Manual exchange blood transfusion protocol

This guidance for health professionals from Great Ormond Street Hospital (GOSH) is on manual exchange blood transfusion protocol.

The complications of sickle cell disease and their prevention including acute chest syndrome, stroke and multi-organ failure constitute the commonest group of disorders for which exchange transfusion is indicated.

Red cell exchange transfusion may also be undertaken for other indications, including:

  • Haemolytic disease of the newborn with hyperbilirubinaemia and/or anaemia.

  • Polycythaemia (haematocrit (Hct) >65%).

  • Severe malaria (parasitaemia >10%).

  • The inadvertent administration of RhD positive blood components to RhD negative individuals.

  • Some cases of drug toxicity (as advised by the National Poisons Information Service).

  • Hyperleucocytosis eg pertussis, AML.

Usually the aim of exchange transfusion is to remove red cells but since whole blood is drawn white cells, platelets and plasma are also removed (hence use in hyperleucocytosis).

Apheresis is also available at GOSH, however in PICU or NICU emergency manual exchange transfusion will be undertaken in the above circumstances.

Irrespective of the indication, it is important that the procedure is iso-volumetric so that the circulating volume is stable throughout the procedure (Rationale 1), that it is performed by experienced staff who are familiar with the procedure and that it is undertaken following discussion with the responsible consultant.

Background

The indication for exchange transfusion will determine the volume of blood to be exchanged. Thus, a partial exchange, single volume or double volume exchange may be required.

Normal circulating volume at different ages and gestation

  • premature infants - 90-100ml/kg

  • term infants - 80-90ml/kg

  • infants over three months of age and children - 70ml/kg

This guideline is appropriate for infants, children and young people who weigh under 50kg. For individuals weighing more than 50kg an exchange transfusion will be calculated in units of blood rather than mls/kg.

Different specifications of red cell components are available for use in neonates and children in the UK requiring transfusion (see Appendix 1). These guidelines are to be read in conjunction with the Blood Transfusion Policy, available internally to GOSH staff on the intranet.

Be aware that parents may be unwilling for their child to be transfused for a variety of reasons, including religious or cultural views. Approach the subject sensitively and discuss with the consultant if there is refusal.

Types of manual exchange transfusion

Single volume exchange transfusion (SVET)

Volume exchanged - single circulating blood volume (check age and gestation) 70-100mls/kg.

Duration - two hours.

Double volume exchange transfusion (DVET)

Volume exchanged - 2 x circulating blood volume (check age and gestation) 140-200mls/kg.

Duration - two to four hours. 

Exchange transfusion for sickle cell disease

Volume exchanged 1.5-2 x red cell volume 40-50mls/kg.

Duration - two to four hours.

Partial exchange transfusion for polycythaemia

Volume exchanged (ml) = (Weight in kg) x (blood volume) x (Hct of patient - Hct desired) divided by Hct of patient.

Duration - two hours.

Replacement fluids

Red cells for transfusion have a haematocrit between 0.5-0.7, whilst the desired final haematocrit of the child should be <0.45 in most circumstances.

Thus, replacement fluid usually 0.9% saline or sometimes 4.5% human albumin solution (HAS) is given as well as red cells in a ratio that will give an overall HCT of 0.45.

Volume of replacement fluid (ml) = volume of red cell unit (ml) x (Hct of unit - Hct desired) divided by Hct desired.

Example:

Unit of red cells contains 240mls and Hct is 0.6; desired Hct is 0.45.

Volume of HAS or saline (mls) = 240 x (0.6 - 0.45) = 80mls of replacement fluid divided by 0.45.

Acute complications of exchange transfusion

  • Fluid overload which may require diuretic therapy (Rationale 2).

  • Metabolic disturbances, such as hyperkalaemia associated with tall, peaked T waves and arrhythmias on ECG or metabolic acidosis especially in small or critically ill children; both require correction.

