Evidence Search Service Results of your search request Guideline revision: Therapeutic Plasma Exchange (TPE) in Critical Care ID of request: 7578 Date of request: 5th October, 2015 Date of completion: 20th October, 2015 If you would like to request any articles or any further help, please contact: Tom Roper at tom.roper@bsuh.nhs.uk Please acknowledge this work in any resulting paper or presentation as: Evidence search: Guideline revision: Therapeutic Plasma Exchange (TPE) in Critical Care. Tom Roper. (20th October, 2015). Brighton , UK: Brighton and Sussex Library and Knowledge Service. Sources searched EMBASE (33) MEDLINE (10) UpToDate (1) CINAHL (2) TRIP Database (1) BMJ Best Practice (0) Google (2) Cochrane Library (0) Date range used (5 years, 10 years): 2010 onwards Limits used (gender, article/study type, etc.): Human, adult, English language Search terms and notes (full search strategy for database searches below): Relevant natural language and controlled vocabulary terms were selected and combined. Final result sets were de-duplicated and reviewed for relevance by the searcher, irrelevant results being discarded. For more information about the resources please go to: http://www.bsuh.nhs.uk/work-andlearn/library-services/ . Summary of Results The journal literature doesn't help a great deal. Few of the papers retrieved were high level evidence. Contents National and International Guidance British Committee for Standards in Haematology Guideline on the clinical use of apheresis procedures for the treatment of patients and collection of cellular therapy products Joint United Kingdom (UK) Blood Transfusion and Tissue Transplantation Services Professional Advisory Committee Transfusion Handbook: 11.1: Therapeutic plasma exchange (TPE) Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology Evidence-based guideline update: Plasmapheresis in neurologic disorders Synopses or Summaries UpToDate Therapeutic apheresis (plasma exchange or cytapheresis): Indications and technology Original Research 1. Evaluation of plasma exchange and continuous veno-venous hemofiltration for the treatment of severe avian influenza A (H7N9): A cohort study 2. Safety of intravenous immunoglobulin and plasma exchange in critically ill patients 3. Sequential blood purification therapy for critical patients with hyperlipidemic severe acute pancreatitis 4. Acute generalized pustular psoriasis, von Zumbusch type, treated in the burn unit. A review of clinical features and new therapeutics 5. An institutional review of moderate to severe burn injury and therapeutic plasma exchange 6. Effects of plasma exchange combined with continuous renal replacement therapy on acute fatty liver of pregnancy 7. Hypertriglyceridaemia-induced acute pancreatitis: Is plasmapheresis really indicated? 8. Intravenous immunoglobulin vs plasma exchange in treatment of mechanically ventilated adults with Guillain-Barre syndrome 9. Management of Guillain-Barre syndrome with plasmapheresis or immunoglobulin: our experience from a tertiary care institute in South India 10. Plasmapheresis as treatment for hyperlipidemic pancreatitis. 11. Simultaneous extracorporeal membrane oxygenation and therapeutic plasma exchange procedures are tolerable in both pediatric and adult patients 12. Therapeutic plasma exchange as rescue therapy in severe sepsis and septic shock: Retrospective observational single-centre study of 23 patients 13. Therapeutic plasma exchange in the management of sepsis and multiple organ dysfunction syndrome: a report of three cases. 14. Variable ganciclovir concentrations in a critically ill patient receiving continuous renal replacement therapy and plasma exchange? 15. Complications in patients treated with plasmapheresis in the intensive care unit. 16. ECMO and plasmapheresis due to ANCA positive vasclitis 17. Effects of Double Filtration Plasmapheresis on Nocturnal Respiratory Function in Myasthenic Patients 18. Pharmacokinetic profile of voriconazole in a critically ill patient on therapeutic plasma exchange. 19. Plasma exchange as a complementary approach to snake bite treatment: an academic emergency department's experiences. 20. Plasmapheresis in the Management of Severe Hypertriglyceridemia. 21. Pro-inflammatory cytokine profile of critically ill septic patients following therapeutic plasma exchange. 22. Succ essful use of lipid infusion and plasmapheresis after massive bupropion overdose 23. Supportive Therapy for a Patient With Toxic Epidermal Necrolysis Undergoing Plasmapheresis. 24. Therapeutic plasma exchange as de-coppering technique in intensive care for an adult in a Wilson's crisis 25. Therapeutic plasma exchange: an effective treatment in ethylene dibromide poisoning cases. 26. Treatment and prognostic factors for long-term outcome in patients with anti-NMDA receptor encephalitis: an observational cohort study. 27. A case of HELLP syndrome: an immuno-"logical" approach. 28. Application of hybrid blood purification treatment for severe acute arsine poisoning 29. Direct thrombin inhibitors-a case indicating benefit from 'plasmapheresis' in toxicity: A call for establishing "gUIDELINES" in overdose and to find an "aNTIDOTE"! 30. Effectiveness of Combining Plasma Exchange With Continuous Hemodiafiltration on Acute Fatty Liver of Pregnancy Complicated by Multiple Organ Dysfunction 31. Efficacy and safety of first-line rituximab in severe, acquired thrombotic thrombocytopenic purpura with a suboptimal response to plasma exchange. Experience of the French Thrombotic Microangiopathies Reference Center 32. Plasma exchange in the management of a case of hypertriglyceridaemic pancreatitis triggered by venlafaxine 33. Simultaneous extracorporeal membrane oxygenation and therapeutic plasma exchange procedures are safe and effective in both pediatric and adult patients 34. Surviving the storm: two cases of thyroid storm successfully treated with plasmapheresis 35. Therapeutic plasma exchange in an uncommon disease: Stiff-Person Syndrome: Case report [English;Turkish] Si{dotless}ra di{dotless}si{dotless} bir hastali{dotless}kta terapotik plazma degisimi: Stiff-Person sendromu 36. A phase 2 study of the safety and efficacy of rituximab with plasma exchange in acute acquired thrombotic thrombocytopenic purpura 37. Comparison of IVIg and PLEX in patients with myasthenia gravis 38. N-methyl-D-aspartate receptor autoimmune encephalitis presenting with opsoclonusmyoclonus: Treatment response to plasmapheresis 39. Therapeutic plasma exchange in 4 patients with acute demyelinating encephalomyelitis (ADEM) 40. Therapeutic plasma exchange in an intensive care unit (ICU): a 10-year, single-center experience. 41. A phase II study to assess the safety, efficacy and tolerability of rituximab (mabthera) in combination with plasma exchange in patients with acute thrombotic thrombocytopenic purpura (TTP) 42. Benefit of plasma exchange in haemolyticuremic syndrom (HUS) is not related to removal of sCD40L 43. Physiological changes during and outcome following 'filtration' based continuous plasma exchange in Guillain Barre Syndrome 44. Plasma exchange in patients with the diagnosis of Guillain-Barre syndrome: An experience in intensive care unit 45. The challenges of diagnosing thrombotic thrombocytopenic purpura in the critically ill. A case report Search History National and International Guidance British Committee for Standards in Haematology Guideline on the clinical use of apheresis procedures for the treatment of patients and collection of cellular therapy products (2013) Available online at this link Joint United Kingdom (UK) Blood Transfusion and Tissue Transplantation Services Professional Advisory Committee Transfusion Handbook: 11.1: Therapeutic plasma exchange (TPE) (2013) Available online at this link Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology Evidence-based guideline update: Plasmapheresis in neurologic disorders (2011) Cortese I., Chaudhry V., So YT, Cantor F., Cornblath DR, Rae-Grant A. Available online at this link OBJECTIVE: To reassess the role of plasmapheresis in the treatment of neurologic disorders. METHODS: We evaluated the available evidence based on a structured literature review for relevant articles from 1995 through September 2009. In addition, due to revision of the definitions of classification of evidence since the publication of the previous American Academy of Neurology assessment in 1996, the evidence cited in that manuscript was reviewed and reclassified. RESULTS AND RECOMMENDATIONS: Plasmapheresis is established as effective and should be offered in severe acute inflammatory demyelinating polyneuropathy (AIDP)/Guillain-Barré syndrome (GBS) and in the short-term management of chronic inflammatory demyelinating polyneuropathy (Class I studies, Level A). Plasmapheresis is established as ineffective and should not be offered for chronic or secondary progressive multiple sclerosis (MS) (Class I studies, Level A). Plasmapheresis is probably effective and should be considered for mild AIDP/GBS, as secondline treatment of steroid-resistant exacerbations in relapsing forms of MS, and for neuropathy associated with immunoglobulin A or immunoglobulin G gammopathy, based on at least one Class I or 2 Class II studies (Level B). Plasmapheresis is probably not effective and should not be considered for neuropathy associated with immunoglobulin M gammopathy, based on one Class I study (Level B). Plasmapheresis is possibly effective and may be considered for acute fulminant demyelinating CNS disease (Level C). There is insufficient evidence to support or refute the use of plasmapheresis for myasthenia gravis, pediatric autoimmune neuropsychiatric disorders associated with streptococcus infection, and Sydenham chorea (Class III evidence, Level U). Synopses or Summaries UpToDate Therapeutic apheresis (plasma exchange or cytapheresis): Indications and technology (2015) Fridey JL, Kaplan AA Available online at this link See also Therapeutic apheresis (plasma exchange or cytapheresis): Complications at http://www.uptodate.com/contents/therapeutic-apheresis-plasma-exchange-or-cytapheresiscomplications Original Research 1. Evaluation of plasma exchange and continuous veno-venous hemofiltration for the treatment of severe avian influenza A (H7N9): A cohort study Liu X. Therapeutic Apheresis and Dialysis 2015;19(2):178-184. Avian influenza A (H7N9) is a severe disease with high mortality. Hypercytokinemia is thought to play an important role in the pathogenesis. This study was to investigate the efficiency of plasma exchange (PE)+continuous veno-venous hemofiltration (CVVH) on the removal of inflammatory mediators and their benefits in the management of fluid overload and metabolic disturbance. In total, 40 H7N9-infected patients were admitted to our hospital. Sixteen critically ill H7N9-infected patients received combination of PE and CVVH. Data from these 16 patients were collected and analyzed. The effects of PE+CVVH on plasma cytokine/chemokine levels and clinical outcomes were examined. H7N9-infected patients had increased plasma levels compared to healthy controls. After 3h of PE+CVVH treatment, the cytokine/chemokine levels descended remarkably to lower levels and were maintained thereafter. PE+CVVH also benefited the management of fluid, cardiovascular dysfunction and metabolic disturbance. Of the 16 critically ill patients who received PE+CVVH, 10 patients survived. PE+CVVH decreased the plasma cytokine/chemokine levels significantly. PE+CVVH were also beneficial to the management of severe avian influenza A (H7N9). 