Plasmapheresis Therapy (PLEX Therapy).pptx

Detailed description about Plasmapheresis

1. PLASMAPHERESIS Komal Antil Master of Sciences in Nursing (Neurosciences Nursing) All India Institute of Medical Sciences, New Delhi

2. INTRODUCTION Plasmapheresis is a therapeutic intervention that involves extracorporeal removal, return, or exchange of blood plasma or components. The underlying mechanism of this procedure is accomplished by either centrifugation or filtration using semipermeable membranes.

3. DEFINITION Plasmapheresis is a blood purification procedure used to treat several autoimmune diseases. It is also known as therapeutic plasma exchange. In plasmapheresis, the plasma is separated from the blood and its components. After processing the plasma is reinfused. Plasma exchange is defined as the procedure in which the plasma is separated from the blood and replaced by replacement fluid.

4. TYPES OF PLASMAPHERESIS Three general types of plasmapheresis can be distinguished: Autologous , removing blood plasma, treating it in some way, and returning it to the same person, as a therapy. Exchange , a patient's blood plasma is removed, while  blood products  are given in replacement. This type is called plasma exchange (PE, PLEX, or PEX) or plasma exchange therapy (PET). The removed plasma is discarded and the patient receives replacement donor plasma,  albumin , or a combination of albumin and  saline  (usually 70% albumin and 30% saline). Donation , removing blood plasma, separating its components, and returning some of them to the same person, while holding out others to become blood products that this person donates for those in need. In such a  plasma donation  procedure, blood is removed from the body,  blood cells  and plasma are separated, and the blood cells are returned, while the plasma is collected and frozen to preserve it for eventual use as  fresh frozen plasma  or as an ingredient in the manufacture of  blood products

5. PURPOSE In an autoimmune disease, the immune system attacks the body's own tissues. In many autoimmune diseases, the chief weapons of attack are antibodies, proteins that circulate in the bloodstream until they meet and bind with the target tissue. Once bound, they impair the functions of the target. Plasmapheresis is used to remove antibodies from the bloodstream, thereby preventing them from attacking their targets. It does not directly affect the immune system's ability to make more antibodies, and therefore may only offer temporary benefit.

6. INDICATIONS The disorders where therapeutic plasmapheresis can be done are grouped into four categories by the Apheresis Applications Committee of the American Society for Apheresis (ASFA). Category 1 includes disorders where plasmapheresis can be done as a first-line treatment, C ategory 2 includes disorders where plasmapheresis can be done as a second-line treatment in addition to the existing standard of care, C ategory 3 includes disorders in which the evidence of the benefit of plasmapheresis is minimal, and therapy must be individualized, and C ategory 4 includes disorders in which the evidence suggests that plasmapheresis is either ineffective or harmful, however, may be considered after approval from the institute ethics committee

7. CATEGORY 1 Acute inflammatory demyelinating polyradiculoneuropathy/Guillain-Barre syndrome ANCA-associated rapidly progressive glomerulonephritis (dialysis-dependent or associated with diffuse alveolar hemorrhage) Anti-glomerular basement membrane disease-Goodpasture syndrome (dialysis independent or associated with diffuse alveolar hemorrhage) Chronic inflammatory demyelinating polyradiculoneuropathy Focal segmental glomerulosclerosis (recurrent in the transplanted kidney) Hyper viscosity in monoclonal gammopathies Liver transplantation : Desensitization Myasthenia gravis N-methyl D-aspartate receptor antibody encephalitis Paraproteinemic demyelinating neuropathies/chronic acquired demyelinating polyneuropathies (IgA/IgG/IgM mediated) Progressive multifocal leukoencephalopathy associated with natalizumab Renal transplantation: Desensitization and antibody-mediated rejection Thrombotic microangiopathy (Factor H autoantibodies and ticlopidine) Thrombotic thrombocytopenic purpura Wilson disease (fulminant)

