Download Therapeutic Apheresis in Children

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Introduction to Apheresis
SALWA HINDAWI
MSc, MRCPath, CTM RCPE.
Consultant Haematology & Transfusion Medicine
Director of the blood Transfusion Services
King AbdAlaziz University Hospital
Phlebotomy Course, 11-13 April 2006
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Early History
The word apheresis means, "to take away from"
Blood letting, Egyptian and Greek
Leeches, blood sucking worms.
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Late History
The twentieth century separating blood components
were recognized as a therapy called apheresis.
In the1950s discontinuous-flow manual procedure.
In the 1960s, continuous-flow hemapheresis
machines introduced.
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Late History cont.
By the end of the twentieth century
highly sophisticated machines has
been developed.
In May 1981, one of the most
important educational and scientific
contributions to the apheresis
practice, was establishing the
American Society for Apheresis (ASFA)
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What is Aphereis?
Collection of a particular blood component
from a Donor / patient and the remaining
constituents are Returned to the donor or
patient.
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Methods
1. Centrifugation (specific gravity)
a) Intermittent flow IFC
b) Contineous flow CFc
2. Immunoadsorption
Apheresis by membrane filteration
3. Photopheresis
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Applications
1. Component collections
- Plateletpheresis
- Leucopheresis
- Erythrocytapheresis
- Plasmapheresis
- Stem cell collection
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2. Therapeutic Procedure
-Therapeutic cytapheresis
-Therapeutic plasmapheresis
(plasma exchange)
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Donation Criteria
Donors for apheresis procedure must meet the criteria
applicable as the donors for normal donation.
CBC, ABO and Rh typing, andtibody screening and testing for
transfusion and transmitted diseases(VDRL, anti-HIV I&II,
HIV-1 RNA, anti-HCV, HCV-RNA, HBsAg, ANTI-HTLV I&II,
RPR, anti-HBc and Anti-HBs if Anti-HBc positive) SHOULD
BE DONE.
A drug history should be obtained; donors who have taken
aspirin or aspirin containing medications within 3 days of
donation should be temporarily deferred
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Donation Interval
The interval between platelet donations
should be at least 48 hours, with no more
than two donations in a week and 24 donations
in a year.
plasmapheresis donors may donate as often
as every 48 hours but not more than
twice in a 7-day period.
If it becomes impossible to return the donor's red cells during
apheresis, at least 8 weeks shall elapse before subsequent
apheresis procedure, unless the red cell loss was less than
200 ml.
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Important points to be considered
The technical staff must be properly trained to care for
donors and patients.
Attention must be given to the patients medication schedule
and/or fluids replacement.
Written informed consent must be obtained from the donor
& patient
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Important points to be
considered
Technical difficulties:
Access
Anticoagulation
Volume shift
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Total blood volume according to
body mass/ml rate
82-86 ml/kg
89-105 ml/kg
73-82 ml/kg
70ml/kg
Newborn
Premature
Infant
Adult
Extracorporeal volume (ECV) and TBV
ECV not more than 15% of TBV
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Guidelines For Therapeutic
Apheresis
Category I
standard medical care and accepted as primary therapy
or first-line therapy in conjunction with other initial
therapies.
Category II
Generally accepted, but usually as adjunctive therapy
to other treatment modalities.
Category III
Published data is insufficient to establish efficacy or
risk/benefit. Heroic effort treatment
Category IV
Published control trials lack evidence of efficacy.
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Therapeutic Cytapheresis
1. Plateletpheresis (thrombocytopheresis) the
platelet count can be decreased by as much as
one-third to One-half the initial value.
2. Leucopheresis : e.g leukemia
3. Lymphocytespheresis & photopharesis.
4. Erythrocytapheresis : e.g SCA, severe parasite
infections.
5. Stem cells harvesting, Donor or patient.
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Guidelines for Therapeutic
Cytapheresis
Category I
Category II
Cutaneous T-cell lymphoma
(cytoreduction or
photopheresis)
Hairy cell leukemia
Hyperparasitemia (e.g.,
malaria)
Peripheral blood stem cell
collections for
Hematopoitic reconstitution
(Rheumatoid arthritis)
Leukemia with
hyperleukocytosis
syndrome
Sickle cell syndrome
Thrombocytosis, symptomatic
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Category III
Life-threatening hemolytic
Transfusion reactions
Multiple sclerosis
Organ transplant rejection
(also photopheresis)
Category IV
Leukemia without
hyperleukocytosis
syndromes
Hypereosinophilia
Polymyositis / dermatomyositis
Sickle cell disease
(prophylactic use in
pregnancy)
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Therapeutic Plasmapheresis
It is the removal and retention of the plasma with
return of all cellular components to the patient.
Recommended 1-1.5 plasma volumes be
exchanged
One volume exchange(2-4 L)  unwanted plasma
component to 30% of its initial value .
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Guidelines for Therapeutic
Plasmapheresis
Category I
Thrombotic
Thrombocytopenic Purpra
(TTP).
