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

Double Volume Exchange Transfusion Clinical Pathway – ICU

Venous-Arterial Access Exchange Procedure

Assisting with Double Volume Exchange Transfusion: 2 Access Method – Arterial and Venous Access 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
Preparation of Sterile Field and 4-Way Stopcock Assembly
  • This set-up is used only when both venous (infusion of donor blood) and arterial (withdrawal of patient blood) access is available.
  • 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
    • Ensure UVC and UAC tubing is going to opposite sides of baby
    • 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 arterial 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 arterial 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 arterial catheter to avoid blood leakage and have your helper disconnect the existing stopcock and clave.
    5. Attach arterial 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 previous art line fluid to Port C (this fluid will be used to flush the catheter at the specified time points below).
    7. Attach a syringe to the main port and draw off initial labs.
    8. Hand this syringe off and attach the appropriate sized syringe based on the withdrawal pass volume to the main port.
  • 4-way stopcock, Stopcock is open to arterial catheter
  • Stopcock is open to arterial catheter
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.
    2. Start donor blood transfusion per protocol through venous (infusion) catheter.
    3. Begin cycle of passes always turning the stopcock clockwise.
    4a) Using the syringe on the 4-way stopcock, rotate handle clockwise toward arterial (withdrawal) line and withdraw the pre-determined volume over the desired length of each pass.
    4b) Rotate the handle to the waste bag to discard the withdrawn blood.

    4c) Call out withdrawn volume amount so recorder can track on the log.
    4d) The removal volume should be reconciled with the administration volume to ensure they are equivalent after each pass.

    4e) At least every 15 mins (timed with lab draws), flush arterial catheter with 1–2 mL of heparinized saline drawn from the art line fluid bag attached to the stopcock opposite your arterial line.

    Note: In this picture, the stopcock is open to arterial line to obtain fluid. To flush the arterial catheter, rotate stopcock 180 degrees.
    1. If labs are needed during a pass, hand syringe with “withdrawn blood from arterial line” to the nurse who will send labs. You will skip the discard of blood into the waste bag for this pass.
    2. Use a new sterile syringe to resume procedure.