We often get called to perform an emergency plasma exchange (TPE), red blood cell exchange (RCE) or leukapheresis procedure for patients with certain life threatening diseases. If called, here are a few things you need to do prior to starting the procedure.
WHAT TO DO FOR APHERESIS PROCEDURE
1. Get the patient's name and medical record number. Assess the patient's status and discuss with the clinical team:
If the patient is being transferred here from an outside hospital, call bed control and find out where the patient is being placed, then call for the floor and ask them to notify you when the patient arrives.
Look up the patient's history: Allergies, medications, previous transfusions etc
Has the patient been on an ACE-inhibitor (drugs ending in -pril) within the past 24 hours? (This can cause citrate toxicity)
What is the clinical status of the patient? Intubated? Hemodynamically stable? etc
Has the patient had labs drawn?
Check specifically the BMP (Ca, K, Mg), CBC (Hct/Hgb, platelets) and fibrinogen levels are within normal limits or decide whether the patient requires electrolyte repletion, blood products or plasma prior to starting the procedure.
***If Hct <21% or platelets < 30,000/uL, consider RBC or Plt transfusion. If fibrinogen <120 mg/dL, consider using plasma as replacement fluid or pre-procedural cryoprecipitate. Discuss with attending.
2. Discuss the case with your attending to determine whether the disease process warrants an apheresis procedure, whether it is an emergency, or if it can wait until "normal daytime hours" when there are more nurses available. Use the "2013 Guidelines on the Use of Therapeutic Apheresis in Clinical Practice—Evidence-Based Approach from the Writing Committee of the American Society for Apheresis"
Emergency procedure indications: TTP, acute chest/stroke for sickle cell disease, severe hemolysis in cold agglutinin disease, heart rejection in unstable patients, leukapheresis in patients with stasis symptoms
Urgent procedure indications (need to happen at night, but not medical emergency): myasthenia gravis exacerbation, organ transplant rejection, Wegener's or Goodpasture's disease with alveolar bleeding etc.
3. Determine the plasmapheresis procedure parameters:
Calculate the patient's plasma volume (need patient's height, weight and Hematocrit).
Will we perform a 1x, 1.5x or 2x plasma exchange? (How many Liters will the exchange be? )
Determine the replacement fluid: 5% albumin vs. plasma. ***If fibrinogen <120 mg/dL, consider using plasma as replacement fluid or pre-procedural cryoprecipitate.
Is a blood prime/RBC/Plt transfusion needed? ***If Hct <21% or platelets < 30,000/uL, consider RBC or Plt transfusion.
Are pre-medications required?
Any special instructions?
4. Confirm Line has been placed and confirmed via CXR or other method.
**For the procedure, we require a double or triple-lumen catheter (same used for dialysis- vascath or traumacath). There are extra kits available in the apheresis clinic to expedite the process. Generally speaking, a 15cm/13French catheter is used for IJ access and a 24cm/13French is used for femoral access
After the line has been placed and confirmed, phone the nurse to come in and notify her of the parameters decided for the procedure.
5. Go see and evaluate the patient and obtain consent for the procedure and for blood products to be given.
Perform necessary ROS, and physical exam
In the setting of MG be sure to warn the patients family of the potential for intubation following the procedure.
If it is a TTP patient, obtain consent and for research study.
6. Place orders
Order stat fibrinogen if there is not one in the system
Order the apheresis procedure (see document for steps on how to do this).
Order the replacement fluid (albumin with Ca/K injectables and a Ca drip vs. plasma vs. RBC. *** For patients using plasma, call the blood bank and let them know the patients name/MRN, have them perform the typing stat, and order at least 2.5L type specific plasma be prepared immediately. Have the BB perform typing stat; while simultaneously performing type and screen
Order pre-procedural medications: diphenhydramine 25 mg IV PRN for pruritis, Ondansetron for nausea, etc.
If patient has suspected TTP, make sure an ADAMTS13 level has been obtained prior to starting procedure if suspected TTP. Tell the nurse to obtain 2 blue top tubes prior to starting the procedure if they are consented for research study.
7. Once all the above is complete, it is okay to start the procedure.
Make sure the nurse has reviewed the SOP/is confident in how to perform the procedure
8. You must stay in the hospital for the entire procedure (but not required to stay in the patient's room). You can use this time to write a consult note, procedure note, and submit billing.
If it is early enough in the night that patient is like to be treated again the following day, be thoughtful and place orders for the transfusion residents taking over during the day.
9. Check in with the nurse throughout the procedure. Mention any adverse events in your note.
*Be aware in the setting of cold agglutinin disease blood warmers must be placed at inlet and outlet, and the circuit kept warm; if the patient is not in an ICU crank the heat up in the room
10. Notify attending when the procedure is finished
Special considerations:
RED CELL EXCHANGE (RCE)
-Check labs specifically Ca/K/Hct/Hgb/platelets; HbS levels; order an additional unit of PRBC if necessary for blood prime.
-Calculate the patients’ exchange volume (tmcalc.tk)-update blood bank of exchange volume; note you may need to contact the attending on call for end goal Hct,
-Make sure a STAT type and screen has been ordered, and that the blood bank knows to prepare blood STAT
-Order procedure, diphenhydramine 25 pre/25PRN; calcium drip, and post hemoglobin S
LEUKAPHERESIS
-This is an emergency procedure; do everything you can to facilitate this procedure happening ASAP; hound the line teams/floor/IR-make sure the nurse is here and ready to go; it is paramount to patient safety that these procedures happen without delay.
-These procedures are often lengthy; the nurse is to process 2 PV. Make sure the nurse has reviewed the SOP/is confident in how to perform the procedure, it is critical that they know to target a line Hct of 3-5% (salmon colored) for optimum procedural performance.
-Check labs specifically Ca/K/Hct/Hgb/platelets; order a stat type and screen/unit of PRBC if necessary for blood prime.
-Order procedure, and 1L of normal saline to be used to maintain blood pressure, insure patient volume status
-It is imperative that you check/order/make sure our nurse draws a stat CBC following the procedure to make sure the patient has an adequate post procedure platelet count.