Hemodynamic changes during
exchange transfusion in early neonatal period
Patil R 1,
Kavthekar S 2, Patil N 3, Kurane A 4
1Dr. Rahul Patil, Assistant Professor, 2Dr.
Saiprasad Kavthekar, Assistant Professor, 3Dr. Nivedita Patil,
Professor, 4Dr. Anil Kurane, Professor and HOD, all authors are
affiliated with Department of Pediatrics, Dr D.Y. Patil Medical College
and Hospital Kadamwadi, Kolhapur, Maharashtra, India.
Address for
Correspondence: Dr. Rahul R. Patil, Department of
Pediatrics, Dr D.Y. Patil Medical College and Hospital Kadamwadi,
Kolhapur, Maharashtra, India. drrahulpatil1980@yahoo.com
Abstract
Background:
Exchange transfusion(ET) has remained the gold standard for rapid
lowering of higher bilirubin levels, it is not risk free and mortality
rate vary from 0.5 to 3.3%. The present study was carried out to study
hemodynamic parameters changes during ET in neonates. Materials and Methods: 22
neonates who suffered from hyperbilirubinemia and required double
volume ET were enrolled in this prospective study. ET was carried out
according to standard practice guidelines. Clinical hemodynamic
parameters including heart rate, respiratory rate, blood pressure,
temperature and ECG, % saturation of oxygen (SpO2) and CVP were
monitored continuously before 15 min (pre exchange) during 60-120
min(mid exchange) and after 30 min(post exchange). All data was
analysed statistically. Results:
There was significant increase in mean heart
rate152.78(19.88),155.12(20.50), mean respiratory rate
46.02(8.87),50.92(6.98) and drop in mean Spo2 91.19(4.17),90.67(4.28)
in mid-exchange and post-exchange values respectively as compared to
pre exchange values138.72(17.74),36.79(7.58),93.51(3.28) for mean heart
rate, respiratory rate and mean SpO2 respectively. There was
significant increase in mean diastolic blood pressure values in
post-exchange 45.43(13.88) as compared to pre exchange values
41.83(9.80). Mid-exchange value 8.66(2.12) of mean central venous
pressure was significantly lower from pre-exchange 10.10(1.92) and
post-exchange 9.56(1.98) values. ECG changes did not show any
significant changes during ET. Conclusion:
There were significant adverse effects on all hemodynamic clinical
parameters. Monitoring of neonate is essential during ET which will
prevent complications of ET. Current recommendations for performing ET
are based on balance between the risk of encephalopathy and the adverse
events related to the procedure holds true.
Keywords:
Exchange Transfusion, Hemodynamic changes, Hyperbilirubinemia, Neonate
Manuscript
received: 02nd April 2017, Reviewed: 10th
April 2017
Author
Corrected: 20th April 2017, Accepted for Publication:
30th April 2017
Introduction
Jaundice is most common and one of the most vexing problems for a
pediatrician that can occur in neonate. All newborn infants are born
with hyperbilirubinemia which is defined as total serum bilirubin (TSB)
of 2mg/dl or more [1]. Newborns however, may not appear jaundiced
untill TSB concentration exceeds 5-7 mg/dl [2]. About 60% of term and
80% of preterm infants have clinical jaundice in the first week after
birth but only 0.02 to 0.16 of them develop severe hyperbilirubinemia
(TSB >25mg/dl),which is an emergancy because it may cause
neonatal bilirubin encephalopathy which can result in death or
irreversible brain damage in survivor. The terms bilirubin
encephalopathy and kernicterus represents clinical and pathological
abnormalities resulting from bilirubin toxicity in central nervous
system [3-5].
The most common cause of jaundice in neonates are usually
due to hemolysis from ABO incompatability and Rh
incompability.Other causes are G6PD deficiency, polycythemia,
cephalhematoma, sepsis, hypothyroidism, metabolicdisorders, prematurity
and breastmilk jaundice [6]. Exchange transfusion (ET) and intensive
phototherapy play important roles in the treatment of severe
hyperbilirubinemia of newborns [7]. If phototherapy fails to control
rising bilirubin levels, ET is necessary to lower serum bilirubin
concentration. Although ET has remained the gold standard for rapid
lowering of higher TSB levels, it is not risk free and mortality rate
vary from 0.5 to 3.3% [8]. Despite improvement in Neonatal Intensive
Care in past two decades, ET remains a high risk procedure.
