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Automated method for exchange transfusion.

Radioimmunoassay has provided a safe, quick, sensitive clinical estimate of plasma digoxin levels in adults (Smith, Butler, and Haber, 1969; Chamberlain et al., 1970) and in children (Coltart, Cree, and Howard, 1972). Therapeutic plasma levels are between 1 and 2 ng/ml. However, these levels are estimated at least 6 hours after administration of the drug when full equilibration has taken place between tissue stores and plasma. The pharmacodynamics of digoxin in children have been previously described by Hernandez and his colleagues (1969) using tritiated digoxin. The high plasma levels obtained in this study are due, at least in part, to the fact that the samples were taken before full equilibration had taken place. Though between 220 and 440 ml of blood were exchanged, when digoxin concentrations were between 1 * 3 ng/ml and 12 ng/ml, the digoxin levels were maintained, presumably by re-equilibration of the plasma with the large tissue stores of the drug. A similar situation has been found in adult patients undergoing cardiopulmonary bypass (Coltart et al., 1971), in which procedure the plasma is heavily diluted by the volume of blood priming the bypass machine. However, though no digoxin is administered on the day after surgery, these patients have a digoxin concentration identical with the preoperative figure. Thus in both exchange transfusion and cardiopulmonary bypass, the large tissue stores of digoxin not only limit any tendency for an acute fall in plasma concentration, but also allow a restoration of plasma level as re-equilibration occurs. Electrocardiographic changes during digoxin therapy in neonates in heart failure have been described (Levine and Blumenthal, 1962). Significant cardiographic changes including arrhythmias have been noted during exchange transfusions (Van Praagh, 1961). Monitoring was used during all exchanges in this study and no significant changes were seen.