2. Safety of intravenous immunoglobulin and plasma exchange in critically ill patients Clark S.L. Neurological Research 2015;37(7):593-598. Objective: To assess the safety profile of intravenous immunoglobulin (IVIG) and plasma exchange (PLEX) when used to treat critically ill patients. Methods: We performed a retrospective analysis of consecutive patients who received IVIG or PLEX while admitted to our medical intensive care unit (ICU), neuroscience ICU or haematologic/oncologic ICU between 2007 and 2011.Patients who were transferred into an ICU while receiving therapy or who continued therapy after discharge from the ICU were included in the analysis. Results: A total of 118 consecutive patients were included in the study. Fifty-nine patients received IVIG. Twenty of these patients (34%) developed renal failure during the hospitalisation, including 15 (25.4%) in whom renal function worsened during or shortly after IVIG administration and 4 (6.8%) in whom IVIG was considered a possible cause. Transfusion reactions occurred in five patients (8%). Seven patients (12%) did not receive the full intended course of IVIG. Thirty-four patients (58%) who received IVIG died during their hospitalisation. Fifty-nine patients received PLEX. Hypotension requiring an intervention was noted with 39 sessions (8.5%) and led to discontinuation of the session in 11 (2.4%). Other adverse events included line-related infections (n=4), pneumothorax (n=4) and electrolyte abnormalities and transfusion reactions (n=10). Six patients (10%) did not receive full intended treatment course of PLEX. Nineteen patients (32%) treated with PLEX died during their hospitalisation. Discussion: Intravenous immunoglobulin and PLEX are generally well tolerated by critically ill patients. Intravenous immunoglobulin was associated with worsening renal function in one-quarter of patients. 3. Sequential blood purification therapy for critical patients with hyperlipidemic severe acute pancreatitis Wang H.L. World Journal of Gastroenterology 2015;21(20):6304-6309. AIM: To evaluate the efficacy of sequential blood purification therapy in the treatment of critical patients with hyperlipidemic severe acute pancreatitis. METHODS: Thirty-one intensive care unit (ICU) patients with hyperlipidemic severe acute pancreatitis treated at the Second Affiliated Hospital of Harbin Medical University were divided into either a study group (n = 15; July 1, 2012 to June 30, 2014) or a control group (n = 16; July 1, 2010 to June 30, 2012) based on the implementation of sequential blood purification therapy. The control group received continuous venous-venous hemofiltration (CVVH) on the basis of conventional treatments, and the therapeutic dose of CVVH was 30 mL/kg per hour. The study group received sequential plasma exchange and CVVH on the basis of conventional treatments. The anticoagulation regimen of CVVH is the regional citrate anticoagulation. Mortality rate on day 28, rates of systemic and local complications, duration of ICU, and time to target serum lipid level, as well as physiologic and laboratory indices were compared between the two groups. RESULTS: The mortality rate on day 28 was significantly lower in the study group than in the control group (13.33% vs 37.50%; P < 0.05). The duration of ICU stay was significantly shorter in the study group than in the control group (7.4 +/- 1.35 d vs 9.19 +/-2.99 d, P < 0.05). The time to target serum lipid level was significantly shorter in the study group than in the control group (3.47 +/- 0.52 d vs 7.90 +/- 1.14 d, P < 0.01). There were no significant differences in the rates of systemic complications and local complications between the two groups (60% vs 50% and 80% vs 81%, respectively). In the comparisons of physiologic and laboratory indices, serum albumin and C-reactive protein were significantly better in the study group than in the control group after treatment (37.8 +/- 4.6 g/L vs 38.9 +/- 5.7 g/L, and 20.5 +/- 6.4 mg/L vs 28.5 +/- 7.1 mg/L, respectively, both P < 0.05). With the exception of plateletcrit, no other indices showed significant differences between the two groups. CONCLUSION: Sequential blood purification therapy is effective in the treatment of ICU patients with hyperlipidemic severe acute pancreatitis and can improve patient prognosis. Available from National Library of Medicine in this link 4. Acute generalized pustular psoriasis, von Zumbusch type, treated in the burn unit. A review of clinical features and new therapeutics Pizano L.R. Burns : journal of the International Society for Burn Injuries 2014;40(4):e35e39. Generalized pustular psoriasis (GPP) is an immune-mediated dermatologic condition that is characterized by a widespread eruption of sterile, subcorneal pustules. Cases of GPP may present to the burn intensive care unit (ICU), and they may be confused with toxic epidermal necrolysis (TEN) due to the generalized erythema and desquamation. GPP often benefits from admission to an ICU for management of fluid and electrolyte imbalances and for complications such as pneumonitis, renal dysfunction and sepsis. We present the case of a 42 year-old man who was transferred to the burn unit for presumed TEN where he was diagnosed with GPP and successfully treated with intravenous cyclosporine and supportive care. Our objective is to increase awareness of this condition in the critical care community, discuss clinical and laboratory findings, and to review the treatment guidelines published by the National Psoriasis Foundation in August 2012. We also discuss the latest reports utilizing biological response modifying drugs. Available from Elsevier in this link 5. An institutional review of moderate to severe burn injury and therapeutic plasma exchange Rivera E.A. Journal of Burn Care and Research 2014;35:-. Introduction: For patients with moderate to severe burn injury, crystalloid resuscitation remains the foundation of initial therapy. Nevertheless, a subgroup of patients fail resuscitation and develop burn shock. Our institution has defined resuscitative failure and protocolized adjuncts including therapeutic plasma exchange (TPE). We have observed patients who fail to respond after initial TPE and subsequently undergo a second plasma exchange. For this project, we hypothesized that patients who require more than one plasma exchange do not survive. Methods: An IRB approved retrospective review was conducted of all patients receiving plasma exchange at our burn center between January 2008 and June 2013. Data collected included age, burn size, revised Baux score, presence of inhalational injury, ventilator days, ICU length of stay and mortality. A review of patients and outcomes during the same time period with similar thermal injury at our institution were compared. Results: A total of 365 pediatric and adult patients were admitted to our ICU with thermal injury greater than 15% TBSA between January 1, 2008 and June 31, 2013. A total of 44 (12%) patients received plasma exchange; 7 (2%) patients underwent 2 plasma exchanges; no patient underwent a third plasma exchange. Data are summarized in the Table. Conclusions: Most patients respond to a single TPE with improved hemodynamics. Patients who require two plasmapheresis treatments tend to have significantly larger burns. Whereas the number of patients who require more than one plasma exchange have a significantly higher mortality rate than those who responded to one intervention ~ 30% did survive. Hence the need for more than one plasma exchange should not be considered to be an indication to withdraw aggressive critical care. (Table presented). 6. Effects of plasma exchange combined with continuous renal replacement therapy on acute fatty liver of pregnancy Yu C.B. Hepatobiliary and Pancreatic Diseases International 2014;13(2):179-183. BACKGROUND: Acute fatty liver of pregnancy (AFLP) in the third trimester or early postpartum period can lead to fatal liver damage. Its traditional therapy is not very effective in facilitating hepatic recovery. The safety and effect of plasma exchange (PE) in combination with continuous renal replacement therapy (CRRT) (PE+CRRT) for AFLP still needs evaluation. METHODS: Five AFLP patients with hepatic encephalopathy and renal failure were subjected to PE+CRRT in our department from 2007 to 2012. Their symptoms, physical signs and results were observed, and all relevant laboratory tests were compared before and after PE+CRRT. RESULTS: All the 5 patients were well tolerated to the therapy. Four of them responded to the treatment and showed improvement in clinical symptoms/signs and laboratory results, and they were cured and discharged home after the treatment. One patient succeeded in bridging to transplantation for slowing down hepatic failure and its complications process after 2 treatment sessions. Intensive care unit stay and hospital stay were 9.4 (range 5-18) and 25.0 days (range 11-42), respectively. CONCLUSION: PE+CRRT is safe and effective and should be used immediately at the onset of hepatic encephalopathy and/or renal failure in patients with AFLP. &#xa9; 2014, Hepatobiliary Pancreat Dis Int. All rights reserved. Available from Elsevier in this link 7. Hypertriglyceridaemia-induced acute pancreatitis: Is plasmapheresis really indicated? Collis L.G. Journal of the Intensive Care Society 2014;15(1):66-69. A 47-year-old man presented with severe acute pancreatitis, thought to be hypertriglyceridaemia-induced. Serum triglyceride concentration fell from 42.4 mmol/L to 5.9 mmol/L by day three with fasting alone. Hypertriglyceridaemia precipitates a small but significant proportion of acute pancreatitis episodes, especially during pregnancy. Treatment strategies are discussed, with special focus on plasmapheresis. The reduction in serum triglyceride concentration achieved by plasmapheresis is similar to that achieved by fasting alone, or in conjunction with insulin or heparin therapy. It is possible that plasmapheresis may offer the patient more harm than benefit. Currently, there is insufficient evidence to either recommend or reject plasmapheresis in triglyceride-induced acute pancreatitis. &#xa9; The Intensive Care Society 2014. Available from Highwire Press in this link 8. Intravenous immunoglobulin vs plasma exchange in treatment of mechanically ventilated adults with Guillain-Barre syndrome Charra B. Pan African Medical Journal 2014;18:-. Introduction: The aim of the study is to compare efficacy of IvIg