A Transfusion Safety Technologist at a 380 bed community hospital in Mississauga, Ontario, Canada reports that at her hospital they currently treat 3 sickle cell patients with manual partial exchange transfusion in their outpatient hematology clinic. The patients usually receive 2-4 units of packed cells every 4 weeks. They are trying to develop a standardized nursing protocol for manual exchange transfusion throughout the hospital. The nursing staff in the hematology clinic is very familiar with the manual exchange process; however the inpatient nursing staff is not. This recently became an issue when a 4th exchange transfusion patient was admitted to ICU on a Friday evening requiring an urgent manual exchange. Since the hematology clinic is not open on the weekend there were no nurses in the hospital able to perform the procedure. The ICU nurse educator and the inquiring colleague are seeking information from other hospitals in order to create a comprehensive, easy to follow nursing protocol. They have researched a number of articles and texts on the management of sickle cell anemia patients and their current method of manual exchange seems (at least in their opinion) to be one that is commonly employed:

1. Bleed one unit (500mL) of blood from the patient, infuse 500mL of saline.
2. Bleed a second unit from the patient, infuse two units of blood.
3. Repeat steps 1 and 2; if the patient has a large red blood cell mass, repeat once more.

Workload and competency are the biggest concerns for inpatient nursing staff. The nurses will need to monitor the patients more frequently for hypovolemia. The inquiring colleague has been unable to locate any Canadian Hospitals who are currently treating Sickle Cell Patients with manual exchange transfusion. The few hospitals in Canada which do use exchange transfusion are larger teaching hospitals which use automated exchange transfusion (her hospital does not currently have this capability). Are there any community hospitals in the United States (or elsewhere) which have developed a comprehensive nursing protocol for manual exchange transfusion?

The following comments have been received.

ADDENDA Sept. 4, 2006

1. A clinical hematologist with years of experience treating patients with Sickle Cell Disease comments that the NIH monograph on the Management of SCD, published in 202 (4th ed) describes a procedure similar to that reported by the Canadian colleague who initiated this discussion:

1. Bleed 500 ml, give 500 ml saline
2. Bleed 500 ml, infuse 2 units packed RBCs
3. Repeat steps 1 & 2
4. Repeat steps 1 & 2 again for a large red cell mass

The monograph can be accessed at http://www.nhlbi.nih.gov/health/prof/blood/sickle/index.htm. The exchange info is in chapter 25 on transfusion.

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