In this section
Apheresis is of Greek origin and means to
"take away". Plasmapheresis therefore means removal of plasma.
Plasma constitutes 55% of circulating blood
volume. The other 45% is formed elements, such as RBC's, WC's and
platelets. The components of plasma include:
Therapeutic Plasma Exchange (TPE) occurs when
the removed plasma is replaced or exchanged with a replacement
fluid, usually 4% albumin, FFP, or a combination of both. The
removal of autoantibodies, immune complexes, inflammatory mediators
and cytokines is the intended benefit of the procedure in the renal
TPE may be used for a variety of other non
renal diseases with Haematological and Neurological
Separation of plasma and whole blood may be
performed by filtration or by centrifugation.
The Fresenius 4008 haemodialysis machine is
used here at the Royal children's Hospital,
Melbourne, with adaptation and filters
specific to plasma exchange. The filters have pore sizes up to 0.5
micrometers allowing the passage of immune complexes.
A single plasma volume is approximately
50ml/kg. Therefore a double exchange, which is most common, is 100
ml/kg. The volume can also be calculated as follows:
As in Haemodialysis, the extracorporeal blood
circuit volume should not exceed 8% of the total blood volume,
calculated at 80 ml/kg. Blood prime will be required in some
circumstances, especially in small children (<20kg).
Blood line volumes for the Fresenius machine
Paediatric: Arterial 59ml
Paediatric: Arterial 59ml
Sizes and priming volumes are:
PSu 1s-0.3m2 SA, 36ml priming volume.PSu 2s-0.6m2 SA, 70ml priming volume.LF-030-00 0.3m2 SA, 30ml
priming volLF-050-00 0.45m2 SA, 50ml
priming volPF 1000 N 0.15m2 SA, 23
ml priming volPF 2000 N 0.35m2 SA, 41
Units of Heparin
Units of Heparin
The above dosage guidelines may need
to be exceeded in patients with a low haematocrit or when the
plasmafiltration rate is high.
Filtration rate should commence
slowly- .2 ml/kg/min grading up to no more than .5 ml/kg/min when
When using 4% albumin, a faster rate
of isovolaemic exchange can be undertaken (eg 3 litre exchange over
The limitation to rate of exchange
when using FFP is due to the presence of 17% ACD, which is only
around 4% in albumin replacement.
4% Albumin is the most commonly used
replacement fluid, with FFP x1 or 2 units at the end of therapy to
minimize the risk of bleeding.
PICU uses an electrolyte balanced
replacement solution produced by RCH pharmacy - this is generally
not necessary for plasma exchange in the ambulatory care unit, but
may be prescribed in special circumstances at the discretion of the
IVIG may be ordered for
administration at the end of the exchange procedure.
Some disease such as HUS and TTP are
more effectively treated by using FFP as the replacement fluid.
Reactions to Albumin and FFP are not
uncommon, and it is recommended that patients known to react
receive Hydrocortisone and/or Promethazine or cetirizine
hydrochloride at the beginning of treatment.
All patients should have a PRN dose
written up at the bedside in case of a reaction.
Refer to Pharmacopeia for
procedure describes the process for Therapeutic Plasma Exchange (TPE) using the
Spectra Optia® Apheresis System.
procedure applies to all trained Apheresis Nurses who perform TPE to patients
under the care of The Department of Nephrology at The Royal Children’s Hospital
(RCH). Trained Apheresis Nurse refers to Div 1 Nurses who have been trained and
assessed to be competent in TPE using the Spectra Optia® Apheresis System.
Nurses who are undergoing apheresis tuition may also perform this procedure
under direct supervision of a trainer in accordance with unit policies and
is the responsibility of the Parent Unit
making the referral to;
is the responsibility of the Covering
Nephrologist or delegate to;
is the responsibility of the Apheresis
is the responsibility of the Quality
Manager (QM) or equivalent to ensure implementation, maintenance and
compliance with this procedure.
Blood Bank, RCH Laboratory Services
– Central venous catheter.