versus PE in treatment of mechanically ventilation adults with GBS in intensive care unit. Methods: It is a prospective, non randomized study, realized in a medical ICU from 2006 to 2010. We included all patients with GBS who required mechanical ventilation (MV). We defined two groups: group 1 (group treated by IvIg: 0.4 g/kg/day for 5 days) and group 2 (group treated by PE: 4 PE during 10-14 days). We collected demographic characteristics, clinical and therapeutic aspects and outcome. Statistical analysis used: The quantitative variables are expressed on mean +/- standard derivation and compared by Student test. The statistic analysis has been based on SPSS for windows. P < 0.05 is considered as significant. Results: Forty-one patients (21 in group 1 and 20 in group 2) were enrolled. The mean age was 37.4 +/- 9.2 years, with a masculine predominance (75.4%). Electromyogram in all patients found acute inflammatory demyelinating polyradiculoneuropathy in 80.5 % of patients. The mean length of hospitalization was 45.3 +/- 9.2 days. The length of hospitalization of the IvIg group is less long than PE group (p = 0.03). The weaning of the MV was more precocious in IvIg group than PE group (p = 0.01). Also, the beginning of motility recuperation was precocious at IvIg group than PE group (p = 0.04). Conclusion: Our work reveals a meaningful difference for the MV weaning and precocious recovery in IvIg group compared to PE group. &#xa9; Boubaker Charra et al. Available from National Library of Medicine in this link 9. Management of Guillain-Barre syndrome with plasmapheresis or immunoglobulin: our experience from a tertiary care institute in South India Kishore C.K. Renal failure 2014;36(5):732-736. Guillain-Barre syndrome (GBS), an acute inflammatory demyelinating polyneuropathy is the most common generalized paralytic disorder. The objective was to study the outcome of disability grade in two groups of GBS treated with plasmapheresis alone and treated with IVIg alone. A retrospective analysis of all consecutive patients with GBS, admitted in our intensive care unit during the period of 3 years, 2009-2012 were included in the study. All patients of GBS who were to be treated with plasmapheresis or IVIg, the modality of management were always decided at their preference and consent after explaining the modalities to patient/family. The plasma exchange done was ~200-250mL of plasma per kilogram weight in five sessions (40-50mL/kg per session) within 7-14 days. The replacement fluid contained 100mL of 20% albumin diluted in 1000mL of normal saline and 1000mL of fresh frozen plasma. IVIg was administered as 0.4g/kg body weight daily for 5 days. Our observations brought out the following, both the plasmapheresis and IVIg treatments were effective in reducing the disability grade amongst all time points, i.e., at presentation, immediate post-therapy and after 4 weeks. There was a marginal superiority in plasmapheresis over IVIg effect. However, whether the delay in presentation as noted in our study probably would have contributed to this effect was conjectural. 10. Plasmapheresis as treatment for hyperlipidemic pancreatitis. Ramírez-Bueno A. European journal of internal medicine 2014;25(2):160-. Severe hypertriglyceridemia with an accumulation of chylomicrons and triglyceride figures >1000 mg/dL can cause acute pancreatitis, a potentially fatal complication. The option of rapid reduction in triglyceride concentrations is attractive and possible with plasmapheresis. We present the results of an analysis of 11 patients admitted to the intensive care unit with severe hypertriglyceridemic pancreatitis and treated with plasmapheresis. The procedure was repeated until serum triglycerides were below 1000 mg/dL. We recorded anthropometric, clinical data as well as final outcome. In eight patients a single plasma exchange was sufficient to reduce triglyceride figures <1000 mg/dL. Only three patients died, all with the worst severity indexes and who experienced the longest delay before the procedure. Our results, together with a review of the literature, confirm the need for a randomized clinical trial to compare conventional treatment vs. plasmapheresis in patients with severe hypertriglyceridemic pancreatitis. © 2013. Available from Elsevier in this link 11. Simultaneous extracorporeal membrane oxygenation and therapeutic plasma exchange procedures are tolerable in both pediatric and adult patients Dyer M. Transfusion 2014;54(4):1158-1165. Background Extracorporeal membrane oxygenation (ECMO) has been used in patients with pulmonary and/or cardiac disease. In rare circumstances, some patients may have to undergo simultaneous therapeutic plasma exchange (TPE). We sought to characterize simultaneous ECMO and TPE procedures at our institution. Study Design and Methods Retrospective analysis of medical records was performed for patients who underwent simultaneous ECMO and TPE. Patient demographics, diagnoses, TPE indications and variables, procedural complications, blood use, laboratory data, and outcomes were collected. Results Seventy-six patients underwent 293 simultaneous ECMO and TPE procedures; the majority involved pediatric patients, and most patients weighed less than 15 kg. In children, the two most frequent reasons for ECMO were congenital cardiac disease and sepsis; in adults, they were congestive heart failure or cardiomyopathy and severe pulmonary disease. In children, the two most frequent indications for TPE while on ECMO were multisystem organ failure and coagulopathy; in adults, they were humoral rejection of cardiac and pulmonary allografts. Blood product utilization during simultaneous ECMO and TPE was substantial in all patients. The complications of simultaneous ECMO and TPE were hypocalcemia (47 and 27.6% in children and adults, respectively) and hypotension (22.1 and 34.2% in children and adults, respectively). Approximately 45% of children and adults had resolutions of their apheresis indications after completing their TPE regimen. Conclusions Despite the hypocalcemic and hypotensive reactions that occurred during simultaneous ECMO and TPE, apheresis treatment regimens were successfully completed in all patients. With clear communication between ECMO and apheresis teams, along with close patient and instrument monitoring, simultaneous ECMO and TPE is tolerable and can be performed in critically ill children and adults. &#xa9; 2013 American Association of Blood Banks. 12. Therapeutic plasma exchange as rescue therapy in severe sepsis and septic shock: Retrospective observational single-centre study of 23 patients Hadem J. BMC Anesthesiology 2014;14:-. Background: Several case series and small randomized controlled trials suggest that therapeutic plasma exchange (TPE) improves coagulation, hemodynamics and possibly survival in severe sepsis. However, the exact role of TPE in modern sepsis therapy remains unclear .Methods: We performed a retrospective observational single-centre study on the use of TPE as rescue therapy in 23 consecutive patients with severe sepsis or septic shock from 2005 to 2012. Main surrogate markers of multiple organ failure (MOF) before, during and after TPE as well as survival rates are reported. Results: At baseline, mean SOFA score was 13 (standard deviation [SD] 4) and median number of failed organ-systems was 5 (interquartile range [IQR] 4-5). TPEs were performed 3 days (IQR 2-10) after symptom onset and 1 day (IQR 0-8) after ICU admission. The median total exchange volume was 3750 ml (IQR 2500-6000), which corresponded to a mean of 1.5 times (SD 0.9) the individual plasma volume. Fresh frozen plasma was used in all but one treatments as replacement fluid. Net fluid balance decreased significantly within 12 hrs following the first TPE procedure by a median of 720 mL (p = 0.002), irrespective of outcome. Reductions of norepinephrine dose and improvement in cardiac index were observed in individual survivors, but this was not significant for the overall cohort (p = 0.574). Platelet counts decreased irrespective of outcome between days 0 and 2 (p < 0.003), and increased thereafter in many survivors. There was a non-significant trend towards younger age and higher procalcitonin levels among survivors. Nine out of 23 TPE treated patients (39%) survived until ICU discharge (among them 3 patients with baseline SOFA scores of 15, 17, and 20). Conclusions: Our data suggest that some patients with severe sepsis and septic shock may experience hemodynamic stabilisation by early TPE therapy. &#xa9; 2014 Hadem et al.; licensee BioMed Central Ltd. Available from Springer NHS Pilot 2014 (NESLi2) in ; Note: ; Collection notes: AcademicLicense. Please when asked to pick an institution please pick NHS. Please also note access is from 1997 to date only.this link Available from ProQuest in this link Available from National Library of Medicine in this link 13. Therapeutic plasma exchange in the management of sepsis and multiple organ dysfunction syndrome: a report of three cases. De Simone Nicole Journal of clinical apheresis 2014;29(2):127-. Sepsis with multi organ dysfunction syndrome (MODS) is the most common cause of death in patients in noncoronary intensive care units. Currently, there are no specific treatments that reduce mortality in patients with sepsis and MODS. We report three patients who received therapeutic plasma exchange (TPE) for sepsis with MODS who completely recovered. The first patient, a 3-year-old male presented with Methicillin-resistant Staphylococcus aureus-associated respiratory, renal, coagulation, hepatic, and neurologic dysfunction. After 5 TPEs, the patient fully recovered. The second patient was a 36-yearold pregnant female who developed MODS at 22 weeks of gestation. She had developed respiratory, hepatic, renal, cardiovascular, neurologic, and coagulation dysfunction following pneumonia and concurrent urinary tract infection resulting in an intrauterine fetal demise. After 8 TPEs, the patient was discharged home with only mild residual hepatic dysfunction. The third patient, a 50-year-old female with a history of seizure disorder, was found unresponsive in over 100°F heat and diagnosed with Staphylococcus aureusassociated MODS. Her respiratory, coagulation, neurologic, renal, and hepatic systems were affected. The patient underwent 6 TPEs after which she had marked improvement. In conclusion, TPE may be an effective adjunct therapy in MODS by possibly removing toxic mediators and replacing deficient factors using donor plasma. Copyright © 2013 Wiley Periodicals, Inc. 14. Variable ganciclovir concentrations in a critically ill patient receiving continuous renal replacement therapy and plasma exchange? Roberts J.A. International journal of antimicrobial agents 2014;43(6):572-573. Available from Elsevier in this link 15. Complications in patients treated with plasmapheresis in the intensive care unit. Szczeklik Wojciech Anaesthesiology intensive therapy 2013;45(1):7-. Plasmapheresis is one of the methods of extracorporeal blood purification involving the removal of inflammatory mediators and antibodies. The procedure is used in a variety of conditions, including autoimmune diseases. The aim of the present study was to analyse the incidence of plasmapheresis-related complications in patients treated in the intensive care unit (ICU). The analysis involved 370 plasmapheresis procedures in 54 patients. The data were collected from patients' medical records, including procedure protocols. The most common diseases treated with plasmapheresis included: myasthenia gravis (33.3%), Guillain-Barre syndrome (14%), Lyell's syndrome (9.3%), systemic lupus erythematosus (7.4%), and thrombotic thromcytopenic purpura (7.4%). The adverse side effects observed most frequently during plasma filtration were: fall in arterial blood pressure (8.4% of all procedures), arrhythmias (3.5%), sensations of cold with temporarily elevated temperature and paresthesias (1.1%, each). In most cases the symptoms were mild and transient. Severe and life-threatening episodes, i.e. shock, fall in arterial blood pressure requiring pressor amines, persistent arrhythmias and haemolysis, developed in 2.16% of procedures. Plasmapheresis can be considered a relatively safe method of treatment of ICU patients. Continuous observation and proper monitoring of patients provided by highly trained medical personnel are essential for its safety. 