8. CATEGORY 2 Acute disseminated encephalomyelitis Cardiac transplantation: Desensitization Catastrophic antiphospholipid syndrome Cryoglobulinemia; symptomatic/severe Dilated cardiomyopathy, idiopathic (NYHA 2-4) Hashimoto encephalopathy: Corticosteroid responsive encephalopathy associated with autoimmune thyroiditis Hematopoietic stem cell transplantation, ABO-incompatible Lambert-Eaton myasthenic syndrome Multiple sclerosis Myeloma cast nephropathy Neuromyelitis Optica spectrum disorders Overdose, envenomation, and poisoning, such as mushroom Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) Phytanic acid storage disease (Refsum disease) Systemic lupus erythematosus (severe)

9. CATEGORY 3 Acute liver failure ANCA-associated rapidly progressive glomerulonephritis (dialysis independent) Anti-glomerular basement membrane disease, Goodpasture syndrome (dialysis-dependent, no DAH) Aplastic anemia, pure red cell aplasia Autoimmune hemolytic anemia Burn shock resuscitation Cardiac neonatal lupus Cardiac transplantation : Antibody-mediated rejection Chronic focal encephalitis (Rasmussen encephalitis) Complex regional pain syndrome; chronic Erythropoietic porphyria, liver disease Hemolysis liver enzymes low platelet (HELLP) syndrome (postpartum) Hematopoietic stem cell transplantation, HLA desensitization Hemophagocytic lymph histiocytosis; hemophagocytic syndrome; macrophage activating syndrome Henoch-Schoenlein purpura Heparin-induced thrombocytopenia and thrombosis Hypertriglyceridemia pancreatitis Immune thrombocytopenia; refractory

10. CATEGORY 4 Amyloidosis, systemic Dermatomyositis/polymyositis HELLP syndrome (antepartum) Lupus nephritis

11. MECHANISM OF PLASMAPHERESIS During plasmapheresis,  blood , which consists of  blood cells  and a clear liquid called  blood plasma , is initially taken out of the body through a needle or previously implanted  catheter . Plasma is then removed from the blood by a cell separator. Centrifugation Separation takes place according to the specific gravity of the blood components such as RBCs, WBCs, platelets, and plasma Membrane filtration : use of semipermeable membranes: This can selectively remove undesired macromolecules, which then allows the return of the processed plasma to the patient instead of donor plasma or albumin.

12. ARTICLES REQUIRED Spectra optia exchange kit or PL1 exchange kit Anticoagulant citrate dextrose solution – 500ml Double lumen haemodialysis catheterization set- 12 Fr / Central line Replacement fluids (colloids such as FFP, albumin 5%, hydroxyethyl starch-6%, and crystalloids-0.9% NS) Cardiac monitor: for continuous ECG, NIBP and SpO2 monitoring. Sterile drapes ECG electrodes Sterile gauze IV cannula 20/22G Injections: Inj Avil 2ml (PHENIRAMINE), Inj. calcium gluconate Other emergency drugs      

13. Syringes: 10ml, 5ml NS: 500ml Betadine Dressing set Heparin Infusion set Sterile drape Sterile dressing for covering the ports

14. BEFORE PROCEDURE Written informed consent should be taken by the treating physician. Peripheral line to be inserted for the medication and IV fluids Venous access for TPE: Double lumen central venous catheter (size-12 Fr) to be inserted in femoral vein or internal jugular vein before starting TPE. Maintain femoral line / internal jugular throughout the treatment course Arrangement of replacement fluids preferably a day before. Normal blood pressure; if patient is having SBP<100mm Hg Inj. NS 500ml bolus to be given prior to the procedure. Check for DVT , fever , articles every day Maintain aseptic technique while handling lines of the patient Personal hygiene of the patient to be maintained daily. High plasma bound drugs will be removed along with the plasma of the patient.