  • Citrate toxicity, which causes hypocalcaemia leading to paraesthesia and rarely tetany, especially following neonatal exchange transfusion as these red cells are suspended in CPD (citrate, phosphate and dextrose). Tachycardia, U waves and increased QT interval can be seen on ECG. A calcium infusion (1-2ml/kg of 10% calcium gluconate given slowly via a central line) may be required to correct hypocalcaemia. Hypomagmesaemia may also occur. 

  • Hyperkalaemia, which is worsened by hypocalcaemia, may occur and cause cardiac arrythmias, with peaked T waves requiring calcium infusion (1-2ml/kg of 10% calcium gluconate given slowly via a central line). 

  • Rebound hypoglycaemia following transfusion (30 minutes to two hours) as the glucose content within the blood may stimulate insulin secretion.

  • Hypothermia, especially in neonates; ensure that transfused blood is warmed (Rationale 3).

  • Anaphylactoid reactions requiring adrenaline, antihistamine +/- coticosteroid.

  • Hypotension due to other causes such as hypovolaemia, or underlying sepsis.

  • Hypertension (if the diastolic rises by >20mmHg, slow down transfusion and stop if diastolic continues to rise or >100mmHg). In children with sickle cell disease, check full blood count (FBC) to ensure that haemoglobin (Hb) is <120g/L and Hct <0.40.

  • Hyperviscosity especially in those with sickle cell disease or hyperleucocytosis.

  • Fitting (rare, but can occur as a result of hyperviscocity) in patients with sickle cell disease if Hb is allowed to rise to >120g/L (or Hct >0.40) whilst there is a significant amount of HbS in the circulation. May also occur with cerebral involvement by malaria and requires anticonvulsant therapy. 

  • Line complications including infection and thrombo-embolism.

  • Thrombocytopenia especially following large volume exchanges (Rationale 4); a platelet transfusion may be required to maintain platelet count at acceptable levels in critically ill infants.

  • Arrhythmia.

  • Coagulopathy, which may require correction with octaplas and/or cryoprecipitate (Rationale 5). 

  • Necrotising enterocolitis (NEC). Rapid withdrawal of blood from a umbilical venous catheter (UVC) induces negative pressure that may be transmitted to mesenteric veins, which may contribute to NEC.

Inform Blood Transfusion Laboratory if any reaction to a blood transfusion occurs (ext 8527) or out of hours bleep the biomedical scientist on call (bleep 0590).

Process for exchange transfusion

Preliminary investigations

FBC, blood group, antibody screen and crossmatch, HbS% (HbS percentage) in sickle cell patients, urea and electrolytes (U&Es), liver function tests (LFTs), calcium (Ca2+), arterial blood gas (ABG), clotting studies.

Procedure

Isovolumetric method (preferred method)

  • Equipment:

    • Syringes (5ml, 10ml, 20ml, 50ml), needles and three-way tap.

    • 0.9% saline or 4.5% human albumin solution, heparinised saline and Hepsal flushes.

    • High flow infusion pump, IVAC and IV giving sets.

    • Blood giving set, with a warming coil for neonates (Rationale 3 and 6). 

    • Paediatric venesection bag(s), available from Blood Transfusion, and sharps bin.

  • Slow removal of aliquots <5ml/kg from an arterial line, central or peripheral (or central venous) line and simultaneous continuous infusion into a vein, central or peripheral.

  • If a venous line is used for withdrawing blood then a different one should be used for blood infusion.

  • A meticulous record of input and output must be maintained to ensure isovolaemia.

  • Monitor pulse and blood pressure every 15 minutes unless continuous cardiorespiratory monitoring is available; check temperature every hour.

This method should not cause fluctuations of blood volume and pressure. 