Therapeutic Plasma Exchange
Total Blood Volume, (<9.1kg-100mls/kg, 9.2-22.7kg-80mls/kg,
5. EQUIPMENT AND SUPPLIES
aim of the procedure is to separate out plasma from other components of blood,
removing the plasma (and with it disease mediators) and replacing it with a
replacement solution such as Normal Serum Albumin or Fresh Frozen Plasma.
for Plasma exchange include;
Pre Procedure Checks
Optia® Exchange Kit. Cat No: 10220
tubing blood volume
TBV ≤ 1,900 mL
patient’s pre procedure Hb, i.e. anaemia]
Check documentation and / or confirm with Nephrologist or
delegate, that the patient’s;
is complete, request for the procedure is valid, procedure medications are
charted, exchange blood products are available, consents and all investigations
are complete and valid.
The scheduled Plasma exchange procedure must be authorised
by the Nephrologist or delegate to proceed.
6.1 Machine Set-Up
Gather equipment (critical materials are “released” and stored in the
designated trolley) check and record all batch numbers, expiry dates and sign as
indicated on the Apheresis Procedure Record.
Prime the machine with 0.9%NaCl and complete alarm testing. This step must be
completed prior to setting up the blood prime equipment. Check primary priming
6.2 Pre Plasma Exchange
The Apheresis Nurse will explain the procedure to the patient according to the
age and development level and to the parent / caregiver.
Complete a Blood Bank Release Order requesting exchange solution. Request FFP
or albumin solution as applicable, when procedure underway (Blood Bank Ext:
Ensure that the patient has been assessed and any applicable clinical care
management and medication orders have been completed. Administer Pre Meds[BC2] as charted. [Pre Meds include Zyrtec,
Ensure that baseline investigations have been done- FBE (Check that Hb is acceptable,
note HB maybe corrected with blood prime and transfusion of remaining unit over
course of treatment), Albumin (28g/L or higher) and ionised Ca2+ are
a minimum. If testing has not been requested, organise specimens and request, marked
URGENT according to Laboratory
Document baseline observations (Temperature, Pulse, Respiration, Blood
Pressure, and SaO2) and machine calculations of total blood and
plasma volumes according to the child’s height and weight.
Report ANY abnormal baseline
investigations or observations to the Nephrologist or Delegate and treat
patient has documented previous transfusion reactions, consider and discuss
with doctor pre medication.
Check blood products according to organisational requirements RCH Clinical
Guideline. Blood Transfusion – Administration of Fresh Blood Products [cited 2014 Dec 19]. Available from: http://www.rch.org.au/rchcpg/index.cfm?doc_id=9905
6.3 Blood Prime
Set up the blood prime equipment using aseptic technique; ensure that all clamps are closed before attaching the
unit of crossmatched packed red blood cells.
NOTE: For Blood Prime using ARCBS Packed
Cells, use Haematocrit value of 0.60. No predilution, of the packed cells is
Connect the blood to the machine access line.
Attach a blood warmer set and an empty waste collection bag to the end of the
When prompted, on the Spectra Optia,
select “custom prime” to divert the saline instead of connecting the access line
to the donor.
Follow the machine prompts to enter data for the “custom prime”.
Continue priming with the “custom prime” until the blood has primed the return
line as far as possible.
When the “custom prime” is complete, remove “custom prime set-up” from the
access and return lines. The machine access and return lines are now available
to be connected to the donor. If there is a delay in commencing the procedure,
seal lines with sterile caps.
Turn on rinse back facility as it is turned off when custom prime is selected.
6.4 Connecting the Patient
Prepare the patient for connection; check that the dressing trolley has all
required equipment. Using aseptic technique clean both Vascath/Permcath ends
with chlorhexidine solution, obtain blood return to confirm patency of the
Vascath/Permcath and take blood for ANY
outstanding blood testing. Flush both lumens with 5-10mls each of 0.9% NaCl. If there is doubt of correct placement or
adequacy of line placement, notify the Nephrologist or delegate for review.
Document outcome in the record.
Connect the patient via the Vascular accessor AV fistula.
Connect the machine access and return lines to the patient.
NOTE: Patient receives homologous blood
during blood prime procedures.
Monitor patient closely for ANY symptoms associated with a possible
air is not introduced into the system, continually check volume of exchanging product.
