Plasmapheresis in the Management of Severe Hypertriglyceridemia

Abstract

P lasmapheresis is an advanced and established extracorporeal therapy in critical care, a process in which plasma, the fluid part of the blood, is separated from blood cells by a device known as a cell separator. In critically ill patients, plasmapheresis is used to remove toxins, medications, destructive antibodies, and clotting factors from the peripheral circulation. During plasmapheresis, a nurse uses a cell separator that either spins the blood to separate the cells from the fluid or filters the blood through a membrane with extremely small pores that allow only the fluid part to pass through. Although in current practice the terms plasmapheresis and therapeutic plasma exchange (TPE) are often used interchangeably, TPE This article has been designated for CNE credit. A closed-book, multiple-choice examination follows this article, which tests your knowledge of the following objectives:1. Describe use of plasmapheresis for the management of severe hypertriglyceridemia 2. Identify conventional therapeutic modalities used for management of hypertriglyceridemia 3. Discuss effects of hypertriglyceridemia on clinical laboratory tests CNE Continuing Nursing Education CoverPlasmapheresis can benefit a variety of critically ill patients. A woman with diabetic ketoacidosis and severe hypertriglyceridemia was treated with plasmapheresis when conventional treatments did not markedly reduce her triglyceridemia. The patient was admitted to a medical intensive care unit because of diabetic ketoacidosis with severe lipemia. The lipemia-associated interference in laboratory studies made treatment of electrolyte abnormalities extremely difficult. The hypertriglyceridemia was initially treated with insulin, antilipidemic medications, and heparin, but the levels of triglycerides remained elevated, delaying results of needed laboratory studies for hours. After plasmapheresis, the serum level of triglycerides decreased by 77% in less than 24 hours. Severe lipemia interferes with photometric laboratory studies, yielding an underestimation of serum levels of electrolytes. Plasmapheresis is safe, rapid, and effective for emergent management of severe hypertriglyceridemia in critically ill patients. The impact of the procedure on critical care nursing is growing as nurses become involved in the treatment and follow-up care of patients who have plasmapheresis. (Critical Care Nurse. 2013;33[4]:18-24) 18 CriticalCareNurse Vol 33, No. 4, AUGUST 2013 www.ccnonline.org by AACN on May 9, 2018 http://ccn.aacnjournals.org/ Downloaded from takes the actual plasmapheresis procedure a step further: Plasma is separated from whole blood and discarded, and then a volume of replacement fluid equal to the volume of the discarded plasma is infused. Usually a patient has a needle or a catheter inserted into a vein in each arm, allowing the blood to be taken from one arm and circulated through the cell separator to remove the plasma. The aspiration device on the machine is adjusted to remove the undesirable blood components and then return the rest...

Role of therapeutic plasma exchange in the treatment of severe hypertriglyceridemia: an experience

“…The reduction of serum TG is comparable to results achieved by Gavva and colleagues and Seda and colleagues, 84% and 77%, respectively. 6,7 Recently Joglekar and colleagues reported a mean reduction of TG levels to 70% with a mean length of hospital stay of 7.3 days. 4 We found the average hospital stay was 3 days in our cases with the mean reduction in TG levels up to 67%.…”

“…This is due to the advantage of preventing serious complications associated with SHTG and safety experience claimed and published by different authors. 4,[6][7][8] Further, the use of TPE as prophylaxis is beneficial as the time of intervention using TPE might be at critical point. Better results in terms of mortality and morbidity have been achieved in patients as soon as they receive TPE.…”

Origin and therapy for hypertriglyceridaemia in type 2 diabetes

“…For prevention of recurrent severe HTG in susceptible patients, counselling on medication adherence and long-term diet and lifestyle medications should be considered [120] . In extremely severe HTG and drug refractory HTG, plasma apheresis may be required [121,122] , particularly with severe chylomicronaemia complicated by acute pancreatitis. A single session of apheresis can dramatically lower excessive triglyceride levels, 65.8% reduction in 2 h [123,124] .…”

Conservative management in hypertriglyceridemia‐associated pancreatitis

“…Heparin and/or insulin infusions have been successfully used in cases of HTG‐related pancreatitis, especially when hyperglycaemia was present . Uncontrolled and retrospective case reports and series showed reduced TG levels following plasmapheresis , but minimal outcome data. A systematic review of apheresis used in HTG‐associated pancreatitis could not determine benefit for morbidity, mortality or pancreatitis severity .…”