Most of these complications are asymptomatic and transient
such as apnea, bradycardia, cyanosis, vasospasm, hypothermia,
hypoglycemia, hypocalcemia ,hyponatremia and hypokalemia but death can
occur because of cardiac arrythmias, cardiac arrest and respiratory
arrest during ET [9-13]. There were no studies which showed
cardiorespiratory status of newborn during ET.The present study was
carried out to study hemodynamic clinical parameters change during ET
in early neonatal life
Materials
and Methods
This prospective study was carried out in the Division of Neonatology,
Department of Pediatrics, Dr D.Y.Patil Medical College and Hospital
after obtaining clearance from Ethical Committee of the Institution.
Neonates suffering from hyperbilirubinemia, who required ET were
enrolled after informed consent from parents. Indications for ET in
idiopathic hyperbilirubinemia in term neonates were TSB >20
mg/dl in less than 48 hrs of age, TSB > 25mg/dl in>48hrs
of age with failure of intensive phototherapy and in preterm neonates
TSB 15-18mgdl in 1.5-2kg, TSB 18-20mg/dl in 2-2.5kg [2,14 ]. In
haemolytic disease indications were TSB>10mg/dl in<24 hrs
of age, TSB rise >5 mg/dl/day or 0.5mg/hr in >48hrs of
age and PCV>40 at any time [15 ]. Babies having birth weight
<1500 gm, gestational age <33 weeks, chronological age
>7 days, previous partial exchange transfusion or multiple
exchanges, gross congenital anomalies, perinatal asphyxia, clinically
suspected chromosomal anomalies, hydrops fetalis and anemia at birth
were excluded from this study.
ET procedures were performed by the medical team of the unit
under all aseptic precaution. The double volume exchange method
(170ml/kg) was carried out by repeatedly removing and replacing a small
amount of blood (5ml/kg)[Pull-Push Technique] according to standard
practice guidelines through umbilical vein with fresh whole blood
(<72 hours), cross matched with appropriate blood group.
Hemodynamic clinical parameters like heart rate, SpO2 and
blood pressure were monitored by multipara monitor RMS Phoebus p512
manufactured by Recorder and Medicare systems Ltd. Skin temperature was
measured with the help of skin temperature sensor of warmer. ECG
monitoring was done in lead-II and duration of P wave, PR interval, QRS
complex, and QT interval were measured. Respiratory rate was detected
by ECG electrodes by impendence of chest movements. The CVP was
measured by holding calibratated umbilical catheter at 90° to
the infant’s body. All the parameters were monitored
continuously before 15 minutes (pre exchange) during 60-120 minutes
(mid exchange) and after 30 minutes (post exchange) and mean of all the
parameters were calculated.
Baby was kept nil by mouth for 2 hrs before and after ET.
The baby was kept under CFL blue light phototherapy unit before and
after ET. Laboratory investigations like serum bilirubin, hemoglobin,
packed cell volume and other relevant investigations like direct
Coomb’s test and glucose-6-phosphate dehydrogenase (G-6-PD)
as and when required were done prior to ET. At 6 hours post ET serum
bilirubin, hemoglobin and packed cell volume were done and clinical
monitoring was done in the form of heart rate, respiratory rate, blood
pressure, capillary filling time and liver size. Total time taken for
exchange blood transfusion after cannulation was recorded for each baby.
Statistical analysis was done by repeated measure ANOVA
design, for one group factor and one within factor and pair-wise
comparison was done using Tukey test at 5% level for all parameters.
Results
This study was carried out on 22 neonates who underwent ET for
hyperbilirubinemia. The baseline characteristics were shown in Figure
I. The cause of jaundice was haemolytic in 11 cases, most often being
ABO incompatibility seen in 8 cases [Table I] Maximum ET were carried
out on day 4th of life. The average duration of ET was 60 -120 minutes.
