Blood exchange transfusion has become a rare event in most developed countries. As a result, many pediatricians may not have performed or even seen one. However, it remains a frequent emergency rescue procedure for severe neonatal hyperbilirubinemia in many underdeveloped regions of the world. Conventionally, exchange transfusion has been performed via a central umbilical venous catheter by pull-push cycle method and recently peripheral artery/peripheral vein has emerged as an alternative, isovolumetric route. Continuous arterio-venous exchange is possibly more effective though its automation has not been successful. Concerns for procedural and operator related adverse events have been raised in the context of declining indications. A required continued expertise for this life-saving intervention, in the face of rare but critical hyperbilirubinemia and/or unrecognized hemolytic diseases, deserves adaptation of newer technologies to make neonatal exchange transfusion a safer and more effective procedure. Technological innovations and simulation technologies are urgently needed.
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