Original Article

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Exchange Transfusion through Peripheral Route

Sheikh Mushtaq Ahmed, Bashir Ahmed Charoo, Qazi Iqbal, Syed Wajid Ali, Masoodul Hasan, M. Ibrahim, B.Sc; Gh. Qadir, B.Sc.

ABSTRACT
Exchange Transfusion is a procedure commonly used for treating neonatal hyperbilirubinemia, a potentially neurological handicapping condition. The procedure has been traditionally done through the umbilical vein. This may not always be feasible & practicable in every case. e.g., umbilicus may be septic or the baby may be older than one week or have NEC when umbilical vein is shriveled & closed. We have succeeded in doing the procedure through the peripheral route by using the radial & brachial arteries & the antecubital vein. A prospective study carried out in Department of Neonatology, Sher-i-Kashmir Institute of Medical Sciences, which is a tertiary care hospital in the Kashmir valley, from July 2002 to June 2004. Out of a total of 1275 admissions over a two year period, 305 had jaundice among which 198 needed exchange transfusion. Ninety exchange transfusions through peripheral route were done without any complications. Brachial/radial arteries & a good peripheral vein on the other upper limb were used. Exchange transfusion through peripheral vessels is effective and safe alternative to umbilical vessel route. This procedure can be safely used even in hemodynamically unstable neonates.
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Authors affiliations : Sheikh Mushtaq Ahmed, Bashir Ahmed Charoo, Qazi Iqbal ,Syed Wajid Ali, Masood-ul- Hasan, M. Ibrahim,Gh. Qadir, Department of Neonatology, Sheri-Kashmir Institute of Medical MATERIALSAND METHODS: Sciences This study was carried out on hospitalized patients at S.K. Institute of Srinagar, Kashmir
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INTRODUCTION Neonatal jaundice is a common medical emergency in the Neonatal Intensive Care units, because bilirubin is a potentially neurotoxic substance. The limited ability of a neonate to metabolize unconjugated bilirubin predisposes the baby to bilirubin encephalopathy . Exchange transfusion, developed by Diamond more than fifty years back, is a cornerstone to prevent permanent brain damage 2. ET by conventional push-pull technique through the umbilical vein is associated with certain complications, which do not occur in the peripheral route & the procedure is simple & safe . Hospital based two year study was done from July 2002 to June 2004 to compare the two routes of ET.
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Correspondence to: Dr. Sheikh Mushtaq Ahmed Associate Professor Sher-i-Kashmir Institute of Medical Sciences Shameem Ashiana S.K.Colony, Anantnag Kashmir, India 192101

Medical Sciences in the Department of Neonatology (Neonatal Intensive Care Unit- NICU) which is a tertiary care centre in Kashmir. Cases were referred from Obstetric unit of the Institute, Childrens Hospital & Lala Ded Hospital for Women of Medical College, Srinagar & various district headquarter hospitals of the valley. Detailed antenatal, post-natal history, detailed examination of baby and various investigations including Hemogram, Red cell morphology, Reti count, Direct Coombs test, Blood group & Rh-typing, Blood sugar & Calcium, Kidney function test, Serum electrolytes, Arterial blood gases & Blood culture were performed. Serum bilirubin estimation was done pre-exchange, 2hr, 6hr, 12hr & 24hr post-exchange. Cockington charts were used as guidelines for therapeutic intervention . Brachial or radial artery was cannulated with a 24G cannula (Angiocath) under all aseptic precautions. A good peripheral vein or antecubital vein on the other side was cannulated with a 22G or 24G angiocath. Citrate phosphate
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KEY WORDS : Exchange transfusion (ET), Neonatal Hyperbilirubinemia, Peripheral Route.