16. ECMO and plasmapheresis due to ANCA positive vasclitis Tomas D. International Journal of Artificial Organs 2013;36(4):-. Introduction: Wegener's granulomatosis (WG) is a systemic vasculitis characterized by the involvement of respiratory tracts. Alveolar haemorrhage (DAH) occurs as a consequence of pulmonary capillaritis in the ANCA-associated vasculitides. ECMO has been shown to be life-saving for adults with severe hypoxaemia from DAH caused by vasculitis with positive cANCA. We report the case of the patient with DAH from ANCA-associated vasculitis that was supported with ECMO. Case report: A 51-year-old women admitted to intensive care unit due to cause unknown respiratory failure. She was transferred to the ICU of the Cardiothoracic Centre within the first 24 hours after admission with rapid deterioration of blood gases. The emergent veno-venous ECMO was established. The total ECMO run was 21 days. During this period the diagnosis of Wegener granulmatosis complicated with alveolar haemorrhage was made. She underewent repeated course of plasmapheresis and the high dose of steroids, cyclophosphamide and intravenous immunoglobulin were administered during the ECMO period. Results: Patient was transferred to the local hospital requiring conventional artificial ventilation after 25 days. Due to severe critical illness myopathy and polyneuropathy with extreme muscle weakness and medical devices related infection she spent in diffrent hospitals more than 6 months. Finally she had been discharged to home and she was ready to return back to her job approx 1 year after beginning of her troubles. Conclusion: Use of ECMO during treatment of severe hypoxaemia from alveolar bleeding due to vasculitis is rare and there are only few artricles in literature. Although the presence of systemic disease and bleeding diathesis is generally considered to be a contraindication to ECMO, we report the successful use. Reported case shows the complexity, the difficulty and the necessity of the multidisciplinary approach during treatment respiratory failure. 17. Effects of Double Filtration Plasmapheresis on Nocturnal Respiratory Function in Myasthenic Patients Yeh J.H. Artificial Organs 2013;37(12):1076-1079. Assessment of respiratory function using combined oximetry-cutaneous capnography has never been evaluated in patients with myasthenia gravis (MG). We investigated the effects of double filtration plasmapheresis (DFPP) on respiratory status in 18 MG patients. Results of combined oximetry and transcutaneous capnography, MG scores, and acetylcholine receptor antibody titers before and after DFPP treatment were compared. The respiratory monitoring was performed at three time periods (morning, afternoon, and sleep). Mean MG score was markedly lower after DFPP treatment (5.7) than before treatment (7.9). Before DFPP, the minimum pulse oximetric saturation (SpO<sub>2</sub>) level obtained during the night session was significantly lower (P=0.0513 and P=0.0199) than the levels obtained during the two daytime sessions. A similar phenomenon was noted for maximum transcutaneous carbon dioxide tension (PtcCO<sub>2</sub>). After DFPP treatment, the maximum and mean PtcCO<sub>2</sub> levels were significantly higher (P=0.0056) in the morning than in the afternoon. Of all the respiratory function parameters measured, only minimum SpO<sub>2</sub> levels obtained during morning sessions before DFP treatment differed significantly from those obtained after DFPP treatment (P=0.0322). Overall, however, minimum SpO<sub>2</sub> levels as well as mean and maximum PtcCO<sub>2</sub> levels improved significantly during sleep after DFPP. In conclusion, we found that respiratory function abnormalities were common in myasthenic patients without clinical respiratory symptoms. DFPP treatment resulted in minimal improvement of respiratory parameters. &#xa9; 2013 Wiley Periodicals, Inc. and International Center for Artificial Organs and Transplantation. 18. Pharmacokinetic profile of voriconazole in a critically ill patient on therapeutic plasma exchange. Spriet Isabel Therapeutic drug monitoring 2013;35(1):141-. Extracorporeal removal of drugs during therapeutic plasma exchange (TPE) can lead to decreased efficacy, as shown in several reports discussing altered pharmacokinetics (PKs) of antibiotics during TPE. In particular, drugs with a low volume of distribution or a high protein binding are susceptible to extracorporeal removal, as these drugs remain substantially within the intravascular space. No information is known about antifungal drug removal during TPE. We report the PKs of voriconazole in a critically ill patient undergoing TPE. A 61-year-old man, presenting with catastrophic antiphospholipid syndrome for which TPE was started, developed probable pulmonary invasive aspergillosis. Intravenous voriconazole was started. Blood samples were taken under steady state conditions to calculate PK parameters of voriconazole, both with and without TPE. PK parameters (area under the curve, Cl, Vd, and t1/2) were equivalent on both days. Voriconazole has a distribution volume of 4.5 L/kg and a protein binding of 58%, suggesting that drug removal during TPE would not be clinically significant. Our data support this assumption. Based on our findings, it seems that TPE does not alter the PK behavior of voriconazole. Voriconazole dosages should not be adjusted during TPE. 19. Plasma exchange as a complementary approach to snake bite treatment: an academic emergency department's experiences. Zengin Suat Transfusion and apheresis science : official journal of the World Apheresis Association : official journal of the European Society for Haemapheresis 2013;49(3):494-. Snake bites are leading causes of morbidity and mortality worldwide, especially in rural areas. Therapeutic plasma exchange has been used in the treatment of many different conditions such as immunologic diseases, toxicologic disorders, and snake envenomation. The aim of this study is to evaluate the efficacy of plasma exchange treatment on clinical status, outcomes, and discharge of patients who were bitten by venomous snakes. The study was conducted retrospectively in the Emergency Department of Gaziantep University from January 2002 to December 2011. Thirty-seven patients were included in the present study. Routine biochemical and hematologic laboratory parameters were studied before and after plasma exchange. Demographic data, clinical status, and outcomes of patients were recorded. Plasma exchange was performed by using centrifugation technology via an intravenous antecubital or subclavian vein catheter access. Human albumin/fresh frozen plasma was used as replacement fluids. A significant correlation was seen between therapeutic plasma exchange and improvement of laboratory results. None of the study patients lost their limbs. Eight patients were sent to the intensive care unit. The mean length of the hospital stay was 12.2 days (4-28). All patients were discharged with good recovery. No complications were seen during the 3 months following discharge. Plasma exchange appears to be an effective treatment intervention for snake bite envenomations, especially in the management of hematologic problems and in limb preservation/salvage strategies. In addition to traditional treatment methods, plasma exchange should be considered by emergency physicians in cases of snake bite envenomation as a therapeutic approach to facilitate rapid improvement. Copyright © 2013 Elsevier Ltd. All rights reserved. Available from Elsevier in this link 20. Plasmapheresis in the Management of Severe Hypertriglyceridemia. Seda Gilbert Critical Care Nurse 2013;33(4):18-25. Plasmapheresis 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) Available from CRITICAL CARE NURSE in this link Available from EBSCOhost in this link Available from Highwire Press in this link 21. Pro-inflammatory cytokine profile of critically ill septic patients following therapeutic plasma exchange. Hamishehkar Hadi Transfusion and apheresis science : official journal of the World Apheresis Association : official journal of the European Society for Haemapheresis 2013;48(1):75-. Severe sepsis involves a generalized inflammatory response, mediated by a number of various cytokines and factors. Plasma exchange (PE) has been proposed as a therapeutic approach to improve survival of patients with severe sepsis and septic shock. The theory is that removing harmful excessive endogenous inflammatory mediators is beneficial. Upon establishment of a diagnosis of severe sepsis, twelve patients received PE plus conventional sepsis treatment. Interleukin (IL)-6, IL-1β and tumor necrosis factor (TNF)-α were assayed before and after each session of PE. There were no significant changes in cytokine plasma levels after each PE session compared to pre-procedure levels. Among measured pro-inflammatory cytokines, only the plasma levels of IL-6 before the 2nd and 3rd PE sessions were lower than baseline levels (p=0.011 and p=0.012, respectively). All patients tolerated PE therapy well without any adverse effects or homodynamic instability. The results of this study showed that PE does not have a direct and rapid effect on plasma level of TNF-α, IL-1β and IL-6. Copyright © 2012 Elsevier Ltd. All rights reserved. Available from Elsevier in this link 22. Succ essful use of lipid infusion and plasmapheresis after massive bupropion overdose Tolentino S. Critical Care Medicine 2013;41(12 SUPPL. 1):-. Introduction: We successfully treated an adolescent after a massive intentional bupropion overdose by intravenous (IV) lipid infusion followed by plasmapheresis. 