Finally.

Before the procedure, at 2 am.

This morning, I woke up feeling very exhausted. Sometimes I wish that I get at least one day off every week for me to replenish my energy store. I am still tired from my sleepless night on call. I have no leaves left because I am saving them for our umrah trip, insyallah next Wednesday.

But anyway, I am very grateful for the fact that I got to do at least one exchange transfusion (ET) for one of my patients during my last call, two nights ago. It was totally unexpected because none of my friends had briefed me about the case. The baby was about 4 days old, presented with high jaundice, 345 umol/L. Currently, I am in charge of the general pediatrics ward, so I had not known about it earlier. I only got to know about it when I went to the NICU for my on call. Luckily my MO told me about the case. She ran bolus once, and the repeat bilirubin was rising to 351 umol/L and it's obviously not responding to the intensive treatment. It's an indication to proceed with ET... yeay! Severe jaundice can cause kernicterus which can lead to neurological impairment later.

His parents consented the procedure so we started preparing at about 2 am. As soon as the fresh whole blood arrived, I inserted the umbilical vein catheter then proceeded with ET. Before that, I did solat hajat because it was my first time and I was praying that everything goes well, no immediate transfusion reaction or what so ever. And... alhamdulillah, everything went so well, the baby stayed quiet and slept all the time... well, except once when he started kicking and kicked off his UVC, but it was easy to place back the UVC.

The main concept of ET is that we exchange the blood that is full of unwanted bilirubin with a new blood. The amount for exchange is based on 160 ml/kg, so for that baby, we planned to exchange 560 ml of blood. His weight was 3.5 kg. All of the steps were written by the staff nurse assisting, I cannot imagine if the staff nurse didn't document everything because it can be very confusing. You have to alternately draw blood from the baby then transfuse the clean blood, it has to be same amount, and the rate of transfusion has to be steady because if you push the syringe too fast, the patient might became unstable hemodynamically... and that is why we have the vital signs monitor on all the time.

For the early cycles, I draw 10 ml from the baby within 1 minute, then I flush the "waste" into the waste bag, then I take 10 ml from the donor's blood (this has to be done in 1 minute) and transfuse into the patient within 1 minute. It is done through the umbilical vein catheter. So each cycle is 3 minutes and you have numerous cycles, that is why the whole process usually takes about 2 hours. It can be a bit confusing because you tend to forget whether you had just taken the blood out or into the baby, and that is why, the assisting nurse jots down what you just did. To be honest, during the whole process, I felt like I was my iPhone game, the Fruit Juice Tycoon because the game had something to do with manipulating pipes... just like what I did in ET, hihi! I told my mum that I was glad I played a lot of games because it made pick up skills like this very fast!!! :P

This is the rough idea of what ET is about.

Ok... ET was such a good experience although I literally fell asleep as I was slowly pushing the syringe slowly. But I am glad I got to do it. Alhamdulillah. I have 6 more days in pediatrics. After this I'll be in the O&G department insyallah.

Oh yeah, I forgot to tell that post-ET, the serum bilirubin went down to 101 umol/L. Alhamdulillah we managed to save a patient from having kernicterus and the other related complications. Hope the baby lives a meaningful life and a happy life too.