Coagulation factor
inhibitors
Cryoglobulinemia
Goodpasture’s syndrome
Guillain-Barre syndrome
Homozygous familial
hypercholesterolemia
Hyperviscosity syndrome
Myasthenia gravis
Postransfusion purpura
Refsum’s disease
Category II
Rapidly progressive
glomerulonephritis Chronic
inflammatory demyelinating
polyneuropathy
Cold agglutinin
Drug overdose and poisoning
(protein-bound toxins)
HUS
Pemphigus vulgaris
Systemic vasculitis (primary or
secondary to rheumatoid Arthritis or
systemic lupus
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Erythematosus)
Category IV
Category III
ABO-incompatible organ or marrow
transplantation
AIDS (for symptoms of
immunodeficiency)
Maternal treatment of Maternal-fetal
incompatibility (HDN)
Amyotrophic lateral sclerosis
Thyroid storm, Multiple sclerosis
Progressive systemic sclerosis
Aplastic anemia
Fulminant hepatic failure
ITP (chronic) , Lupus nephritis
Pure RBC aplasia , Transfusion
refractorines
Polymyositis / dermatomyositis
due to Alloantibodies (RBC, platelet,
HLA)
Psoriasis , Renal transplant rejection
Rheumatoid arthritis
Warm autoimmune hemolytic anemia
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Adverse Effects of Apheresis
1- Citrate toxicity
2- Vascular complications
hematoma, sepsis, phlebitis, neuropathy.
3- Vasovagal reaction.
4- Hypervolemia.
5- Allergic reaction.
6- Haemolysis.
7- Air embolus.
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Adverse Effects of Apheresis
cont.
8- Depletion of clotting factors.
9- Circulatory and respiratory distress.
10- transfusion transmitted diseases.
11- loss of lymphocytes.
12- depletion of proteins and immunoglobulin
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Signs and Symptoms, Possible Causes, and Treatment of Adverse
Effects during Therapeutic Apheresis
Signs and Symptoms
Possible
Cause(s)
Suggested Treatment(s)
Bradycardia,
hypotension, diaphoresis,
pallor, nausea,feeling of
doom
Vasovagal
reaction,
anxiety, full
bladder,
or unknown
cause
Put patient in Trendelenburg’s position or
elevate feet, administer saline bolus, offer
bedpan, fan patient, stimulate patient (ie,
have patient move extremities as much as
possible), administer ammonia spirit,
aromatic (be sure to protect patient’s
eyes)
Tingling in fingertips or
toes,flushing,
diaphoresis,hypotension/
hypertension,
tachycardia, seizures
Hyperventilat
ion,
anxiety
Have patient breathe in paper bag, offer
fan, encourage very slow deep breathing.
If patient is hypotensive, place patient in
Trendelenburg’s position and administer
saline bolus.
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Tachycardia,
hypotension,
diaphoresis
Antihypertensiv
e Rx:
Beta blockers
Ca channel
blockers
Hypovolemia
Hold antihypertensive Rx before next
procedure. Administer saline bolus, put
patient in Trendelenburg’s position,
increase fluid balance, review type and
volume of replacement fluids, increase %
of colloid if using crystalloid replacement.
Circumoral
paresthesias that may
progress over entire
body, chest tightness,
nausea,
vomiting, flatus,
diarrhea, hypotension,
prolonged QT interval,
tetany
Citrate toxicity,
Hypocalcemia
Decrease whole blood flow rate, increase
WB:ACD ratio, switch to
ACD/heparin anticoagulation, slow FFP
infusion rate, administer calcium PO or IV
(slow push or drip), add calcium to
replacement fluid (continuous flow
procedures only & not FFP or Cryo poor
plasma)
Burning eyes,
periorbital
Edema
Ethylene oxide
allergic
reaction
Discontinue procedure, perform setup
with double prime, use oldest tubing kits
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Hives, urticaria,
wheezing, facial
edema, SOB,
hypotension,
tachycardia
Allergic
reaction
Administer Benadryl IVP,
epinephrine sub q, and/or
solumedrol IV
Back pain, hematuria,
tachycardia,
hypotension,
hemolysis, SOB
Acute
transfusio
n
Reaction
Discontinue blood component and
order transfusion reaction work-up
Flushing, hypotension
ACE
inhibitor
reaction
Change albumin lot number, switch
to FFP or colloid starch replacement,
hold or discontinue ACE inhibitor,
delay therapeutic apheresis for 2448 hours after ACE inhibitor
administration
The procedure should be paused when a reaction occurs and the physician should
be notified. All medical interventions should be prescribed by a physician.
The physician will determine if the procedure should be restarted or aborted.
SOB = shortness of breath; WB = whole blood; ACD = acid citrate dextrose;
FFP = fresh frozen plasma; ACE = angiotensin-converting
enzyme.
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Swedish registry
Since 1996 adverse events (AE) in therapeutic
apheresis (TA) More than 14,000 procedures were
registered during the observation period .
No fatalities occurred
AEs were most frequent in patients with Good
pasture's syndrome (12.5%), TTP/HUS (10.5%) and
Guillain Barre syndrome(11.0).
Transf Apheresis Sci 2001, Aug;25(1):3341
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Conclusion
Donation & Therapeutic Apheresis is safe
and easy effective methods to be used
when needed.
A well-trained and experienced team can
overcome the technical difficulties in
order to complete the procedures
without complications.
Policy and procedure of Donors Apheresis
And Therapeutic Apheresis should be in
place.
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References
1. Henstis, D.W. Risks and safety practices in haemapheresis
procedures. Arch Pathology Lab. Med. 113:273-278, 1989.
2. Strauss, RG et al. Clinical Applications of therapeutic
apheresis: Report of the clinical applications committee.
J Clin Apheresis 6,4, 1993.
3. Meyer D, et al: Red cell collections by apheresis technology
transfusion 33:819-824, 1993.
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4. Denise M. Harmening, Modern Blood Banking & transfusion
Practices, 4th edition 1999.
5. Guidelines for the Blood Transfusion Services in the United
Kingdom 4th Edition 2000.
6. AABB Annual Meeting, Oct 26-29 Orlando, FL USA 2002.
7. AABB annual Meeting, Nov SanDiago, USA 2003.
8. Apheresis Principles and Practice, 2nd Edition, Bruce C. McLeod
2003.
9. AABB Technical Manual 14th Edition, 2005.
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