Figure-I:
Base line characteristics in neonates
Table-I: Causes of
jaundice in neonates
Cause of
Jaundice
|
No. of
cases
|
ABO incompatibility
|
08
|
Rh incompatibility
|
03
|
Cephalhematoma
|
01
|
Prematurity
|
08
|
G-6-PD
|
00
|
Idiopathic
|
02
|
Total
|
22
|
Table-II: Changes in vital
signs during exchange transfusion in neonates
|
Pre-exchange
blood transfusion
|
Mid-exchange
blood transfusion
|
Post-exchange
blood transfusion
|
p-value
(repeated measure ANOVA)
|
HR (bpm)
|
138.72±17.74*#
|
152.78±19.88*
|
155.12±20.50#
|
<0.001
|
RR (/min)
|
36.79±7.58*#
|
46.02±8.87*y
|
50.92±6.98#y
|
<0.001
|
SpO2 (%)
|
93.51±3.28*#
|
91.19±4.17*
|
90.67±4.28#
|
<0.001
|
Temperature (°C)
|
36.54±0.39*
|
36.42±0.37
|
36.35±0.42*
|
0.029
|
SBP (mmHg)
|
69.86±11.74
|
69.80±15.86
|
74.64±20.95
|
0.066
|
DBP (mmHg)
|
41.83±9.80
|
40.60±11.40*
|
45.43±13.88*
|
0.017
|
MAP (mmHg)
|
53.64±10.31
|
53.34±14.08
|
57.33±17.44
|
0.116
|
CVP (cm H2O)
|
10.10±1.92*
|
8.66±2.12*#
|
9.56±1.98#
|
<0.001
|
*p<0.05; #p<0.05, p<0.05 (intragroup
comparison by Tukey test)
Table-III: ECG changes
during exchange transfusion in neonates
|
Pre-exchange
blood transfusion
|
Mid-exchange
blood transfusion
|
Post-exchange
blood transfusion
|
p-value
(repeated measure ANOVA)
|
|
|
|
|
|
P wave (msec)
|
0.059±0.012
|
0.059±0.013
|
0.057±0.011
|
0.483
|
PR interval (msec)
|
0.086±0.008*
|
0.083±0.014
|
0.080±0.014*
|
0.011
|
QRS complex (msec)
|
0.046±0.056
|
0.045±0.080
|
0.044±0.054
|
0.073
|
QT interval (msec)
|
0.255±0.031
|
0.25±0.034
|
0.25±0.036
|
0.071
|
*p<0.05 (intragroup comparison by Tukey test)
Table-IV: Bilirubin,
hemoglobin and PCV changes during and after ET in neonates
|
Pre-exchange blood transfusion
|
Post-exchange blood transfusion
|
Post 6 hrs exchange blood transfusion
|
p-value (repeated measures ANOVA)
|
Total serum bilirubin
|
21.79±6.79*
|
7.86±3.53*#
|
18.94±5.68#
|
<0.001
|
Hemoglobin
|
13.95±2.75*#
|
12.07±2.78*
|
12.29±2.93#
|
<0.001
|
Packed cell volume
|
41.27±8.11*#
|
36.01±8.14*
|
36.46±8.42#
|
<0.001
|
*p<0.05; #p<0.05; (intragroup comparison by
Tukey test)
There was significant increase in mean heart
rate152.78(19.88),155.12(20.50), mean respiratory rate
46.02(8.87),50.92(6.98) and drop in mean SpO2 91.19(4.17),90.67(4.28)
in mid-exchange and post-exchange values respectively as compared to
pre exchange values138.72(17.74),36.79(7.58),93.51(3.28) for mean heart
rate, respiratory rate and mean Spo2 respectively .There was
Significant increase in mean diastolic blood pressure values in
post-exchange45.43(13.88) as compared to pre exchange
values41.83(9.80). Mid-exchange value 8.66(2.12)of mean central venous
pressure was significantly lower from pre-exchange 10.10(1.92) and
post-exchange 9.56(1.98) values. CVP did not show fall less than 3 cm
H2O in any case. [Table II] ECG changes did not show any significant
changes during ET except PR interval, in which there was significant
difference between pre-exchange and post-exchange values. But it had no
clinical significance.[Table III] The temperature was significantly
lowered from pre-exchange to post-exchange periods in all
neonates.(p=0.029).
