Therapeutic Plasma Exchange (TPE) in Critical

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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
[email protected]
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.
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CINAHL (2)
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Date range used (5 years, 10 years): 2010 onwards
Limits used (gender, article/study type, etc.): Human, adult, English language
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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. © 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. © 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. © 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. © 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. © 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
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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. © 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
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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
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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
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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. © 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. © 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. © 2012, the Authors. Artificial Organs © 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. © 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. © 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. © 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 © 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. ©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. © 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. © 2010 Elsevier Ltd.
Available from Elsevier in this link
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11. Medline
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28. CINAHL
29. CINAHL
30. CINAHL
31. CINAHL
32. CINAHL
33. CINAHL
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Results
4153
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8019
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9032
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170976
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28 OR 29
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Criteria
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25434
results.
165
35. CINAHL
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11122
36. CINAHL
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57208
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30 AND 38
results.
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40. CINAHL
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