17 year-old male presented to emergency room after an ingestion of 12 grams bupropion as Wellbutrin-SR taken over 6 hours. Initially he was awake, alert, with stable vital signs and unremarkable labs, but became increasingly somnolent and developed a tonic-clonic seizure resistant to repeated doses of lorazepam. He was intubated, and soon after exhibited hypotension and bradycardia, which degenerated into pulseless electrical activity. Spontaneous circulation returned following standard resuscitation maneuvers, however hypotension and intermittent runs of polymorphic wide-QRS tachycardia persisted. To prevent deterioration, we administered a 140mL IV bolus of 20% Intralipid followed by 800mL infusion over 4 hours based on reported success of "lipid rescue" following certain overdoses. Plasmapharesis was initiated at 21 h post-ingestion and repeated at 34h. He remained arrhythmia-free and hemodynamically stable thereafter, was extubated on hospital day (HD) 5, and discharged on HD 19. Bupropion is highly lipid-soluble and protein-bound. Toxicity manifests at much lower doses as seizures, sinus tachycardia, and conduction derangements; survival after a 12 g overdose is rare. Typical reported toxicity is mild and treated symptomatically. "Lipid rescue" has been used to treat adult cardiovascular collapse after local anesthetic, tricyclic antidepressant (TCA), and serotonin-specific reuptake inhibitor (SSRI) overdose. The postulated mechanism of action is as "lipid sink," wherein the administered lipids bind to the offending drug, prevent its distribution into the fatty tissues, and thus mitigate its toxicity. A cardioprotective effect of "lipid rescue" has also been proposed. Despite several reports of successful "lipid rescue" in pediatric patients, its utility is not well established. This is the first report of "lipid rescue" followed by plasmapheresis after a massive overdose of bupropion in a pediatric patient. The combination of "lipid sink" and plasmapheresis (used to eliminate bupropion complexed to lipids and proteins) likely contributed to our patient's survival. Available from KSS Journals @ Ovid in this link 23. Supportive Therapy for a Patient With Toxic Epidermal Necrolysis Undergoing Plasmapheresis. Seczynska Bozena Critical Care Nurse 2013;33(4):26-39. A patient with severe toxic epidermal necrolysis underwent 2 cycles of therapeutic plasma exchange and received specialized wound care for widespread skin damage of more than 80% of his body surface area. Extensive involvement of mucous membranes, including the conjunctivas and the oropharyngeal cavity, and damage of his genitourinary organs required meticulous wound care. Daily care of injuries of tissues affected only in the most severe cases of toxic epidermal necrolysis was provided by an experienced intensive care unit nursing team. A meticulous supportive therapy regimen was a major contributing factor to this patient's remission. (Critical Care Nurse. 2013;33[4]:26-38) Available from CRITICAL CARE NURSE in this link Available from EBSCOhost in this link Available from Highwire Press in this link 24. Therapeutic plasma exchange as de-coppering technique in intensive care for an adult in a Wilson's crisis Reynolds H.V. Anaesthesia and Intensive Care 2013;41(6):811-812. Available from ProQuest in this link Available from ANAESTHESIA AND INTENSIVE CARE in this link 25. Therapeutic plasma exchange: an effective treatment in ethylene dibromide poisoning cases. Pahwa Naresh Journal of clinical apheresis 2013;28(5):374-. Ethylene dibromide (EDB) poisoning is very common in Central India and has fatal outcome. EDB is highly protein bound and, therefore, it is suggested that therapeutic plasma exchange (TPE) may be useful in removing drug from body shortly after ingestion before EDB metabolizes and causes severe end organ damage. The aim of our study is to find the effect of time of start of TPE on survival outcome of EDB poisoning cases. Fiftyeight cases of EDB poisoning were reviewed from 2007 to 2012 in Department of critical care medicine in tertiary care hospitals at Indore. Five patients were discharged against medical advice and lost to follow up. TPE was done in 47 patients as early as possible and irrespective of appearance of clinical symptoms. TPE was not performed in six cases as they were hypotensive at admission. The patients with EDB poisoning were 15-45 yrs old with 3:2 male to female ratio. Out of 47 who received TPE, 39 patients survived. TPE had started within 24 h of ingestions of EDB in 36 out of 39 survived patients. Survival outcome was nine times higher in patients who received TPE within 24 h than after 24 h of ingestion. Survival rate was increased to 100% in patients where TPE was done within 12 h of ingestion of EDB. Early TPE help to remove plasma protein bound toxin with significant mortality reduction. However, delay in start of TPE after ingestion of poison has significant poor survival outcome. Copyright © 2013 Wiley Periodicals, Inc. 26. Treatment and prognostic factors for long-term outcome in patients with anti-NMDA receptor encephalitis: an observational cohort study. Titulaer J. The Lancet. Neurology 2013;12(2):157-. Anti-NMDA receptor (NMDAR) encephalitis is an autoimmune disorder in which the use of immunotherapy and the long-term outcome have not been defined. We aimed to assess the presentation of the disease, the spectrum of symptoms, immunotherapies used, timing of improvement, and long-term outcome. In this multi-institutional observational study, we tested for the presence of NMDAR antibodies in serum or CSF samples of patients with encephalitis between Jan 1, 2007, and Jan 1, 2012. All patients who tested positive for NMDAR antibodies were included in the study; patients were assessed at symptom onset and at months 4, 8, 12, 18, and 24, by use of the modified Rankin scale (mRS). Treatment included first-line immunotherapy (steroids, intravenous immunoglobulin, plasmapheresis), second-line immunotherapy (rituximab, cyclophosphamide), and tumour removal. Predictors of outcome were determined at the Universities of Pennsylvania (PA, USA) and Barcelona (Spain) by use of a generalised linear mixed model with binary distribution. We enrolled 577 patients (median age 21 years, range 8 months to 85 years), 211 of whom were children (<18 years). Treatment effects and outcome were assessable in 501 (median follow-up 24 months, range 4-186): 472 (94%) underwent first-line immunotherapy or tumour removal, resulting in improvement within 4 weeks in 251 (53%). Of 221 patients who did not improve with first-line treatment, 125 (57%) received second-line immunotherapy that resulted in a better outcome (mRS 0-2) than those who did not (odds ratio [OR] 2·69, CI 1·24-5·80; p=0·012). During the first 24 months, 394 of 501 patients achieved a good outcome (mRS 0-2; median 6 months, IQR 2-12) and 30 died. At 24 months' follow-up, 203 (81%) of 252 patients had good outcome. Outcomes continued to improve for up to 18 months after symptom onset. Predictors of good outcome were early treatment (0·62, 0·50-0·76; p<0·0001) and no admission to an intensive care unit (0·12, 0·06-0·22; p<0·0001). 45 patients had one or multiple relapses (representing a 12% risk within 2 years); 46 (67%) of 69 relapses were less severe than initial episodes (p<0·0001). In 177 children, predictors of good outcome and the magnitude of effect of second-line immunotherapy were similar to those of the entire cohort. Most patients with anti-NMDAR encephalitis respond to immunotherapy. Second-line immunotherapy is usually effective when first-line treatments fail. In this cohort, the recovery of some patients took up to 18 months. The Dutch Cancer Society, the National Institutes of Health, the McKnight Neuroscience of Brain Disorders award, The Fondo de Investigaciones Sanitarias, and Fundació la Marató de TV3. Copyright © 2013 Elsevier Ltd. All rights reserved. Available from ProQuest in this link Available from Elsevier in this link 27. A case of HELLP syndrome: an immuno-"logical" approach. Heggermont W.A. Acta clinica Belgica 2012;67(5):375-. We report on a 27-year-old woman who developed severe arterial hypertension on a background of general malaise within 48 hours after vaginal delivery, suggesting severe acute-onset pre-eclampsia. Concomitant biochemical observations of haemolysis, elevated liver tests and low platelets lead to the diagnosis of (post-partum) HELLP syndrome. Our patient was transferred immediately to the intensive care unit (ICU), where she underwent plasmapheresis in combination with intravenous glucocorticoids, nicardipine and labetalol. Our patient recovered fully after three plasmapheresis sessions. Genetic testing of mutations responsible for complement deficits was negative. Available from ProQuest in this link 28. Application of hybrid blood purification treatment for severe acute arsine poisoning Wan-Xin T. International Journal of Artificial Organs 2012;35(3):208-216. Objective: Severe acute arsine poisoning (SAAP) complicated by multiple organ dysfunction syndrome is a critical clinical illness. The limited efficacy of conventional drug therapy prompted us to investigate the application of hybrid blood purification treatment (HBPT) to improve the prognosis in critically ill patients. The present manuscript describes a series of cases treated with HBPT. Methods: Eleven SAAP subjects were enrolled. The study did not include a control group, because of ethical issues. On the basis of conventional therapy, HBPT (plasma exchange [PE] + continuous venovenous hemofiltration [CVVH]) was used to treat SAAP. PE was performed once a day for 5 days, and CVVH was performed after each session of PE for 7 days or more; HBPT treatment duration amounted to an average of 10 days (range 7-18 days). Arsenic was detected in blood and discarded liquid. Clinical indicators, laboratory parameters, and prognostic indicators were assessed. Results: HBPT was smoothly implemented without obvious adverse reaction. It can continuously remove arsenic and terminate hemolysis in a timedependent manner. HBPT also significantly improved the poor clinical manifestations and laboratory indicators of SAAP, leading to a low mortality. Ten patients were discharged because of improved conditions, and only 1 patient died. Conclusions: The early application of HBPT can improve the prognosis of SAAP. The advantage of HBPT is that it can integrate the characteristics of different blood purification technologies to maximize treatment efficacy. &#xa9; 2012 Wichtig Editore. 