Tunneled central catheter
Check: CBC, electrolytes, BUN/Cr, fibrinogen, APTT
Albumin replacement volume: 5% ; 2-3 L
FFP, ideally cryoprecipitated if fibrinogen level is low
Primed with NS
Premedications: APAP 650 mg, PO, may repeat once PRN q4h; diphenhydramine 25 -50 mg IV, PO, may repeat once PRN q4h; Solumedrol 125 mg IV
ADC-A protocol
Rinse back
ADC-A ratio: 10:1
1:15 anticoagulation to blood ratio should be used when platelets are <150K or Hb <11 gm).
Calcium gluconate 10%, 3000 mg IVPB (in 250 mL of NS) - calcium replacement or 1 gm per liter of replacement fluid. OR calcium gluconate 10%, 1 gm in 100 mL of NS to be infused via IV pump. OR 330 mg of calcium chloride per each liter of plasma replacement fluid.
ACDA, 1000 mg IVPB anticoagulation
Benadryl, 25 mg IVP - itching
Solumedrol, 100 mg IVP - preventive
Alteplase 1 mg/mL if need for blood return.
Template:
I am seeing this patient for continuation of pheresis. Patient started plasmapheresis for myasthenia gravis 8 years ago. She usually gets plasmapheresis every other Tuesday twice a month at . Her IV access is single-lumen IV port used as outtflow for apheresis and returns are through a peripheral vein in the antecubital fossa. The plan is to get AV fistula for long-term plasmapheresis. Short-term we can probably use current set up or we can use a tunneled catheter. She is aware of all the side effects associated with plasmapheresis. She is getting IV 5% albumin as replacement fluid. Myasthenia gravis was diagnosed 10 years ago. She denies any issues with hypocalcemia. She denies any issues with clotting or history of anemia requiring blood transfusion. She denies any electrolytes disorders. Denies any history of infections.
Procedure of plasmapheresis explained to the patient. Side effects include blood loss, risk of infection, risk of allergy to the blood products, fluid electrolyte disturbances, possible benefits include improvement in disease status. Patient agreeable to undergo the procedure. Patient will sign the consent.
We will use 3 liter 5% albumin as replacement fluid. She will get ACDA anticoagulation. Will get fibrinogen level every 2 weeks. She understands there is a possibility that we have to use FFP's as necessary to keep fibrinogen level within target limit. Risk and benefits of procedure have been discussed by neurology.
POTS acting up during apheresis:
Patients with POTS during aphresis may have exacerbation of their POTS symptoms. In these cases and those who become hypotensive, placing them in Trendelenburg position (feet elevated above head) and giving them 250 mL or 500 mL of normal saline to get it back up, after plasmapheresis; as a rinse-back.
Plasmapheresis and MG
Plasmaphersis has shorter onset of action, and is often the initial therapy of choice.
250 mL/kg total divided every other day x 5-6 exchanges (3 - 5 L or 40 - 50 mL of plasma/kg per treatment), onset of action: 1-7 days; maximal effect: 1-3 wk. Sometimes may need treatment over 7-14 days.
Advantages: Putative. Directly removes Ach rcp abs, anti-MUSK abs and other plasma components such as soluble adhesion molecules and cytokines from circulation. Clinical efficacy relates to reduction in ab levels. Faster onset of action than IVIG; improvement in 75% of cases after 2-3 exchanges.
Therapeutic plasmaphersis with replacement of plasma volume, each exchange using 5% albumin, every other day for total of 5 treatments.
Patients usually need placement of a dialysis-capable catheter. Recommend adjusting timing of administration of protein-bound medications to after each pheresis on the treatment days. Patient will need careful monitoring of fibrinogen and may require FFP if his fibrinogen is less than 150 mg/dL prior to apheresis procedure.
Replacement Fluid: Albumin 3000 mL.
Medications Given During The Procedure: 14.4 mEq Ca++ (2.4 mEq Ca++ supplemented per 500 mL albumin)
Check fibrinogen following day after PLEX. If fibrinogen level is <100 mg/dL, give 2 pooled units of cryoprecipitate.
Disadvantages: Need central line (Quinton), risk of line inf, hypocalcemia, hypofibrinogenemia, hypotension, dysautonomia, hypothermia, thrombocytopenia, thromboembolism. HIT can also occur after several sessions as heparin is used in the plasmapheresis. Toxic reaction to the citrate in the PLEX can occur.
Can be before the day of surgery. Benefits last only a 2 - 4 weeks (short lived)
ACE inhibitors must be stopped 24 - 72 hrs before treatment and until treatment is complete. It can result in anaphylactic shock.
If patient does not show response to PLEX in 2 weeks, IVIG may be tried.
Only Level III evidence supports treatment of myasthenic crisis with plasmapheresis.
Plasmapheresis and GBS:
Plasma exchange: 250 mL/kg total divided every other day for 5 exchanges ( 3-5 L per treatment; 40-50 ml of plasma/kg qod). Most effective if started within 7 days of symptom onset.
Requires invasive central line placement (Quniton); risk of line infection, hypocalcemia, hyperfibrinogenemia, hypotension, dysautonomia, cardiac arrhythmias, vasovagal syncope, hypothermia, thrombocytopenia, thromboembolism, allergic reaction to albumin, and anemia.
The replacement fluid is saline combined with albumin, 5%. Central line is needed with possible attendant complications: H'ge, PTx, infection. Check fibrinogen levels prior to the next plasma exchange, as they may become markedly reduced during plasma exchanges.
Contraindications: septic shock, recent myocardial infarction, marked dysautonomia, active bleeding.
Plasma exchange removes autoantibodies, immune complexes, complement, and cytokines and boosts T-cell suppressor function.
Plasmaphresis and IV immunoglobulin (IVIg are comparably effective in improving outcomes and shortening duration when administered early to patients who cannot walk or have respiratory failure. Fewer complications may occur with IVIg.
Patients who do not respond to one (IVIg or PLEX) do not respond to the other (PEx or IVIg).
Patients with anaphylaxis to IVIg, severe IgA deficiency, CHF, renal failure in the setting of diabetes may receive PLEX.