  1. Commence infusion of blood at predetermined rate (two to four hours) through venous line.
  2. Arterial line needs three-way tap attached.
  3. Peripheral arterial line needs to have heparinised saline syringe attached to end of three-way tap (Rationale 7).
  4. Turn three-way tap on to child. Slowly aspirate predetermined aliquot (dependent on age and size of child or infant) into syringe. Do not stop movement of flow when using a peripheral arterial line. 
  5. Turn the three-way tap off to the child and discard blood into venesection bag, available from Blood Transfusion.
  6. Heparinised saline should run between cycles through arterial line at 0.5-1ml/hour. 
  7. Repeat blood removal from arterial/central/peripheral venous line every 15 minutes, ensuring at all times that the volume being removed roughly keeps pace with volume being replaced by pump.
  8. Rapid changes in blood volume may cause hypotension, cardiac arrhythmias, hypoxia and metabolic instability.
  9. Check clotting halfway through procedure if performing a DVET and if abnormal treat with octoplas and or cryoprecipitate.
  10. Procedure usually takes 90-120 minutes (SVET) or two to four hours (DVET).

Post exchange transfusion

Check:

  • FBC.

  • Coagulation studies.

  • U&Es including calcium and magnesium.

  • LFTs.

  • Blood gas and glucose.

  • Continuous cardiorespiratory monitoring on intensive care unit or at least four-hourly observations.

  • Observe appearance of abdomen in neonates for 24-48 hours and consider keeping infant Nil By Mouth for four hours post exchange (Rationale 8).

  • When using an umbilical arterial or venous line inspect toes, feet and buttocks for signs of circulatory compromise.

Sickle cell disease

Indications for emergency exchange transfusion in sickle cell disease

  • Acute cerebrovascular accident (stroke). 

  • Acute sickle chest syndrome resulting in respiratory failure (clinically defined as an increasing oxygen requirement in a tiring child). 

  • Non-resolving mesenteric ('girdle') syndrome - silent, distended abdomen. 

  • Multi-organ failure. 

  • Fulminant priapism lasting >4 hours despite other measures.

(CVA and acute chest syndrome are the commonest reasons for PICU admission.)

Elective indications in sickle cell disease

Exchange transfusion may be undertaken electively in preparation for a planned surgical procedure to reduce the risks of surgery/anaesthesia or to improve its outcome. Elective transfusions are, as a rule, performed by the local hospital prior to admission to GOSH.

Partial exchange transfusion - manual or automated - may be required to achieve optimum Hb and/or HbS levels.

Aims of exchange transfusion in sickle cell disease

  • To reduce HbS to <30% to prevent further vaso-occlusion; if the child is a double heterozygote, the combined abnormal haemoglobins need to be reduced to <30% eg HbS + HbC.

  • To improve oxygen-carrying capacity.

  • To correct anaemia and achieve a final Hb < or = 120g/L.

Initial investigations

  • FBC.

  • Group, antibody screen and crossmatch (2ml blue top EDTA sample). 

  • Ensure that the Blood Transfusion Laboratory is aware that the blood is required for a child with sickle cell disease, and they will provide ABO, Rh and K compatible (Rationale 9), HbS negative red cells. An extended red cell phenotype is usually requested in the first year of life and should be available from SpICE or the Blood Transfusion Laboratory at the local hospital. 

  • An HbS percentage is required before exchange transfusion only if the child has been transfused within the preceding four months (Rationale 10). This can be performed out-of-hours in exceptional circumstances, discuss with the on-call haematology biomedical scientist (bleep 0596) and the laboratory haematology SpR (available via switchboard).

Volume

  • A total exchange of 1.5-2 times a child's red blood cells volume is required. Whole blood is withdrawn and this is replaced by packed red cells and normal 09.% saline.

  • Volume of blood to be requested from Blood Transfusion in mls = 50 x weight (kg)
    Important considerations for procedure in sickle cell disease patients.

  • If Hb <60g/L start by transfusing 5ml/kg red cells then proceed to venesection (Rationale 11).

  • If Hb >60g/L start by giving a bolus of 10ml/kg of normal saline, then proceed to venesection.

  • Venesect 30ml/kg and replace with 20ml/kg of red cells in the first cycle. This process should take about 120 -180 minutes, depending on the rate of flow of blood and the clinical condition of the patient.

  • Check FBC midway through the exchange.

  • Do not routinely use diuretics (Rationale 12).