29. Direct thrombin inhibitors-a case indicating benefit from 'plasmapheresis' in toxicity: A call for establishing "gUIDELINES" in overdose and to find an "aNTIDOTE"! Kamboj J. American Journal of Therapeutics 2012;19(6):e182-e185. Patient presented with passage of fresh blood mixed with clots per rectum. In the ER, she was found to have bright red blood per rectum with clots, with frank blood on nasogastric tube. She was on dabigatran for atrial fibrillation and aspirin, with intermittent intake of ibuprofen. Vitals were positive for orthostatic hypotension. The pertinent findings in the physical examination were altered mental status with orientation*1, weak peripheral pulses, irregularly irregular heart rate, and bilateral pitting edema 2+ in bilateral lower extremities. Patient was intubated and put on mechanical ventilation. A massive transfusion protocol was followed. Laboratories and imaging: hemoglobin/hematocrit, 7.2/22.1; white blood cells, 7.7, platelet, 210; international normalized ratio, 2.5; prothrombin time, 19.2; activated partial thromboplastin time, 88.2; CMP was WNL; BNP, 621; fibrinogen, 500 mg/dL. Electrocardiogram showed atrial fibrillation with inferolateral ischemia. Ultrasonography of the liver and gallbladder showed no acute pathology. Echocardiogram showed an EF of 70% with hyperdynamic LV. Patient was transferred to the intensive care unit. Dabigatran, aspirin, and nonsteroidal anti-inflammatory drugs were discontinued, and antihypertensives were held. She was given blood and FFPs. Hemoglobin, hematocrit, and coagulation profile was monitored every 6 hours. Gastroenterology, general surgery, interventional radiology, and hematology services were called stat. IR placed a double-lumen, power central venous catheter. In gastroenterology, EGD and colonoscopy was performed, which showed active bleed at distal esophagus, stopped with local epinephrine. No active bleed seen on colonoscopy. The patient was put on Nexium drip. Hematology service recommended thrombin time (>200) and factors 2, 5, 7, 9, 10-41(l), 80, 68, 48(l), 61. Prothrombin time and activated partial thromboplastin time mixing studies were done, which indicated the presence of thrombin inhibition. Prothrombin complex concentrate at 50 U/kg was started to reverse the effect of dabigatran, and platelets were transfused to reverse the effect of aspirin. They also discussed that the half-life of dabigatran being 17 hours, and the drug would not be toxic at this point, as the patient was already 24-hour inpatient by now. The hemoglobin trend: 7.4->6.4->8. 2->7.5->6.6. At this point, the need for further intervention in form of hemodialysis or plasmapheresis was considered. The patient was given plasmapheresis and hemoglobin and hematocrit stabilized. The patient was kept on continued mechanical ventilator support for the night and extubated next day. The hemodynamics stabilized and the patient was transferred to the general medical floors after 1 day of observation, after extubation. &#xa9; 2012 Lippincott Williams & Wilkins. 30. Effectiveness of Combining Plasma Exchange With Continuous Hemodiafiltration on Acute Fatty Liver of Pregnancy Complicated by Multiple Organ Dysfunction Chu Y.F. Artificial Organs 2012;36(6):530-534. Acute fatty liver of pregnancy (AFLP) is a rare disease of progressive hepatic insufficiency and secondary systemic complications that induce significant maternal risk. The application of combining plasma exchange (PE) and continuous hemodiafiltration (CHDF) is a novel concept for patients with AFLP. Since 2002, we have utilized the combination of PE with CHDF as adjunctive medical therapy for 11 AFLP patients with multiple organ dysfunction. Before PE and CHDF initiation, four patients had signs and symptoms of encephalopathy, four required ventilatory support, and all 11 were developing liver failure, significant renal compromise, and coagulopathy. PE combined with CHDF for patients was initiated a mean of 2days postpartum (range, days 0-3). Daily or every other day PE combined with CHDF was undertaken on two to eight occasions for each of the 11 patients. Ten patients responded with composite clinical and laboratory improvement and were discharged to the ward, then cured and discharged from hospital; one patient died of septic shock. Average duration of hospitalization was 17days (range, days 9-38) from time of admission to discharge; the average duration of intensive care unit was 10days (range, days 4-23). No significant PE- and CHDF-related complications occurred. These results indicate that combing PE and CHDF in a series-parallel circuit is an effective and safe treatment for patients with severe AFLP. This finding may have important implications for the development of an effective treatment for patients with AFLP suffering multiple organ dysfunction. &#xa9; 2012, the Authors. Artificial Organs &#xa9; 2012, International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc. 31. Efficacy and safety of first-line rituximab in severe, acquired thrombotic thrombocytopenic purpura with a suboptimal response to plasma exchange. Experience of the French Thrombotic Microangiopathies Reference Center Froissart A. Critical Care Medicine 2012;40(1):104-111. Objective: To assess the efficacy and safety of rituximab in adults responding poorly to standard treatment for severe autoimmune thrombotic thrombocytopenic purpura. Design: Open-label prospective study. Outcomes in the survivors were compared to those of 53 historical survivors who were given therapeutic plasma exchange alone or with vincristine. Setting: Hospitals belonging to the Reference Network for Thrombotic Microangiopathies in France. Patients: Twenty-two adults with either no response or a disease exacerbation when treated with intensive therapeutic plasma exchange. INTERVENTION: Add-on rituximab therapy, four infusions over 15 days. Measurements and Main Results: One patient died despite two rituximab infusions. In the rituximab-treated Patients, the time to a durable remission was significantly shortened (p = .03), although the plasma volume required to achieve a durable remission was not significantly different compared to the controls. Platelet count recovery occurred within 35 days in all 21 survivors, compared to only 78% of the historical controls (p < .02). Of the rituximab-treated Patients, none had a relapse within the first year but three relapsed later on. In Patients treated with rituximab, a rapid and profound peripheral B-cell depletion was produced, lasting for 9 months and correlating with higher a disintegrin and metalloproteinase with thrombospondin-13 activity and lower anti-a disintegrin and metalloproteinase with thrombospondin-13 antibody titers. These differences were no longer significant after 12 months. No severe side effects occurred. Conclusions: Adults with severe thrombocytopenic purpura who responded poorly to therapeutic plasma exchange and who were treated with rituximab had shorter overall treatment duration and reduced 1-yr relapses than historical controls. &#xa9; 2012 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins. Available from KSS Journals @ Ovid in this link 32. Plasma exchange in the management of a case of hypertriglyceridaemic pancreatitis triggered by venlafaxine Sevastru S. BMJ case reports 2012;2012:-. The authors present a case of a young, non-diabetic Caucasian male patient with longstanding depression who had recently been started on venlafaxine. He presented to the emergency department with central abdominal pain, drowsiness and vomiting with a raised serum amylase. He was diagnosed with acute pancreatitis (AP) that was confirmed following an abdominal ultrasound and CT. His initial biochemistry was immeasurable in the first 12 h of admission due to macroscopically visible hyperlipidaemia. In the absence of any other causes of AP, hyperlipidaemia was the most likely aetiology. He was transferred to the intensive care unit where he was managed by lipidic restriction, fluid resuscitation and 3 consecutive days of plasma exchange. Plasma triglyceride levels were reduced from 42.9 to 2.4 mmol/l following plasma exchange. He made a full recovery and at discharge was investigated for familial hypertriglyceridaemia and referred to a multi-disciplinary team for follow-up. His venlafaxine was stopped on admission. 33. Simultaneous extracorporeal membrane oxygenation and therapeutic plasma exchange procedures are safe and effective in both pediatric and adult patients Dyer M. Transfusion 2012;52:21A-22A. Background/Case Studies: Extracorporeal membrane oxygenation (ECMO) has been used in pediatric and adult patients with pulmonary and/ or cardiac disease. In rare circumstances, these patients may have to undergo concomitant therapeutic plasma exchange (TPEX). Clear communication between the ECMO and apheresis teams regarding extracorporeal volumes, anticoagulation, oxygen carrying capacity, and electrolyte monitoring is essential to safely performing simultaneous ECMO/TPEX in this critically ill patient population. We sought to characterize simultaneous ECMO/TPEX procedures at our institution and the pediatric and adult patient populations in which they were performed. Study Design/Methods: Retrospective analysis of the medical records was performed for patients who underwent simultaneous ECMO/TPEX between 2005 and 2012. Data collected included: patient demographics/diagnoses, TPEX indications/ parameters, complications encountered during TPEX, blood products utilized during TPEX, and 30-day mortality. Results/Findings: 76 patients underwent 293 simultaneous ECMO/TPEX procedures; the majority involved pediatric patients, most of whom weighed <15 kg. Patient and TPEX parameters are shown in the Table. All TPEX procedures were 1.0 or 1.5 volume plasma exchanges. In children, the top 2 reasons for ECMO were congenital cardiac disease and sepsis; in adults, they were congestive heart failure/cardiomyopathy and severe pulmonary disease. In children, the top 2 reasons for TPEX while on ECMO were multisystem organ failure and coagulopathy; in adults, they were humoral rejection of cardiac and pulmonary allografts. Blood product utilization during simultaneous ECMO/TPEX was substantial in both pediatric and adult patients. The most common complications of simultaneous ECMO/TPEX were hypocalcemia and hypotension. 43.5% of children and 45.3% of adults had a correction of their apheresis indication after their TPEX regimen. Conclusion: Despite the relatively high rate of hypocalcemic and hypotensive reactions during simultaneous ECMO/TPEX, all reactions were treated/ resolved and TPEX regimens were successfully completed in all patients. With clear communication between ECMO and apheresis teams along with close patient monitoring, simultaneous ECMO/TPEX can be safely and effectively performed in critically ill pediatric and adult patients. Blood banks should be involved in the discussion to initiate patients on simultaneous ECMO/TPEX so that the appropriate blood products are readily available. (Table Presented) . 