has significantly reduced neonatal morbidity and mortality. None of the surviving neonates in our series required either thoracentesis or paracentesis following delivery, and 40% did not require neonatal exchange transfusion. (d) Treatments may be safely performed until pulmonic maturity has been established and/or an EFW of greater than 2,000 g has been reached, reducing problems of prematurity. (e) Central vein and umbilical vein hypertension may be arrested or prevented, thereby allowing fetal liver function to return to normal. While isoimmunization stands as a disease that has been quite successfully reduced in frequency and severity by the careful attention and treatment by obstetricians, cases still occur. Due to the reduced frequency of severe disease, fewer physicians are trained and experienced in performing this difficult procedure. As fewer transfusions are required, the value of regionalized treatment centers will have to be considered carefully, in order to maximize the experience and efficiency of the intravascular intrauterine transfusion treatment teams.

Partial exchange transfusion in term polycythemic neonates: Absence of association with severe gastrointestinal injury: H.A. Hein and S.S. Lathrop. Pediatrics 80:75–78, (July), 1987

Partial exchange transfusion in term polycythemic neonates: Absence of association with severe gastrointestinal injury: H.A. Hein and S.S. Lathrop. Pediatrics 80:75–78, (July), 1987

Partial Exchange Transfusion in Term, Polycythemic Neonates: Absence of Association With Severe Gastrointestinal Injury

Partial exchange transfusion is often used to treat neonatal polycythemia. Concern about the risk of necrotizing enterocolitis following the procedure has recently been raised. We report a retrospective analysis of 185 term, polycythemic neonates who received partial exchange transfusion. No evidence of severe gastrointestinal injury was found. The technique for partial exchange transfusion we report consists of removal of blood from the umbilical vein with reinfusion of a commercial plasma substitute through a peripheral vein. Based on our data and a literature review, we offer suggestions for future conduct of partial exchange transfusion in polycythemic neonates.

Hyperkalemia after neonatal exchange transfusion: Risk eliminated by washing red cell concentrates

Questionnaire adresse a 17 centres de transfusion de la Croix-Rouge canadienne sur les types de produits sanguins utilises pour les exsanguino-transfusions (EST) neonatales et sur les taux plasmatiques de potassium doses dans ces produits. Les resultats montrent que l'hyperkaliemie post-EST peut etre eliminee par emploi de sang total frais de moins de 24 h ou par lavage des concentres d'hematies avant reconstitution avec du plasma frais congele

Changes in the management of severely Rh-immunized patients

Since July 1, 1978, we have instituted the following changes in the management of severely Rh-immunized patients: (1) serial amniotic fluid optical density (ΔOD450) values and real-time ultrasound scanning beginning at 21 weeks' gestation, (2) fetal transfusion as early as the twenty-third week, (3) ultrasound surveillance during and after intrauterine transfusions, and (4) planned premature delivery with neonatal exchange transfusions for selected cases between 29 to 32 weeks and for all patients after 32 weeks' gestation. The perinatal survival rate (83.8%) in 37 isoimmunized pregnancies managed with this regimen was significantly higher (p < 0.05) than in 34 such pregnancies (55.9%) managed according to the protocol utilized during the previous four years.

Neonatal Exchange Transfusions Complicated by Transfusion-Induced Malaria

Two neonates who became infected with Plasmodium vivax subsequent to exchange transfusion are described. This complication of neonatal exchange transfusion is unusual in that only two other similar cases have been reported to the Centers for Disease Control. Although malaria is an unusual complication, it should be kept in mind when considering the differential diagnoses of fever following neonatal exchange transfusion. The risk of transfusion-induced malaria may be increasing due to the influx of immigrants from areas endemic for malaria. Careful blood donor selection and blood donor education may minimize this risk.

The Effect of Neonatal Exchange and Later Blood Transfusion on Lymphocyte Cultures

ABSTRACT: As blood transfusion has a beneficial effect on renal graft survival and may confer a protection against preeclampsia, the effect of neonatal or late blood transfusion on lymphocyte cultures was studied. Mixed lymphocyte reactions were significantly less even 20 years after transfusion.

Pharmacokinetic considerations in exchange transfusion in neonates.

Neonates undergoing blood exchange often receive concomitant therapy. Questions may be raised whether dosage regimen alterations are necessary to replace drug lost as a result of the exchange procedure. Our study reports the changes in plasma concentration of kanamycin during an exchange transfusion and a pharmacokinetic analysis of the effect of the exchange on drug elimination. The relationships of the volumes of distribution, elimination rate constant, and time after dosing on the fraction of the dose eliminated in the blood exchange are developed on the basis of a one-compartment body model. Computer simulations using the equations developed were used to estimate the fraction of a dose that might be removed as a result of an exchange transfusion. As the disposition rate constant or the apparent volume of distribution increase, i.e., the clearance of the drug increases, the fraction of the dose removed by the exchange process decreases. Thus, significant amounts of drug removal may occur in an exchange transfusion for drugs with low clearance when the exchange is initiated early in the drug dosing interval. In our study, only 3% of the kanamycin dose was removed as a result of the exchange process, and dosing adjustment would not be required. This was in part due to initiation of the exchange late in the dosing interval, although the maximum calculated percentage of the dose which could have been removed under the exchange conditions employed was only 10%.

Donor blood for neonatal exchange transfusion.

Donor blood for neonatal exchange transfusion.

A NEW BLOOD WARMER

The Medimpact electronic in-line blood warmer has been assessed experimentally. It was found to be capable of warming cold stored blood (4°C) to 32° C at a flow of 560 ml/hr and of being positioned very near to the intravenous cannula. It is suitable and safe for massive blood transfusion in infants weighing up to 14 kg or for neonatal exchange transfusion.

Exchange transfusion with ACD-adenine blood. A follow-up study.

Twenty‐seven children had received neonatal exchange transfusions (one to seven times) with ACD‐adenine red cell concentrate containing 7 mg adenine per 100 ml of blood. They were evaluated in a follow‐up study at about five years of age. The examination comprised a history and physical examination, routine blood and urine examination, urine culture, serum creatinine and pitressin test. In no case could any renal damage be demonstrated. No correlation was found between the number of transfusions with ACD‐adenine blood and the values of serum creatinine and pitressin test.

Effects of agitation of donor blood on neonatal exchange transfusions.

Neonatal exchange transfusions have been simulated with a mechanical apparatus and mathematically. Both approaches show that the donor blood should always be well agitated during exchange transfusions to avoid undesired fluctuations in the baby's hematocrit and hemoglobin levels.