  • In the second and subsequent cycles, 30ml/kg of red cells should be venesected and replaced by 15ml/kg of red cells. Thus in total, 60ml/kg is venesected and replaced with 35ml/kg of red cells plus 25ml/kg of saline. However, if the starting Hb is >100g/L further vensection will be required.

  • It is important that the final Hct does not exceed 0.4.

Post exchange transfusion

  • If the final Hb >120g/L and/or Hct >0.4, venesection will be required (where venesecting 5mls/kg will reduce the haemoglobin by 10g/L). 

  • If final Hb <90g/L, further transfusion will be required (where transfusing 4ml/kg will increase the haemoglobin by 10g/L).

  • HbS percentage aiming for <30% if homozygous (HbSS) or <15% in double heterozygote. If this has not been achieved after the second cycle, please discuss with the laboratory Haem SpR to discuss whether a parial axchange transfusion or top-up transfusion is required.

  • Monitor arterial blood gases where acute chest syndrome is the indication for exchange transfusion (Rationale 13).

  • Monitor neurological status where stroke or other neurological complications are the indication for exchange transfusion.

Where there is a single site of vascular access available, the exchange is performed sequentially.

'Push and pull' method

  • If the Hb <60g/L start by transfusing 5ml/kg red cells then proceed to venesection (Rationale 11).

  • If the Hb >60g/L, give a bolus of 10ml/kg of normal saline, then venesect 10ml/kg in aliquots of 10-50ml.

  • Transfuse 5ml/kg of red cells over 30-45 minutes.

  • Venesect a further 10ml/kg, then transfuse 10ml/kg red cells over 90 minutes.

  • Give a further bolus of 5ml/kg normal saline, then venesect 10ml/kg.
    Transfuse 5ml/kg red cells over 30-45 minutes.

  • FBC to check Hb, if Hb <60g/L transfuse 5ml/kg red cells (Rationale 11).

  • Give a bolus of 5ml/kg of normal saline.

  • Venesect 10ml/kg, then transfuse 5ml/kg of red cells over 30-45 minutes.

  • Venesect a further 10ml/kg, then transfuse 5ml/kg red cells over 30-45 minutes.

  • Give a bolus of 5ml/kg of normal saline, then venesect 10ml/kg.

  • Transfuse 10ml/kg red cells over 90 minutes.

Neonates

Haemolytic disease of the newborn

With the introduction of routine antenatal anti D prophylaxis, severe Haemolytic Disease of the Newborn (HDN) requiring exchange transfusion is uncommon (Rationale 14).

However, HDN may occur in mothers who are already sensitised, or may be due to ABO incompatibility or antibodies against other red cell antigens.

Aims of exchange

  • To prevent kernicterus due to hyperbilirubinaemia (Rationale 15).

  • To correct severe anaemia.

  • To remove antibody-coated red cells.

Initial investigations

  • FBC, U&Es, LFTs, Calcium (Ca2+). 

  • Blood glucose.

  • Arterial blood gas.

  • Blood Group (ABO and RhD typing) and antibody screen- ensure that the Blood Transfusion Laboratory is aware that the blood is required for a neonatal exchange transfusion and they will supply irradiated, CMV negative neonatal red cell.

  • Maternal crossmatch sample for blood group, antibody screen and indirect antiglobulin test.

Vascular access

  • An umbilical venous catheter and/or umbilical arterial catheter is preferred, but peripheral arterial and venous lines can be used.

  • Volume of blood required (mls) = 160-200 x weight (kg). 

  • Check age and gestation.

Important considerations

  • A double volume exchange will remove 90% of the initial red cells and 50% of the intravascular bilirubin.

  • A single volume exchange will remove 75% of red cells and this may be performed when severe anaemia with heart failure is the main problem, rather than hyperbilirubinaemia.

  • The exchange transfusion should be carried out by experienced staff who are familiar with the procedure in NICU.

  • Continuous maximum phototherapy should be given throughout the procedure (NICE Guidance CG98 2010 updated August 2014). 