34. Surviving the storm: two cases of thyroid storm successfully treated with plasmapheresis Carhill A. BMJ case reports 2012;2012:-. Thyroid storm is a rare, but critical, illness that can lead to multiorgan failure and carries a high death rate. The following case series describes two adult men with Graves' disease who presented in thyroid storm and either failed or could not tolerate conventional medical management. However, both patients responded well to plasmapheresis, which resulted in clinical and biochemical stabilisation of their disease processes. The treatment option of plasmapheresis should be considered as a stabilising measure, especially when patients have failed or cannot tolerate conventional therapy. Plasmapheresis leads to amelioration of symptoms and a significant decline in thyroid hormone levels, providing a window to treat definitively with thyroidectomy. 35. Therapeutic plasma exchange in an uncommon disease: Stiff-Person Syndrome: Case report [English;Turkish] Si{dotless}ra di{dotless}si{dotless} bir hastali{dotless}kta terapotik plazma degisimi: Stiff-Person sendromu Hergunsel O. Turkiye Klinikleri Journal of Medical Sciences 2012;32(6):1762-1765. Stiff-Person syndrome (SPS) is a rare and disabling disorder characterized by continuous motor unit activity causing severe rigidity and episodic spasms in axial and limb muscles. It deteriorates the quality of life and causes a serious burden in the patient's life. It is frequently associated with other autoimmune diseases such as diabetes mellitus. Treatment with intravenous immunoglobulin, anti-anxiety drugs, muscle relaxants, anticonvulsants will improve symptoms, but will not cure the disorder. Therapeutic plasma exchange is an alternative treatment for the patients resistant to other treatment options. Here, we report a patient with SPS treated in intensive care unit and underwent therapeutic plasma exchange. &#xa9; 2012 by Turkiye Klinikleri. Available from ProQuest in this link 36. A phase 2 study of the safety and efficacy of rituximab with plasma exchange in acute acquired thrombotic thrombocytopenic purpura Scully M. Blood 2011;118(7):1746-1753. The safety and efficacy of weekly rituximab 375 mg/m2 (x4), given within 3 days of acute TTP admission, with standard therapy (PEX and steroids) was evaluated. Clinical outcomes were compared to historical controls (n 40) who had not received rituximab. Within the trial group, 15 of 40 required ICU admission and 15% of all cases with the highest troponin T levels on admission were ventilated. Before the second rituximab infusion, 68% of cases had a platelet count > 50 x 109/L and 38% > 150 x 109/L. Fewer PEX were required in whites compared to nonwhite in the rituximab group (mean 14 vs 21, P .0095). Inpatient stay was reduced by 7 days in the non-ICU trial cases compared to historical controls (P .04), especially in whites, with a mean reduction of 7 days (P .05). Ten percent of trial cases relapsed, median, 27 months (17-31 months), compared to 57% in historical controls, median 18 months (3-60 months; P .0011). There were no excess infections or serious adverse events with rituximab. In conclusion, rituximab appears a safe and effective therapy. Inpatient stay and relapse are significantly reduced in the rituximab cohort. Rituximab should be considered in conjunction with standard therapy on acute presentation of TTP. This study was registered at www.clinicaltrials.gov as NCT009-3713. &#xa9; 2011 by The American Society of Hematology. Available from Highwire Press in this link 37. Comparison of IVIg and PLEX in patients with myasthenia gravis Barth D. Neurology 2011;76(23):2017-2023. Objective: Both IV immunoglobulin (IVIg) and plasma exchange (PLEX) are immunomodulatory treatments used to treat patients with myasthenia gravis (MG), but the choice of which treatment to administer to patients is limited due to lack of evidence from adequately powered, masked, randomized, standardized trials. Methods: We randomized 84 patients with moderate to severe MG defined as a Quantitative Myasthenia Gravis Score for disease severity (QMGS) of >10.5 and worsening weakness to IVIg (Gamunex, Talecris Biotherapeutics) 1 g/kg/day for 2 consecutive days or PLEX (Caridian Spectra) 1.0 plasma volume exchanges for 5 exchanges. The patients were evaluated at day 14 after treatment for the primary efficacy parameter of change in QMGS and secondary clinical and electrophysiologic parameters and were followed for a total of 60 days. Results: Both IVIg and PLEX reduced the QMGS, and IVIg was comparable to PLEX in efficacy. The dropout rate was the same for both treatment arms and both treatments were well-tolerated. The presence of acetylcholine receptor antibodies and greater baseline disease severity predicted a better response to therapy. The postintervention status revealed that the same proportion of patients improved with treatment: 69% on IVIg and 65% on PLEX. The duration of improvement was similar with both treatments. Conclusions: IVIg has comparable efficacy to PLEX in the treatment of patients with moderate to severe MG. Both treatments are well-tolerated, and the duration of effect is comparable. Either treatment may be offered to patients depending on availability of resources. Classification of Evidence: This study provides Class I evidence that IVIg and PLEX have comparable efficacy and are equally tolerated in adult patients with moderate to severe MG within 2 weeks of treatment. Glossary: AChRAb: acetylcholine receptor antibodiesANCOVA: analysis of covarianceANOVA: analysis of varianceCI: confidence intervalICU: intensive care unitIVIg: IV immunoglobulinMG: myasthenia gravisMGFA: Myasthenia Gravis Foundation of AmericaMuSK: muscle-specific tyrosine kinasePLEX: plasma exchangeQMGS: Quantitative Myasthenia Gravis Score for disease severityRNS: repetitive nerve stimulationSFEMG: single-fiber EMG testingUHN: University Health NetworkVAS: visual analog scale. Copyright &#xa9; 2011 by AAN Enterprises, Inc. All rights reserved. Available from Ovid in this link Available from NEUROLOGY in this link 38. N-methyl-D-aspartate receptor autoimmune encephalitis presenting with opsoclonus-myoclonus: Treatment response to plasmapheresis Smith J.H. Archives of Neurology 2011;68(8):1069-1072. Objectives: To report the clinical, laboratory, and radiographic features and the response to plasmapheresis in a patient with encephalopathy, opsoclonus, and myoclonus whose cerebrospinal fluid was positive for N-methyl-D-aspartate receptor-IgG. Design: Case report. Setting: St Marys Hospital, Rochester, Minnesota. Patient: A 27-year-old woman with a history of episodic migraine developed subacute progressive myoclonus, opsoclonus, and encephalopathy. Results: Magnetic resonance imaging demonstrated nodular leptomeningeal enhancement in the superior cerebellar folia and subsequent T2 hyperintensities in the periventricular regions and amygdala. A positron emission tomographic scan of the head demonstrated predominantly frontotemporoparietal cortical hypometabolism with sparing of the primary sensory and motor cortices. Cerebrospinal fluid examination revealed a lymphocytic pleocytosis, mildly elevated protein level, elevated IgG index, and positive oligoclonal banding. Autoimmune cerebrospinal fluid screening revealed a neural-specific IgG that bound to synapse-rich regions of mouse hippocampus and cerebellar granular layer; the neural-specific IgG was confirmed to be N-methyl-D-aspartate receptor specific. No neoplasm was detected by physical examination or by whole-body computed tomography and positron emission tomography. A 5-day course of high-dose intravenous methylprednisolone sodium succinate yielded limited improvement, and the patient subsequently required intensive care unit admission following a pulseless electrical activity arrest associated with pulmonary embolism. The encephalopathy improved dramatically after plasmapheresis. Conclusions: This case highlights opsoclonus and myoclonus as manifestations of autoimmune N-methyl-D-aspartate receptor encephalitis in the setting of a novel appearance on positron emission tomography, and it shows a remarkable clinical response to plasmapheresis. &#xa9;2011 American Medical Association. All rights reserved. 39. Therapeutic plasma exchange in 4 patients with acute demyelinating encephalomyelitis (ADEM) Banez-Sese G. Transfusion 2011;51:-. Background/Case Studies: Acute Demyelinating Encephalomyelitis (ADEM) is a rare immune-mediated, acute inflammatory disease that affects the brain and spinal cord. ADEM typically follows a viral or bacterial infection or vaccination. It is seen in both children and adults. The pathogenesis is not fully understood but the demyelination is thought to be secondary to transient autoimmune response against the myelin and other autoantigens. The onset of ADEM may be sudden with signs and symptoms (s/s) such as fever, headache (HA), delirium, lethargy & coma, with rapid deterioration of neurologic s/s that may lead to death. Therapeutic measures include steroids, intravenous immunoglobulin (IVIG) and therapeutic plasma exchange (TPE). We report 4 cases of adult ADEM treated with TPE after lack of clinical improvement following high-dose steroids. Study Design/Methods: Retrospective chart review of 4 patients (pts) diagnosed with ADEM between 2008 & 2011. A total 6 TPEs were performed on 4 pts using COBE Spectra . Each pt's TPE was performed using 1 blood volume. The replacement fluid was 5% albumin, with fresh frozen plasma added if fibrinogen levels were critically low. Results/Findings: Four patients, ages 25, 30, 34 and 66 years old, were admitted with complaints (c/o) HA, fever, malaise, and rapidly declining mental status. They were transferred to the Neurology Intensive Care Unit and eventually intubated. The pts had absent brainstem reflexes. Three out of the 4 pts were diagnosed with viral encephalitis (1 measles, 1 Epstein Barr Virus and a non-specific virus). The fourth pt was diagnosed with bacterial meningitis. Additionally two pts traveled within one month of demise: 1 to Central America and 1 to Europe. As their neurologic examinations continued to deteriorate so did their brain stem reflexes. The Magnetic Resonance Imaging of 3 pts showed diffuse abnormal white matter changes in the brain. Following diagnosis of ADEM, pts received high dose steroids, followed by TPEs, with 2 out of 4 pts receiving IVIG. Pts showed no clinical improvement to any of the therapeutic interventions, including TPEs. Families decided to withdraw pts before completing the series of 5 procedures and pts were taken off life support followed by subsequent demise. Conclusion: ADEM is a rare condition associated with a high rate of morbidity and mortality. It is not immediately diagnosed after an inflammatory condition of the central nervous system. Once diagnosed, the role and timing of TPEs in pts on highdose steroids are not clearly established. However, the American Society for Apheresis defines ADEM as a category III indication for TPE, with the optimum role of TPE not well defined. Providing TPE at the onset of steroid therapy may be strongly considered in the future with review of more ADEM cases. 