Therapeutic plasma exchange in the intensive care unit: Rationale, special considerations, and techniques for combined circuits

Abstract

Therapeutic plasma exchange (TPE) is an extracorporeal blood purification technique with proven efficacy in a variety of conditions, including in the intensive care setting. It is not uncommon for a critically ill patient to require more than one extracorporeal procedure in addition to TPE. This review focuses on the combination of TPE with other extracorporeal circuits in a critical care setting via a single vascular access (either in‐series, parallel, or a hybrid mode) which is often referred to as performing procedures “in tandem.” Authors performed literature review via pubmed.gov using search terms: plasma exchange, plasmapheresis, apheresis, tandem circuits, combined circuits, critical care, ICU, CRRT, hemodialysis, and ECMO. Thirty‐eight English‐language, peer‐reviewed papers were appraised that satisfied the content of this review on techniques for combining circuits with plasma exchange, as well as describing the advantages of tandem procedures and potential complications that can arise. Performing these procedures simultaneously can be advantageous in reducing total procedure and staffing time, avoiding placement of additional central lines, reducing overall need for anticoagulation, and limiting multiple blood primes in certain populations. However, the described combined circuits are complex, associated with higher complications, and require a skilled team to understand and mitigate the potential complications associated with these combined procedures.

Plasmapheresis in the ICU

“…Such procedures could be performed sequentially or simultaneously via single or multiple access points. Systems could be combined in series, parallel, or hybrid mode [9].…”

A novel device and system concept for therapeutic plasma exchange in rats

“…Afterward, plasmapheresis has started to be used for the treatment or has been used in different disorders as first‐line therapy, primary stand‐alone treatment, or in combination with other therapeutic means, such as thrombotic thrombocytopenic purpura, myasthenia gravis, neuromyelitis optic, multiple sclerosis, Guillain–Barre syndrome, Chronic Inflammatory Demyelinating Polyneuropathy, Goodpasture's syndrome, Rapidly Progressive Glomerulonephritis, systemic vasculitis, immune thrombocytopenica, transplant sensitization, transplant rejection (antibody type), Waldenstrom's macroglobulinemia, and hyperviscosity syndrome [3]. Although the beneficial effects of plasmapheresis have been proven in different human diseases [4–6], full understanding of mechanisms of plasmapheresis action requires further extensive research [7]. Until now, the proposed mechanisms for effects of TPE are [8–10]: (i) removal of the “bad” antibodies; (ii) stimulation of proliferation of B cells and plasma cells, increasing their sensitivity to immunosuppressants; (iii) removal of the immune complexes with enhanced macrophage/monocyte function; (iv) replacement of the missing plasma components; (v) withdrawal of cytokines; (vi) modification of the lymphocyte numbers; (vii) augmented activity of T regulatory and suppressor cell activity; and (viii) correction of T‐helper cell type 1/2 ratio, by favoring Th1 predominance.…”

“…Cosmin-Teodor Mihai and Bogdan Ionel Tamba should be considered joint senior authors. beneficial effects of plasmapheresis have been proven in different human diseases [4][5][6], full understanding of mechanisms of plasmapheresis action requires further extensive research [7]. Until now, the proposed mechanisms for effects of TPE are [8][9][10]: (i) removal of the "bad" antibodies; (ii) stimulation of proliferation of B cells and plasma cells, increasing their sensitivity to immunosuppressants; (iii) removal of the immune complexes with enhanced macrophage/monocyte function; (iv) replacement of the missing plasma components; (v) withdrawal of cytokines; (vi) modification of the lymphocyte numbers; (vii) augmented activity of T regulatory and suppressor cell activity; and (viii) correction of Thelper cell type 1/2 ratio, by favoring Th1 predominance.…”

Management of Bivalirudin Dosing and Replacement Fluid During Therapeutic Plasma Exchange in Children on Extracorporeal Membrane Oxygenation

“…Plasma can then be discarded, whereas the cellular components are returned to the patient with a replacement fluid. 5,6 Therapeutic plasma exchange is occasionally indicated for patients supported on ECMO in the management of specific conditions including transplant graft rejection and sepsis with multiorgan failure. 7,8 The influence of plasma removal during TPE on drug dosing levels and therapeutic effect has become an area of growing study.…”

“…7 In addition, the choice of TPE replacement fluid, full fresh frozen plasma (FFP), all albumin, or a combination of FFP and albumin could lead to depletion of clotting factors and significant coagulopathy. 5 As such, TPE on ECMO has the potential to cause significant coagulopathy and disturbance in systemic anticoagulation increasing the risk of both bleeding and clotting. There are no current dosing guidelines for bivalirudin for patients on ECMO during TPE.…”