  • Ensure adequate hydration throughout the process.

  • The infant should be Nil By Mouth and and procedure will take two to four hours depending on the size of the child and their clinical stability.

  • Inspect toes, feet and buttocks for signs of circulatory compromise, if using umbilical arterial or venous catheter.

  • Check FBC, Bilirubin, arterial blood gas midway through the exchange.

Post exchange transfusion

  • Investigations after exchange transfusion - FBC, LFTs, Bilirubin, U&Es, Ca2+ , blood glucose within two hours. 

  • Phototherapy should be resumed until satisfactory fall in bilirubin is achieved and sustained (Rationale 16). 

Dilutional partial exchange transfusion in neonates for polycythaemia

Neonatal polycythaemia may manifest as jitteriness, hypoglycaemia or apnoea, or may be asymptomatic. It is more likely to occur in infants with placental insufficiency, infants of diabetic mothers, twin-twin transfusion and those with trisomy 13, 18 or 21.

Aim of a partial dilutional exchange transfusion

  • To prevent hyperviscosity which may be associated with sludging in small vessels, thrombosis or bleeding.

  • To reduce Hct to 55%.

Indications for dilutional exchange transfusion in neonates

  • Recommended if Hct >75 even if the infant is asymptomatic.

  • Consider if Hct 65-74 and symptomatic.

Initial investigations

FBC including Hct, U&Es, LFTs, Ca2+, blood glucose.

Vascular access

  • An umbilical venous catheter and/or umbilical arterial catheter is preferred, but peripheral arterial and venous lines can be used.

Volume exchanged (ml) = (Weight in kg) x (blood volume) x (Hct of patient - Hct desired) divided by Hct of patient.

Using 85ml/kg for a term infant and 95ml/kg for a preterm infant.

Important considerations

  • The calculated volume of 0.9% Saline or 4.5% human albumin solution (consultant preference) can be infused constantly through one line whilst aliquots of 5ml (if <2.5kg) or 10ml (if >2.5kg) of blood are removed every five to 10 minutes, via the other line.

  • SVET over one to two hours dependent on stability of patient.

  • Monitor pulse, blood pressure, oxygen saturations and respiratory rate throughout the procedure.

  • Inspect toes, feet and buttocks for signs of circulatory compromise, if using umbilical arterial or venous catheter.

  • After procedure, recheck FBC and Hct, and ensure ongoing adequate hydration (Rationale 17).

Pertussis

In severe pertussis infection in infants under 90 days of age there is a high mortality in those with severe leucocytosis and pulmonary hypertension. Exchange transfusion can be considered after discussion with the duty consultant.

The aim of exchange transfusion is:

  • To reduce leucocytosis and thrombus formation. 

  • To improve oxygenation.

  • To prevent progression to cardiogenic shock.

Indications for exchange transfusion in pertussis infection in infants

  • Recommended if white cell count (WBC) >100 x 109/l even if child has little or no organ failure.

  • Consider if WBC 70-100 and evidence of worsening respiratory failure.

  • Consider if WBC >50 and echocardiographic evidence of pulmonary hypertension.

Initial investigations

  • FBC, U&Es, LFTs, Ca2+, clotting, blood glucose. 

  • Extended T cell subsets (but should not unduly delay exchange). 

  • Blood Group (ABO & RhD typing) and antibody screen. Ensure that the Blood Transfusion Laboratory is aware that the blood is required for an infant receiving exchange transfusion and they will issue CMV negative and irradiated red cells if patient <6 months post EDD).

  • Optimal practice is to perform an echocardiogram but should not unduly delay exchange.

Volume of blood to be requested (mls):

  • 160 x weight (kg) for a term infant.

  • 200 x weight (kg) for a premature infant.

Important considerations

  • There are a number of published case reports showing improvement following a double volume exchange transfusion (Romano et al 2004; Rowlands et al 2010).

  • The exchange transfusion should be carried out by experienced staff who are familiar with the procedure for PICU.