15. PATIENT PREPARATION No specific patient preparation is needed for this procedure. However, while inserting a central line, a local anesthetic may be needed. For this purpose, 2% lidocaine injection is used routinely. In pediatric patients, sedation with opioids and benzodiazepines may be considered for pain and anxiety control. The patient is positioned supine for plasmapheresis; however, the position, especially of the neck, may be altered according to the location of central venous access to maintain adequate blood flow throughout the procedure. A close watch on patient vitals is recommended throughout the procedure to assess for volume depletion, hypocalcemia, and complications of fresh frozen plasma transfusion

16. EXCHANGE SET

17. BASIC PRINCIPLES OF TPE

18. BASIC PRINCIPLES OF TPE – CHANNEL

19. CONNECTOR

20. STEPS The steps for performing plasmapheresis using centrifuge-based equipment are as follows: Initially, a waste of around 3-5 mL blood from the central venous catheter is discarded. After drawing baseline samples for complete hemogram, calcium, and fibrinogen, it is flushed with 5-10 mL of heparinized saline. The double lumen catheter is now connected to the machine tubing to start the priming procedure. The machine calculates total body volume (TBV), and the effective plasma volume (which equals TBV × (1 – hematocrit)) of the patient based on the operator entered height and weight. The replacement product to be used and its desired volume (40 - 60 mL/kg) is decided by the clinician, and entered into the machine, based on which it calculates the centrifuge speed. The separated plasma is discarded by the machine, and the RBCs are returned back to the patient along with the replacement fluid. Finally, post-procedure, tubings are connected to heparinized saline, and reinfusion is initiated. Post-plasmapheresis blood for fibrinogen and calcium is sent again, and lumens of central venous catheters are flushed.

21. POST PROCEDURE Unload the kit Clean the machine with alcohol Discard the plasm waste products as per protocol Ensure post-procedure monitoring of the patient

22. CONTRAINDICATION The contraindications for therapeutic plasmapheresis are as follows: Non-availability of central line access or large bore peripheral lines Hemodynamic instability or septicemia Known allergy to fresh frozen plasma or replacement colloid/albumin Known allergy to heparin Hypocalcemia (restricts the use of citrate as an anticoagulant during the procedure); relative contraindication Angiotensin-converting enzyme (ACE) inhibitor used in last 24 hours; relative contraindication

23. COMPLICATIONS Hypocalcemia or hypomagnesemia as a result of the use of citrate anticoagulation. This is managed with the intravenous replacement of calcium and magnesium. Transfusion reactions ( managed symptomatically with pheniramine, hydrocortisone/dexamethasone, and/or epinephrine) Fluid and electrolyte imbalance(Hypocalcemia, Hypokalemia) Bleeding diathesis due to hypofibrinogenemia and thrombocytopenia. Removal of erythropoietin and drugs bound to plasma proteins Gastrointestinal symptoms like nausea and vomiting Anaphylactoid reactions to fresh frozen plasma Hypotension Flushing Hypothermia Hypotension Dyspnea thrombocytopenia Hematoma Coagulopathies Transmission of viral disease

24. NURSING RESPONSIBILITIES Identifying each patient correctly and obtaining consent Analyzing blood work results Preparing the plasmapheresis machine and needed equipment Taking notice if medications were taken prior to the procedure To monitor for vital signs, level of consciousness, and vascular access throughout the procedure To monitor for hypotension or any other reaction to the blood product To monitor for any other complications during the whole process

25. CONCLUSION Plasmapheresis is a therapeutic intervention that involves extracorporeal removal, return, or exchange of blood plasma or components. The underlying mechanism of this procedure is accomplished by either centrifugation or filtration using semipermeable membranes. There is a greater risk of infection to the patient in this procedure, therefore aseptic techniques should be used during the procedure.

26. REFERENCES Dvoretskiĭ LI, Vorob'ev PA, Ryzhko VV. Lechebnyĭ plazmaferez [Therapeutic plasmapheresis]. Ter Arkh. 1984;56(6):137-44. Russian. PMID: 6382670. Assessment of plasmapheresis: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 1996; 47: 840–843 [PubMed] [Google Scholar] Farkkila M, Kinnunen E, Haapanen E, Iivanainen M. Guillain-Barré syndrome: quantitative measurement of plasma exchange therapy. Neurology 1987; 37: 837 [PubMed] [Google Scholar] I. Cortese, V. Chaudhry, A. Rae-Grant, Evidence-based guideline update: plasmapheresis in neurological disorders, American Academy of Neurology. 2011; 294-300 https://www.ncbi.nlm.nih.gov/books/NBK560566/ https://www.healthline.com/health/plasmapheresis