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dextrose (CPD) fresh blood was used for the procedure & phototherapy was used pre- & post-exchange. Two operators carried out the procedure using aliquots of 5-10 ml on withdrawal & infusion. Three-way stop cocks were used on either side and arterial catheter flushed with 0.5ml of heparin solution (5 units/ml) after every 50ml. Procedure was performed under radiant warmer with monitoring of heart rate, respiratory rate, body temperature & oxygen saturation (by pulse oximetry). Repeated exchanges, if required, were done through the same lines and the catheters removed after 24 hrs. Common causes for ET were idiopathic, prematurity, ABO incompatibility, Rh incompatibility, polycythemia & birth asphyxia. We preferred normal saline over plasma in partial exchange for polycythemia
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TABLE 2
Peripheral exchange Weight(gm) 2001 & above 1501-2000 <1500 Serum Bilrubin(mg) >20 <20 Number of exchanges One Two More than two Route of Exchange Brachial Radial Number 90 32 18 40 40 50 70 15 5 20 70 Percentage 100 35 20 45 45 55 77.7 16.6 5.7 22.3 77.7

RESULTS: Out of a total of 1275 admissions over a period of two years from July 2002 to June 2004, 305 (23.92%) had jaundice. Out of 305 patients, 198 patients (15.53% of total admissions and 64.91% of jaundice patients) needed exchange transfusion. Ninety patients (7.06% of total admissions and 45.45% of jaundice patients) were subjected to peripheral exchange transfusion. Male to female ratio was 65:35.

TABLE 1
Total no of cases Jaundice cases Exchange transfusion needed Peripheral exchange No of pts Percentage 1275 100 305 23.92% 198 90 15.53% 7.06% (45.45% of jaundice patients)

Gestational age of the babies was between 28-40 weeks (mean 34.5 weeks). Out of 90 peripheral exchange transfusions done, 67 (75%) babies were less than 2.5kgs weight & 23 (25%) were more than 2.5kgs. Out of the total 90 peripheral exchange transfusion cases, babies weighing above 2000gm were 32 (35%), 1500-2000gm were 18 (20%) and less than 1500gm were 40 (45%). Total serum bilirubin was more than 20mg in 40 (45%) patients and less than 20mg in 50 (55%). Seventy babies (77.7%) needed one exchange transfusion, 15 (16.6%) needed two and 5 (5.7%) needed more than two exchange transfusions (Table2). DISCUSSION Peripheral vessels have been used as an alternative for exchange transfusion in selected patients . Very few centers have adopted this as an elective procedure. Campbell and Stewart used a 22G catheter for blood replacement without any excessive hemolysis. Fox et al have shown that 24G catheter does not cause more hemolysis than either a 3.5 of 5 Fr umbilical catheter. Conventional methods using umbilical vein cause immediate and delayed complications, which include
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tachycardia, bradycardia, cardiac arrest, pulmonary edema, introduction of infection through umbilical stump, portal hypertension, hemoperitoneum, intestinal perforation, air embolism & necrotizing enterocolitis . Peripheral exchange can cause complications like cerebral embolism by clot originating from radial artery. This can be prevented by using a small cannula, avoiding stasis & bubbles entering the artery, small flush volume & use of heparin . We used brachial artery in 20 patients and radial artery in 70 patients without any major complications, except for slight blanching in two of radial group patients. This transient phenomenon reversed by itself. However, radial artery is a preferred vessel for peripheral ET. By using peripheral vessels for exchange transfusion we can eliminate the complications of umbilical venous catheterization. GI complication is not a problem. Feeding can be continued compared to no feeding for 24hrs in umbilical route exchange transfusion. We have found decreased chances of sepsis, complete exchange & more safety in peripheral exchange transfusion. Cost-wise peripheral exchange transfusion is very cheap as we need only two angiocaths, two stop-cocks & two 10ml syringes as compared to a complete exchange set (vygon) as is used for umbilical route. Also temperature control is found to be better as the body of baby is not to be exposed. Same advantages with ET have been seen by Satish Saluja, et al . CONCLUSION Exchange transfusion through peripheral vessels is quite effective & safe elective alternative thus avoiding likelihood of severe complications related to umbilical vessel catheterization. The flow in artery is free & blood can be easily removed & re-infused through the vein. This procedure can be used even in hemodynamically unstable neonates. This leads to higher safety profile with respect to cardiorespiratory problems associated with the procedure.
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