Monitor ionised Ca2+ after initial 30 or 40 minutes, but more often
in the patient has liver failure or fasting or symptomatic of hypocalcaemia. If
ionised Ca2+ is low, notify Clinician and refer to stat Ca2+
order. Complete the Apheresis Record as indicated.
6.5.3 Monitor vital signs (Temperature,
Pulse, Respiration, Blood Pressure, SaO2) at 15minute intervals or
more or less often as indicated by donor’s condition. Regularly assess donor
for signs of citrate toxicity, if hypocalcaemia (Ca2+
<1.17mmol/L) develops, mild to moderate symptoms to note are;
6.5.4 Pause Procedure and urgently take
and despatch additional samples for analysis (FBE, electrolytes and ionised Ca2+)
at the first onset of symptoms suggestive of hypocalcaemia (anxiety,
restlessness, tingling, paraesthesia or tetany[SM3] ).
Refer to: HSCT Programme standard operating
procedure: Management of Hypocalcaemia during Apheresis (AP-P-004).
6.5.5 Appropriate actions for symptoms
of hypocalcaemia include slowing the processing rate, decreasing Ca2+:Blood ratio, administration of single infusion
of 0.5ml/kg, 10% Calcium Gluconate (2.2 mmol of Ca in 10ml) to a maximum of
30mls, diluted in 20-50mls of 0.9% Normal Saline, infused over one hour.
Symptoms of hypotension and other adverse reactions to note and respond to include;
dressing and Consider repositioning lines.
observations to exclude transfusion reaction.
investigations for transfusion reaction.
procedure, notify Nephrology Registrar or Fellow for review.
to RCH Clinical Practice Guideline Blood Product Transfusion [cited 2016 February 5. Available from:
procedure. Call MET. Refer to RCH Clinical Practice Guideline Anaphylaxis [cited 2016 February 5]. Available from:
Refer to: RCH Clinical Practice Guideline MET
Criteria-Call 777 for help [cited 2016 February 5]. Available from: http://www.rch.org.au/clinicalguide/cpg.cfm?doc_id=7783
Encourage light food and fluids as per the childs request throughout the
At completion, if satisfactory target achieved press DISCONNECT (DO NOT START
RINSEBACK for blood prime), proceed to DISCONNECT and CONFIRM.
Obtain post exchange investigations[BC4] , as applicable to the medical
6.7 Post Procedure
Complete post procedure vital signs, observations and clinical review.
Disconnect patient from the machine.
the patient’s vital signs (Temperature, Pulse, Respiration, Blood Pressure, and
As required, the Nephrologist or Delegate, may review the patient before transfer
to the primary ward.
Clean and decontaminate the Spectra Optia according to manufacturer’s
recommendations, note room temperature readings and complete the Maintenance
Print 2 copies of the procedure report, label with patient details and include one
in the patient medical records and the other in the Apheresis Log Book.
dynamically stable patient during and following Plasma exchange procedure.
Spectra Optia® Apheresis System. Plasma Exchange Procedure Guide.
HSCT Programme standard operating procedure; Staff Training and Assessment.
Programme standard operating procedure; Apheresis Training Procedure. AP-P-003.
9.4 HSCT Programme standard operating procedure;
Management of Hypocalaemia during Apheresis. AP-P-004.
9.5 RCH Clinical
Practice Guideline Blood Product Transfusion [cited 2016 February 5]. Available from:
RCH Clinical Practice Guideline Anaphylaxis [cited 2016 February 5]. Available from:
RCH Clinical Practice Guideline MET Criteria-Call 777 for help [cited 2016 February 5]. Available from:http://www.rch.org.au/clinicalguide/cpg.cfm?doc_id=7783
statement to redirect the prescriber to TPE with filter protocol which uses
filter and blood lines down to volume of approx. 130 mls. (paed lines+LF-030)
Can probably be less using neonatal lines-never tried at RCH.
include: Zyrtec, Hydrocortisone,
used to pause the machine pumps at any sign of citrate reaction! Is it worth
routinely do post bloods, but might want to add Titres or perhaps clotting for
some select patients???? Probably the easiest way to demonstrate that plasma exchange (PLEx)
procedure has been successful would be measurement of immunoglobulins (IgM
& IgG) at commencement and end of PLEx (prior to admin of IVIG).