Procedure for manual EBT in an LMIC setting
| Pre procedure | 1. Blood tests: Complete blood count, reticulocytes, lactose dehydrogenase, biochemistry, HbS percentage. 2. Blood: 6-8 cross-matched units of HbS-negative, <7 day-old PRBCs, ABO, Rh D compatible. Calculate the number of units of PRBCs to exchange as follows: • If Hb >8.0 g/dL, 4-8 units • If Hb 6.0-7.9 g/dL, 4-6 units • Hb <6.0 g/dL, up to 4 units 3. High flow venous access: standard femoral line or large vein cannula if patient has inaccessible large bore veins. Blood can be aspirated from the line using 20-50-mL syringes, which can be counted before discarding. The patient should lie in the left lateral position or sit upright during the procedure to prevent compression of the inferior vena cava by the weight of the pregnant uterus. |
| Procedure | 1. Run 500-mL normal saline infusion 15-30 min to ensure hydration before the procedure. 2. Set up the blood to be transfused before the venesection and warm the blood prior to transfusion to avoid hypotensive emergencies. 3. Venesection—removing 450-500 mL of blood over approximately 15-30 min. 4. Close monitoring of blood pressure, heart rate, temperature, and SpO2 is mandatory as follows: o Before and after removal of every unit of blood o Before and 15 min into the transfusion of each unit of blood o And as clinically indicated For Hb ≥8.0 g/dL (Day 1) Venesect first unit while infusing 500 mL of normal saline. Venesect second unit, then transfuse first unit PRBC over 30-40 min. Venesect third unit, then transfuse second unit over 1 h. Venesect fourth unit, then transfuse third unit over 2 h. Infuse additional N/S to ensure overall fluid balance throughout the procedure. Day 2 Check FBC and HbS level. Assess clinically; if unsatisfactory improvement and/or insufficient reduction in HbS level, proceed as follows: • If Hb <9.0 g/dL, transfuse fourth and fifth units (over 3 h each) • If Hb >9.0 g/dL, repeat the red cell exchange from venesect first unit For Hb 6.0-7.9 g/dL (Day 1) Venesect first unit, then transfuse first unit. Venesect second unit, then transfuse second, third, and fourth units. Day 2 Check FBC and HbS level. Assess clinically; if unsatisfactory improvement and or insufficient reduction in HbS, repeat the red cell exchange using the Hb level obtained. For Hb <6.0 g/dL Top off transfusion. Each unit should be transfused over 90 min to 3 h, depending on clinical condition, to Hb >8-10 g/dL (more slowly when cardiovascular instability or renal abnormalities are present). Day 2 Check FBC and HbS level. Assess clinically; if unsatisfactory improvement and or insufficient reduction in HbS, EBT using the Hb level may be required. |
| Post procedure | Hb level or PRBC volume and HbS level must be obtained after each exchange procedure. Do not exceed an Hb level of 10 g/dL or PCV of 33% if HbS is more than 30% because of risk of hyperviscosity. Continue close observation. |
| Pre procedure | 1. Blood tests: Complete blood count, reticulocytes, lactose dehydrogenase, biochemistry, HbS percentage. 2. Blood: 6-8 cross-matched units of HbS-negative, <7 day-old PRBCs, ABO, Rh D compatible. Calculate the number of units of PRBCs to exchange as follows: • If Hb >8.0 g/dL, 4-8 units • If Hb 6.0-7.9 g/dL, 4-6 units • Hb <6.0 g/dL, up to 4 units 3. High flow venous access: standard femoral line or large vein cannula if patient has inaccessible large bore veins. Blood can be aspirated from the line using 20-50-mL syringes, which can be counted before discarding. The patient should lie in the left lateral position or sit upright during the procedure to prevent compression of the inferior vena cava by the weight of the pregnant uterus. |
| Procedure | 1. Run 500-mL normal saline infusion 15-30 min to ensure hydration before the procedure. 2. Set up the blood to be transfused before the venesection and warm the blood prior to transfusion to avoid hypotensive emergencies. 3. Venesection—removing 450-500 mL of blood over approximately 15-30 min. 4. Close monitoring of blood pressure, heart rate, temperature, and SpO2 is mandatory as follows: o Before and after removal of every unit of blood o Before and 15 min into the transfusion of each unit of blood o And as clinically indicated For Hb ≥8.0 g/dL (Day 1) Venesect first unit while infusing 500 mL of normal saline. Venesect second unit, then transfuse first unit PRBC over 30-40 min. Venesect third unit, then transfuse second unit over 1 h. Venesect fourth unit, then transfuse third unit over 2 h. Infuse additional N/S to ensure overall fluid balance throughout the procedure. Day 2 Check FBC and HbS level. Assess clinically; if unsatisfactory improvement and/or insufficient reduction in HbS level, proceed as follows: • If Hb <9.0 g/dL, transfuse fourth and fifth units (over 3 h each) • If Hb >9.0 g/dL, repeat the red cell exchange from venesect first unit For Hb 6.0-7.9 g/dL (Day 1) Venesect first unit, then transfuse first unit. Venesect second unit, then transfuse second, third, and fourth units. Day 2 Check FBC and HbS level. Assess clinically; if unsatisfactory improvement and or insufficient reduction in HbS, repeat the red cell exchange using the Hb level obtained. For Hb <6.0 g/dL Top off transfusion. Each unit should be transfused over 90 min to 3 h, depending on clinical condition, to Hb >8-10 g/dL (more slowly when cardiovascular instability or renal abnormalities are present). Day 2 Check FBC and HbS level. Assess clinically; if unsatisfactory improvement and or insufficient reduction in HbS, EBT using the Hb level may be required. |
| Post procedure | Hb level or PRBC volume and HbS level must be obtained after each exchange procedure. Do not exceed an Hb level of 10 g/dL or PCV of 33% if HbS is more than 30% because of risk of hyperviscosity. Continue close observation. |
FBC, full blood count; PCV, packed cell volume.