dr. aswin kumar. s ii year m.d., immunohematology & blood transfusion vinayaka mission medical...

THERAPEUTIC PLASMA EXCHANGE OUR EXPERIENCE AT SALEM

Dr. Aswin Kumar. SII year M.D., Immunohematology & Blood Transfusion

Vinayaka Mission Medical College, Salem

INTRODUCTION

• APHERESIS, The Greek word ‘Pheresis’ meaning “to take away,” involves the selective removal of blood constituents from donors or patients.

Desired components

Red blood cell

Platelets Plasma

Whole blood

INTRODUCTION

Therapeutic plasma exchange (TPE),is anextracorporeal blood purification technique used to remove large molecular weight substance like

1. Pathogenic autoantibodies (e.g. Myasthenia Gravis: autoantibody)

2. Cryoglobulins or other abnormal plasma proteins (e.g. Waldenstorm's macroglobulinemia)

3. Immune complexes (e.g. Goodpasture's syndrome)

INDICATIONS

Approximately 300,000 plasma exchange procedures are performed worldwide for various indications like

• Neurological - GBS,MG

• Renal -Good pasture syndrome

• Hematological-TTP, Sickle cell crisis

• Dermatology –Pemphigus vulgaris

• Toxins-Amanita phalloids, OPC

OUR EXPERIENCE

• We started TPE in Jan 2011 till date we have done 110 procedures on 36 patients

Paraquat poisonig

Guillain Barre Syndrome

Myasthenia gravis

Motor neuron disease

Parainfectious demyelinat-ing polyneuropathy

18 Patients12 patients

4 patients

1 1

Total no of patients : 36

CASE DISTRIBUTION

DIAGNOSIS No of PatientsCategory of Indication

(AABB/ASFA)

Number of procedure per

patientTotal procedures

Guillain barre syndrome

12 I 5 60

Myasthenia gravis

4 I 5 20

Motor neuron disease

1 I 5 5

Parainfectious demyelinating

spondyloarthropathy

1 I 5 5

Paraquat poisoning

18 III 1 20

AGE DISTRIBUTION

0 - 20 years20 - 40 years

40 - 60 years60 - 80 years

16

11

4

5

4

GENDER DISTRIBUTION

Male; 19Female; 17

Total patients = 36

PROCEDURE

• Instrumentation : Hemonitics cell separator (MCS+)

• Done at : ICU under the supervision of emergency physician

• IV access : Central venous catheter (femoral or internal jugular vein)

• Anticoagulant : Acid citrate dextrose (ACD) anticoagulant is used in 1:16 ratio

KEEP AN EYE ON

• Pulse• Blood pressure • Urine output• Blood flow• Signs of citrate toxicity

VOLUME OF PLASMA EXCHANGE

Formula: The volume of plasma to be exchanged is

determined by patients estimated plasma volume (EPV) and hematocrit (hct)

EPV = 0.07 x weight(kg) X (1-hct) in liters

PLASMA VOLUME EXCHANGE

Plasma Volume Exchange

Percent Removed

0 0%

0.5 39.3%

1.0 63.2%

1.5 77.7%

2.0 86.5%

2.5 91.8%

3.0 95.0%

Efficiency of removal is greatest early in the procedure and diminishes progressively during the exchange.

NUMBER OF PROCEDURES

• Neuro-immunological cases Approximately 5 procedures were

done on alternate days

• Paraquat poisoning Single large volume exchange (1-1.5

plasma volume exchange)

•1 •2 •34 5

REPLACEMENT FLUIDS

REPLACEMENT FLUIDS

• Fresh frozen plasma (30 – 40%)

• Colloids(6% hydroxyethyl starch) (30%)

• Crystalloids (30%)

ADVERSE REACTIONS

No adverse reactionsAdverse reactions

0

5

10

15

20

25

30

27

9

Total cases - 36

27

9

ADVERSE REACTIONS

HypotensionFever and chillsCatheter pluggingCitrate toxicity

3 patients2 patients

2 patients

1 patient

SIGNS OF RECOVERY

In Neuro-immnological cases recovery is assessed by

• Recovery from assisted ventilator support• Improvement in muscle power and early

mobilization

CLINICAL DATA

neuro-immunological Paraquat Poisoning

18 18

1112

76

Total cases Mech.Ventilation spontaneous respiration

NEURO-IMMUNOLOGICAL MORTALITY

Total number of Patients - 18

Recovered Mortality

Cause of death Respiratory failure

17 patients

1 patient

MORTALITY IN PARAQUAT POISONING

survivors56%

Non survivors44%

Total case : 18

10 patients8 patients

CONCLUSION

The efficacy of plasma exchange in various clinical indications are categorized as follows

Category I – Standard acceptable therapyCategory II – Sufficient evidence to suggest

efficacy usually as adjunctive therapy Category III – inconclusive evidence of efficacy or

uncertain risk/benefit ratio Category IV – Lack of efficacy in controlled trials

CATEGORY - I INDICATIONS(first line therapy )

Neurological:• Guillain Barre synd• Myasthenia Gravis• CIDP• Demyelinating

polyneuropathy with IgG & IgA

Hematological:• TTP• Sickle cell crisis• ABO mismatch Marrow

transplant• Cryoglobinemia

Others:• Cutaneous T cell

Lymphoma• Good pasteur synd• Hypercholestrolemia• Phytanic acid storage

disease• Amanita phalloides

poisoning

CATEGORY - II INDICATIONS

Neurological:

• Lambert -Eaton synd• Acute CNS inflamatory

demyelinating disease• Sydenham’s chorea• PANDAS• Refsum’s diseases

Hematological:

• ITP• Maternal-fetal Rh

incompatability• Coagulation factors inhibitors

Renal & Others:

• RPGN• Acute renal failure

due to cast nephropathy

• Graves disease• Digitalis toxicity• Pemphigus vulgaris• Bullous pemphigoid• Toxic epidermonecrolysis

CONCLUSION

• TPEs are successfully performed worldwide but implementation of plasma exchange in our country is still lacking

• The risks and complications associated with this procedure are minimal and manageable

• Utilization of this procedure in large scale will prove beneficiary to patients

CONCLUSION

Therapeutic plasma exchange is• Safe• Cost effective and • Efficacious when performed with expertise in appropriate

indications

TPE

Thank you