TSB immediate post exchange value 7.86(3.53) was
significantly lower from pre-exchange 21.79(6.79) and 6hrs
post-exchange 18.94(5.68) values [Table IV].
Discussion
The critical level of TSB, which may be considered to cause bilirubin
encephalopathy is a function of birth weight, gestational age,
chronological age, internal milieu and other functions like concealed
hematomas, hemolysis etc. Therefore ominous serum bilirubin level is
highly individualised for neonates. ET remains the only reliable method
for removing bilirubin from the body, at a particular time in
anticipation that serum bilirubin may cross blood brain barrier and
cause kernicterus. There is decrease in frequency of ET in last two
decade because of anti Rh immunoglobulin for mothers and widespread use
of phototherapy that was the reason behind small sample size in our
study. ET is still required in up to 7% of neonates admitted to
nurseries [16].
In the present study heart rate, respiratory rate were
increased and spo2 , temperature were decreased significantly in all
neonates during ET from pre exchange value without any major changes in
ECG. CVP was more in pre exchange and decreased in mid exchange and
again raised in post exchange period.
Increased heart rate and respiratory rate was mostly due to
cry, irritability, pain and uncomfortable posture during procedure.
Decrease in SpO2 was mostly due to change of neonatal blood with adult
blood as HbA has less affinity for oxygen. Hey EN et al [17] observed
hypothermia during ET, similar finding in our study. Cardiac
arrhythmias mentioned during ET were mainly due to umbilical cannula in
heart, electrolyte abnormalities like hyperkalemia, hypocalcemia [2].
Panagopoulous G et al [13] observed cardiac arrhythmias, cardiac
arrest, respiratory arrest, cyanosis and collapse. Pre exchange CVP
rise was due to irritability and vasospasm and in post-exchange, it
might be due to volume overload, congestive cardiac failure or
vasospasm and wrong position of catheter [18]. Hypotension was
transient in our study and improved in most cases by adjustments of
aliquots in our study. Aranda et al [19] observed 10 ml blood
withdrawal and infusion completed within 3 minutes resulted in
reversible changes in aortic pressure, whereas the same procedure
completed within 45 to 60 seconds resulted in a progressive fall in the
systolic pressure and in narrowing of the pulse pressure and advised an
exchange rate of 5 ml/kg per 3 minutes.
There was a significant decrease in immediate post-exchange
serum bilirubin by 65.52% and rise in serum bilirubin at 6 hrs up to
83.10% in the present study. Similar to earlier studies which reported
an average fall of 55% (38-73%) after ET in the pre-exchange value of
serum bilirubin [21,22]. The rebound phenomenon could be explained on
the basis of influx of tissue bilirubin to the blood circulation. This
was due to the stable fraction of serum bilirubin in the tissues which
equilibrates with the vascular compartment after ET [22] or it may be
new bilirubin from metabolised hemoglobin derived from damaged
erythrocytes.
Conclusion
There were significant adverse effects on all hemodynamic clinical
parameters. Monitoring of baby in the form of heart rate, respiratory
rate, blood pressure, SpO2, CVP, temperature, ECG, is essential during
ET where complications like apnea, congestive cardiac failure, cardiac
arrest, hypothermia, hypotension can be easily detected and treated
accordingly during procedure. Current recommendations for performing ET
are based on balance between the risk of encephalopathy and the adverse
events related to the procedure holds true [23].
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How to cite
this article?
Patil R, Kavthekar S, Patil N, Kurane A. Hemodynamic changes
during exchange transfusion in early neonatal period. J
PediatrRes.2017;4(04):275-280.doi:10. 17511/ijpr.2017.04.06.