40. Therapeutic plasma exchange in an intensive care unit (ICU): a 10-year, single-center experience. Yilmaz Ali Abbas Transfusion and apheresis science : official journal of the World Apheresis Association : official journal of the European Society for Haemapheresis 2011;45(2):161-. Therapeutic plasma exchange (TPE) is a blood purification method that effectively allows for the removal of waste substances by separating out plasma from other components of blood and the removed plasma is replaced with solutions such as albumin and/or plasma, or crystalloid/colloid solutions. Plasma exchange therapies are becoming increasingly essential, being used in daily practice in critical care settings for various indications, either as a first-line therapeutic intervention or as an adjunct to conventional therapies. This retrospective clinical study analyzes 10-year therapeutic plasma exchange activity experience in an 18-bed ICU at a tertiary care university hospital with a large, critically-ill patient population. Medical records of 1188 plasma exchange procedures on 329 patients with different diagnoses admitted from January 2000 to July 2010 were evaluated. The aim of the study was to determine the TPE indications and outcomes of the patients who underwent TPE in the ICU with conventional therapy. The secondary endpoints were to determine the differences between different patient groups (septic vs. non-septic indications) in terms of adverse events and procedural differences. Copyright © 2011 Elsevier Ltd. All rights reserved. Available from Elsevier in this link 41. A phase II study to assess the safety, efficacy and tolerability of rituximab (mabthera) in combination with plasma exchange in patients with acute thrombotic thrombocytopenic purpura (TTP) Scully M. Blood 2010;116(21):-. Idiopathic adult TTP is an acute life threatening disorder, in which antibodies, primarily IgG, are detected against ADAMTS 13. We undertook a a phase II trial in 40 patients between 2006-09 of Rituximab, 375mg/m2, weekly for 4 weeks, within 3 days of admission of acute TTP, in conjunction with standard therapy (PEX and steroids). Results have been compared to 40 historical controls (2000-2006), who had not received Rituximab, but had received other immunosuppressive treatments. The female to male ratio was 2:1, age 42 years (21-76), compared to 42 years (15-78) in the historical group. A third of trial patients required ITU admission and 15% were intubated and ventilated at presentation. One patient was withdrawn from the trial. Pre the 2nd Rituximab infusion, 68% had a platelet count >50 x10<sup>9</sup>/L and 38% >150 x10<sup>9</sup>/L. Six cases received more than 4 Rituximab infusions (maximum of 8), primarily non-Caucasian, guided by ADAMTS 13 assays. There was a significant reduction in days admitted in hospital in the Rituximab group (median 16.5 days) compared to historic controls (median 20 days) (p=0.04, Spearman correlation), specifically in Caucasian patients (12.5 V's 16 days-Rituximab V's Historical groups) (p=0.0005 Pearson Correlation). There was no overall significant difference in the number of PEX to remission. ADAMTS 13 activity on admission was median <5% (NR 55-126%). Median Anti ADAMTS 13 IgG was 40% (6-162%, NR:<4.2). Following 4 Rituximab infusions, median ADAMTS 13 activity was 43% (7-67%), median Anti-ADAMTS13 IgG was 12% (2-74%). In the historical group, 48% relapsed, median 18 months (3-60 months). In the Rituximab group, follow up 16-40 months, 10% relapsed, median 27 months (17-31). There were no excess infections in the Rituximab group. There were three deaths in the Rituximab cohort at days 11,15 and 25, due to progressive cardiac/neurological disease. In conclusion, Rituximab appears to be a safe and effective therapy given during acute TTP in conjunction with PEX and steroids. No significant difference was seen in the number of PEX to remission, compared to historical controls. However, there was a significant reduction in the number of days in hospital in the Rituximab group. The risk of relapse up to 40 months is significantly reduced in the Rituximab cohort. In patients with acute TTP, Rituximab should be considered in conjunction with standard therapy. Available from Highwire Press in this link 42. Benefit of plasma exchange in haemolyticuremic syndrom (HUS) is not related to removal of sCD40L Lovric S. NDT Plus 2010;3:-. Introduction and Aims: Haemolytic-uremic syndrome (HUS) in adults is a severe disease with renal failure, microangiopathic hemolytic anemia, platelet clumping and thrombocytopenia. Several mechanisms leading to HUS have been identified, like infections, hypertension and organ transplantation. Plasma exchange with fresh-frozen plasma is widely used as a therapeutic option. The costimulatory molecule CD40 ligand (CD40L) is expressed on activated T cells and platelets. CD40L exists in a soluble form (sCD40L) and activated platelets are the major source of sCD40L. Recent studies suggest that sCD40L may play a pathogenetic role in atherothrombotic complications in cardiovascular disease as well as in inflammation and thrombosis. So far neither sCD40L nor its possible modulation by plasma exchange has been evaluated in patients with HUS. Methods: Nine critically ill HUS patients with renal failure were studied. Plasma exchange (PE) was conducted daily (up to 5 sessions) in each patient. Plasma sCD40L levels were measured by ELISA assay before and after each round of PE and throughout the treatment course. Furthermore, platelets count, number of fragmentocytes and serum-Lactate dehydrogenase (LDH) levels were monitored. Ten apparently healthy volunteers served as controls. Results: However, plasma sCD40L levels in HUS patients (139+/-23.2 ng/mL) did not differ compared to those observed in healthy controls (174+/-51.9 ng/mL, ns). Furthermore sCD40L levels are not related to circulating platelets, LDH serum levels and number of fragmentocytes. However, plasma sCD40L levels decreased through a course of up to 5 sessions of PE. Conclusions: sCD40L does not seem to play a pathogenetic role in HUS and the benefit of plasma exchange in this disease is not related to removal of sCD40L. Available from Highwire Press in this link 43. Physiological changes during and outcome following 'filtration' based continuous plasma exchange in Guillain Barre Syndrome Jayasena Y.A.A. Transfusion and Apheresis Science 2010;42(2):109-113. Background: Therapeutic plasma exchange is an extracorporeal blood purification technique designed for the removal of large molecular weight substances from plasma. It is the first line treatment in Guillain Barre Syndrome (GBS) improving outcome. Aim: To study the outcome in GBS following therapeutic plasma exchange (TPE) utilizing a modified, cost saving, filtration based plasma exchange technique. Methodology and findings: Consenting patients with GBS underwent TPE using a modified regime of two 48 h sessions as a cost saving strategy. The second session was conducted only if there was inadequate benefit from the first session. Nerve conduction studies confirmed the diagnosis of GBS. Results: Fifteen patients were studied. One died following a cerebro-vascular accident. Of the remaining 14 patients, five showed improvement in muscle power at least by one grade in one limb within 48 h of plasma exchange. The duration of intensive care unit stay was 10 (median) days (range 4-66). Nine required mechanical ventilation for (median) 15 days (range 4-50). The mean 24 h urine output increased significantly since the initiation of plasma exchange was 6262.92 ml (SD = 8867.24, P = 0.032) at 48 h and 6474.92 ml at 72 h (SD = 6364.81, P = 0.003). The pulse rates and blood pressures were not significantly different before and after plasma exchange. Complications attributable to plasma exchange were mild; a hypersensitivity reaction and a tendency to ooze from a puncture site. Conclusion: 'Continuous' TPE, the modified cost saving technique seems to improve the outcome of patients with Guillain Barre Syndrome with minimal complications. &#xa9; 2010 Elsevier Ltd. All rights reserved. Available from Elsevier in this link 44. Plasma exchange in patients with the diagnosis of Guillain-Barre syndrome: An experience in intensive care unit Ali G. Journal of Postgraduate Medical Institute 2010;24(4):284-288. Objective: To assess the effectiveness of plasma exchange in patients with Guillain-Barre syndrome. Methodology: This descriptive study was conducted at Intensive Care Unit Lady Reading Hospital Peshawar from March 2008 to July 2010. Twenty eight patients were included in study after fulfilling inclusion criteria. All the diagnosed cases of Guillain-Barre syndrome were admitted in Intensive care Unit Post Graduate Medical Institute Lady Reading Hospital Peshawar and 4 sessions of plasma Exchange therapy was initiated in every patient after informed written consent. Results: Out of 28 patients 19 were male (67.85%) and 9 were female (32.14%). Mean age was 32.32 years and mean duration of stay in Intensive Care Unit was 6.32 days. Out of these 28 patients, 60.71% (17) recovered and 39.3% (11) expired despite treatment and 2 patients developed adverse events secondary to Plasma Exchange. In 25 (89.29%) patients breathlessness was reported as their major symptom beside motor weakness, while in 19 (67.85%) patients, pain was also reported. Conclusion: Early referral to Intensive Care Unit, management of complications, good nursing care and specific therapy with Plasma Exchange within seven days of onset of symptoms improve prognosis and Plasma Exchange has proved beneficial to supportive treatment alone in Guillain-Barre syndrome with minimal side effects. 45. The challenges of diagnosing thrombotic thrombocytopenic purpura in the critically ill. A case report Bindi M.L. Transfusion and Apheresis Science 2010;43(2):167-170. Thrombotic thrombocytopenic purpura (TTP) is associated with high mortality rates. TTP may have various and different presentations depending on the organs involved. It is now recognized to be the consequence of reduction of blood levels of the disintegrin and metalloprotease with thrombospondin motifs (ADAMTS)-13. Prompt diagnosis of TTP is paramount, because plasma exchange is the only treatment capable of improving patient's survival with a dual mechanism: removal of anti-ADAMTS-13 auto-antibodies and infusion of the active protease available in the fresh frozen plasma. We report herein on the challenges in diagnosing TTP-like complications of post-surgical facial surgery in a young male patient. &#xa9; 2010 Elsevier Ltd. Available from Elsevier in this link Opening Internet Links The links to internet sites in this document are 'live' and can be opened by holding down the CTRL key on your keyboard while clicking on the web address with your mouse Full text papers Links are given to full text resources where available. For some of the papers, you will need an NHS OpenAthens Account. If you do not have an account you can register online. You can then access the papers by simply entering your username and password. 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