  • Each aliquot is 10-20mls and each cycle of withdrawal of blood and replacement of blood is performed over three to five minutes.

  • Continuous cardiopulmonary monitoring is required. Also monitoring temperature every 30 minutes.

Investigations after exchange transfusion

  • FBC, U&Es, Ca2+, clotting, blood glucose.

  • Repeat echocardiogram the following day (Rationale 18).

Malaria

In severe infection with plasmodium falciparum malaria, there is a high mortality in those with a high parasitic load, multi organ failure and disseminated intravascular coagulation.

Antimalarial drug therapy, together with supportive treatment, is the mainstay of therapy but in certain circumstances exchange transfusion therapy may be considered as an adjuvant therapy.

The aim of exchange transfusion is:

  • To reduce parasitic load.

  • To reduce toxaemia.

  • To correct anaemia and increase oxygen-carrying capacity.

Indications for exchange transfusion in malaria

  • Consider if parasitaemia >10% and multi organ failure.

  • Consider if parasitaemia >10% and not repsonding to antimalarial drug therapy.

  • Consider if parasitaemia >30%.

Initial investigations 

  • FBC, U&Es, Ca2+, blood glucose.

  • Clotting screen, fibrinogen, D-dimers.

  • Malerial thick and thin blood films for parasitaemia levels.

  • Blood Group (ABO & RhD typing) and antibody screen - ensure that the Blood Transfusion Laboratory is aware that the blood is required for a child receiving exchange transfusion (blood will be CMV negative and irradiated if patient < 6 months post EDD)

Volume of blood to be requested (mls):

  • 80 x weight (kg) for a single volume exchange.

  • 160 x weight (kg) for a double volume exchange.

Important considerations

  • There are a number of published case reports showing improvement following a single or double volume exchange transfusion (Rowland et al 2010; Boctnor 2005). 

  • The exchange transfusionm should be carried out by experienced staff who are familiar with the procedure in PICU (Lalloo et al 2007). 

  • The procedure will take two to four hours depending on the size of the child and their clinical stability.

  • Each aliquot is 10-20 mls. 

  • Continuous cardiopulmonary monitoring is required. Also monitor temperature every 30 minutes.

Investigations after exchange transfusion

  • FBC, U&Es, Ca2+, clotting and blood glucose.

  • malerial thick and thin blood films for parasitaemia levels.

Inadvertent administration of RhD positive red cells to an RhD negative female of child bearing potential

  • The antigens of the Rh blood group system are highly immunogenic, and thus administration of small amounts of RhD positive red cells to a RhD negative child can lead to alloimmunisation with implications for future pregnancies in women (Rationale 19).

  • Urgent treatment is required and the preferred treatment will depend on the volume of blood transfused. Advice on management of the patient should be sought from the Consultant Haematologist responsible for transfusion who can discuss with an NHSBT medical consultant.

  • Suppression of alloimmunisation can be achieved with administration of anti-D immunoglobulin.

  • When a large volume of inappropriate red cells has been transfused, an emergency exchange transfusion might be considered (Nester et al 2004). However, a number of points need to be taken into consideration and discussed with the child and family, such as the advantages and disadvantages of exchange blood transfusion versus no intervention, the clinical state of the child and initial indication for blood transfusion.

  • A single volume exchange removes 65-70% of RhD positive red cells and a double volume exchange will remove 85-90% of red cells.

  • Following exchange transfusion, the residual volume of RhD positive red cells should be estimated and intravenous anti-D immunoglobulin administered. Thereafter anti-D immunoglobulin may be detectable for up to six months or more and so tests for immune anti-D may not be conclusive for nine to 12 months. The removal of these cells from the patient’s circulation can be monitored by flow cytometry at NHSBT. 

