Double Volume Exchange Transfusion — Venous Access Only Exchange Procedure — Clinical Pathway: ICU

Double Volume Exchange Transfusion Clinical Pathway – ICU

Venous Access Only Exchange Procedure

Assisting with Double Volume Exchange Transfusion: Single Access (Push-Pull) Method – Venous Access Only Procedure

Pre-Procedure
  • Ensure NPO
  • Order IV fluids for peripheral IV
  • Hold TPN during procedure
  • Order carrier fluids for secondary lumens depending on vascular access
  • Order labs
  • Identify the timer to be used during exchange
    • Consider Apgar timer on bed
Sterile Field Preparation and 4-Way Stopcock Assembly
  • This assembly is used when only venous access is available (push-pull technique). If double lumen UVC in place, use the larger lumen.
  • Semi-sterile field preparation (existing catheters are not sterile):
    • Stop phototherapy
    • Bedside staff don hats and masks
    • Open exchange transfusion tray
    • Provider performing procedure don sterile gown and gloves in addition to hat and mask
    • Establish sterile field on the warmer bed and place sterile drape/towels down
  • Assembling the Stopcock
    1. Attach sterile saline syringe and flush each port of the exchange transfusion stopcock.
      1. The exchange transfusion stopcock works differently than other stopcocks — the main port coming from the handle is always open and will be open (for infusion or withdrawal) to whichever port the handle is pointed towards.
      2. When disconnecting syringes from the main port ensure that it is not open to the venous catheter — i.e., have the main port open to the waste bag or pointed downward.
    2. Place exchange transfusion stopcock and attached waste tubing (pre-attached to port B) on sterile field. Hand the waste bag and the distal end of the waste tubing to a non-sterile helper.
    3. Have non-sterile helper lift umbilical venous catheter at stopcock, hold the catheter with a piece of sterile gauze. Clean the distal end of the catheter and the connection to the existing stopcock with an alcohol wipe.
    4. Gently pinch the venous catheter to avoid blood leakage and have your helper disconnect the existing stopcock and clave.
    5. Attach venous catheter to Port A of the exchange transfusion stopcock using the flush to overfill to avoid air bubbles.
    6. Have the non-sterile helper then attach the donor blood tubing from the hotline tubing to Port C using a t-connector between the hotline warmer blood tubing. (Nurse should secure the hot-line warmer tubing to the bed using tape).
    7. Attach a syringe to main port to draw initial labs and hand syringe to nurse sending labs
    8. Attach an appropriate size syringe (depending on pass volume) to the Main port in preparation to start exchange.
  • 4 way stopcock
Final Preparation
for the Procedure
  • Gather team
  • Perform safety time-out
  • Verbal announcement and confirmation of exchange calculations
  • Confirm timer source
Performing the Procedure
  • The exchange transfusion 4-way stopcock works differently than a standard stopcock.
  • The main port coming from the handle is ALWAYS OPEN and will be open to whichever port the handle is pointed towards.
  • Always rotate the exchange transfusion stopcock CLOCKWISE.
    1. Based on start time, determine lab schedule.
    4 Way Stopcock: Rotate the handle towards the UVC
    2a) Rotate the handle towards the UVC (patient) and withdraw pre-specified volume of blood over pre-specified length of pass
    (3 mins unless otherwise specified).
    4 Way Stopcock: Rotate the handle towards waste bag
    2b) Rotate the handle towards waste bag. Discharge patient blood and call out volume withdrawn.
    4 Way Stopcock: Rotate the handle toward donor blood
    2c) Rotate the handle toward donor blood. Draw up volume of donor blood equivalent to volume of blood withdrawn.

    2d) Rotate the handle toward UVC (patient) and push in donor blood over 1 min and call out volume transfused (Figure 2a)
    2e) Repeat steps 2a–2d.

    1. If labs are needed during a pass, draw the labs after the step in the cycle of passes where the patient’s blood is withdrawn (step 2a). Hand the syringe with the withdrawn blood to the nurse (you will skip the discard of blood into the waste bag for this pass).
    2. Attach a new sterile syringe and restart at step 2c- drawing up donor blood.