Preparing for Apheresis Procedure: Red Blood Cell Exchange

Red blood cells (RBC) are cells in the blood that carry oxygen to all parts of the body. In diseases, such as sickle cell disease or in certain infections, red blood cells become abnormal or infected and cannot carry oxygen effectively. RBC exchange is used when it becomes necessary to remove abnormal red blood cells and replace them with healthy ones.

RBC exchange is done through a process called apheresis. During this process, some of your child’s blood is removed from their body through an IV (intravenous) needle, catheter, or special apheresis port in one arm, processed, then returned to the body through another line into the other arm. As the blood flows through the machine, it separates red blood cells from your child’s blood and exchanges them with red blood cells from healthy donors. In children with small or fragile veins, a central venous catheter may be placed in the chest to do this exchange.

An anticoagulant, or blood thinner, is added to keep the blood from clotting in the machine. The amount of blood that flows outside of your child’s body through the machine and tubing at any time during the procedure is about 1 cup.

The length of the procedure varies from child to child and depends on the amount of abnormal red blood cells that need to be exchanged. RBC exchange takes from 1 to 4 hours.

RBC exchange is a safe procedure, but side effects can occur. Common side effects include fatigue, nausea, dizziness, feeling cold, and tingling in the fingers and around the mouth. It is very important to tell medical staff if these symptoms occur. Serious problems such as allergic reactions to donor red blood cells and infections due to viruses such as hepatitis and HIV from donor blood can happen, but are extremely rare.

Starting 2 to 3 days before apheresis:

• Have your child eat calcium rich foods (like milk, yogurt and cheese). This will help lessen the side effects from the anticoagulant (citrate) used during the procedure.
• Have your child drink plenty of liquids before and after the procedure - at least 6 to 8 glasses a day. It makes it easier to find a vein when it’s puffy and well-hydrated if an IV is needed.
• Have your child eat a good meal before the procedure. The procedure is best tolerated with food in their stomach.
• Have your child dress in loose clothing and short sleeves to allow for access to catheter or arms if IV is needed.
• Ask your doctor about pain reducing cream or other type of local anesthetic placed on the skin before getting IVs or over your port. You can place this on your child at home 30 minutes before the procedure.

• A pre-medication may be necessary before getting an exchange (transfusion) if there is a history of previous reactions to blood products.
• Your child will have a heart monitor placed with stickers on the chest and will have vitals checked every half hour.
• Your child will be asked to use the restroom right before the procedure. If they need to pee during apheresis, a urinal or portable potty chair (commode) is
• Blood will be drawn for labs before, during and after the procedure using the same line used for the apheresis tubing (whether in the arm or central line).
• Your child can sleep, listen to music, watch TV, or play on an iPad during the procedure.
• If an IV is necessary, arm movements will be limited to prevent the IV catheter from getting dislodged.
• We cannot disconnect your child from the machine until the end of the procedure. Your child will not be able to get up and walk around during the collection.
• It’s fine for your child to eat and drink during the procedure. Ask your nurse about the hospital room service menu and how to order.
• In the unlikely event of the apheresis machine malfunction due to clotting the procedure might be stopped. This could result in blood loss. The amount of blood that flows outside of your child’s body at one time (through the machine and tubing) is about 1 cup.

• Your child can start their regular (light) activity and foods right away.
• The anticoagulant used during the procedure may put your child at risk for bleeding for up to 4 hours after apheresis. Have your child avoid rough play for this time period.
• If an IV was used, leave the bandage on for at least 4 hours. If you see bleeding at the site soaking through the bandage, apply fingertip pressure for 5 minutes and keep the bandage on for an additional 4 hours.

Although rare, sometimes there is a reaction to an exchange (transfusion). For the next few hours, watch for any of the following symptoms, which may signal that your child is having a reaction

• Shortness of breath or difficulty breathing — CALL 911
• Fever or chills
• Rash or itching
• Back pain below the ribs
• Nausea or throwing up
• Confusion or anxiety
• Dark or reddish urine
• Yellowing of the skin or eyes (this may be sign of delayed reaction if it happens days or weeks after the transfusion)
• A change in your child’s health that concerns you.

Activity precautions if your child was given a medicine that makes them groggy or sleepy: Keep watch for the next 4 to 6 hours or until the effects of the medicine have fully worn off. Your child may need help when walking. Supervise their activities to make sure they do not fall, ride a bike, drive a car or use dangerous machinery for at least 12 hours.