Rationale

Rationale 1: To prevent fluctuations in blood volume and pressure.
Rationale 2: To prevent cardiac failure.
Rationale 3: Red cells are stored at 2-6oC. Infusion of large volumes of red cells may cause hypothermia.
Rationale 4: Due to dilution.
Rationale 5: To prevent hypothermia.
Rationale 6: To maintain patency of arterial line.
Rationale 7: To maintain haemostasis.
Rationale 8: Abdominal distension and tenderness occurs with necrotising enterocolitis.
Rationale 9: To reduce alloimmunisation.
Rationale 10: If there has been no recent transfusion, the HbS will be approximately 90% in a homozygous individual; combined abnormal haemoglobins will be approximately 90% in a double heterozygote.
Rationale 11: To prevent hypovolaemia.
Rationale 12: Dehydration may worsen sickle cell complications.
Rationale 13: Hypoxia is one of the hallmarks of acute chest syndrome, and can progress to respiratory failure.
Rationale 14: Haemolytic disease of the foetus/newborn is most commonly caused by sensitisation to the RhD antigen in RhD negative women during pregnancy, but most women in the UK receive routine antenatal anti D prophylaxis to prevent sensitisation.
Rationale 15: Extremely high levels of bilirubin can cross the immature blood brain barrier, causing damage to the developing brain, known as kernicterus.
Rationale 16: Phototherapy aids elimination of bilirubin in the neonate.
Rationale 17: Dehydration increases the heamatocrit.
Rationale 18: To monitor degree of pulmonary hypertension.
Rationale 19: Women may then be at risk of haemolytic disease of the foetus/newborn during pregnancy due to the production of anti D antibodies.

References

Reference 1:
NICE guidance CG98 (2010 updated August 2014) Neonatal Jaundice. NICE guidance CG98: CG98.

Reference 2:
Romano MJ, Weber MD, Weisse ME, Siu BL (2004) Pertussis pneumonia, hypoxia, hyperleukocytosis and pulmonary hypertension: improvement in oxygentation after a double volume exchange transfusion. Paediatrics 114(2): e264-6.

Reference 3:
Rowlands HE, Goldman AP, Harrington K, Karimova A, Brierley J, Cross N, Skellett S and Peters MJ (2010) Impact of Rapid Leucodepletion on the Outcome of Severe Clinical Pertussis in Young Infants. Paediatrics 126(4): e816-27. Epub 2010 Sep 6.

Reference 4:
Boctor FN (2005) Red blood cell exchange transfusion as an adjunct treatment for severe paediatric falciparum malaria, using automated and manual procedures. Pediatrics 116(4): 592-5.

Reference 5:
Lalloo DG, Shingadia D, Pasvol G, Chiodini PL, Whitty CJ, Beeching NJ, Hill DR, Warrell DA, Bannister BA (2007) UK malaria treatment guidelines. Journal of Infection 54(2): 111-21.

Reference 6:
Nester TA, Rumsey DM, Howell CC, Gilligan DM, Drachman JG, Maier RV, Kyles DM, Matthews DC and Pendergrass TW (2004) Prevention of immunization to D+ red cells with red blood cell exchange and intravenous Rh.immune globulin Transfusion 44(12): 1720-23.

Reference 7:
Hennem S and Nulty H (2013) Great Ormond Street Hospital Blood Transfusion Policy. London, Great Ormond Street Hospital for Children NHS Foundation Trust.

Reference 8:
NHS Sickle Cell and Thalassaemia Screening Programme (2007) Quality Requirements for Health Services Caring for Children and Young People with Haemoglobinopathies.Viewed on: 26/10/2011.

Reference 9:
British Committee for Standards in Haematology (2004) Transfusion Guidelines for Neonates and Older Children. British Journal of Haematology 124(4): 433-53.

Document control information

Lead Author(s)

Marilyn Roberts-Harewood, Consultant Haematologist, Haematology

Additional Author(s)

Sophie Skellett, Consultant, Paediatric Intensive Care

Document owner(s)

Marilyn Roberts-Harewood, Consultant Haematologist, Haematology

Approved by

Hospital Transfusion Committee

Reviewing and Versioning

First introduced: 
27 July 2011
Date approved: 
11 December 2014
Review schedule: 
Two years
Next review: 
10 December 2016
Document version: 
4.0
Previous version: 
3.0