Plasmapheresis

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					Plasmapheresis

  蔡壁如 報告
  2003/05/12
      What is Plasmapheresis
• Plasma and Apheresis
• Plasmapheresis exactly means the method
  of plasma separator itself or the way for
  plasma separation
• Plasma exchange means the method of
  substitution of plasma with other human’s
  plasma or with other substitutional fluid
                    Aim
• Plasmapheresis and plasma exchange is to
  take out causative substances of the disease,
  especially high molecular weight substances,
  and to supply normal plasma component
           Blood purification
•   Hemodialysis :IHD, SLEDD
•   Hemoperfusion: Biological adsorption
•   Hemofiltration :CVVH, CHDF
•   Plasma exchange
•   Double filtration
•   Blood transfusion
Molecular weight of removed substances by blood purification therapy
Plasma exchange
Plasma Separator
    • Centrifugal separation




    • Membrane separation
Centrifugal Separation
Centrifugal Separation
Membrane
Separation
        Comparison between centrifugal and
              membrane separation
                             Centrifugal        Membrane
                             Separation         Separation
Cost of disposables          Economical         Expensive
Availability of continuous   Depending on the   Available
performance                  apparatus
Modification                 Complicated        Easy
Operation                    Complicated        Easy
Contamination of platelet    Existing           Free
Separation of Blood cell     Available          Not available
components
Double filtration
              Membrances
             Membrane              Pore size
Plasma separator      Plasmacure   0.2 m
Plasma fractionator   Evaflex 2A   10 nm
                      Evaflex 3A   20 nm
                      Evaflex 4A   30nm
                      Evaflex 5A   30nm
Dialyzer              KF           < 10nm
Molecular weight of removed substances by blood purification therapy
Double filtration
              Plasmapheresis
健保適應症:
• 1. SLE,CNS involvement
• 2. Myasthenia gravis crisis
• 3. Macroglobulinaemia
• 4. Goodpasture’s disease
• 5. Multiple myoloma
• 6. Guillain-Barre syndrome
• 7. Idiopathic Thrombocytopenic Purpura, Hemophilia
• 8. 其他經專案申請,同意實施者
Clinical Application
Paper Review
 Extracorporeal Treatment for Septic Patient : New
Adsorption Technologies Their Clinical Application
• Continuous Hemofiltration : CVVH , CVVHD
• Plasma Exchange              Removal of Endotoxin
    Cytokine Removal by Plasma Exchange with
Continuous Hemodiafiltration in Critically Ill Patient

• Septic hepatic failure
   – Serum T-Bil > 10mg/dl
   – Grade 2 or higher coma score
• Aggravated autoimmune disease : SLE, RA
• Hemorrhage shock and encephalopathy syndrome
• Thrombotic microangiopathy



                         Therapeutic Apheresis 6(6):419-424
Diagnosis criteria for
Hemorrhage shock and encephalopathy syndrome
• Clinical
   –   Shock
   –   Coma and convulsions
   –   Bleeding ( or laboratory evidence of DIC )
   –   Diarrhea
   –   Oliguria
• Laboratory
   –   Falling hemoglobin level (>3 g/dl below admission valve )
   –   Prolonged PT, PTT
   –   Low fibrinogen level
   –   Elevated BUN, Cre, GOT, GPT
   –   Metabolic acidosis
• Exclusion
   – Infection and metabolic disorders
   – Reye syndrome (liver histologic findings, plasma ammonium )
   – Staphylococcal toxic shock syndrome

                                                    Therapeutic Apheresis 6(6):419-424
      Apheresis Therapy for Living-Donor Liver
                  Transplantation
• Bridge therapy to liver transplantation
• Supplement to the graft liver until the recovery of
  the hepatic function
• Treatment for multiple organ failure
   – Post-transplantation renal failure
   – Reduce the titers of antibodies
   – ABO type incompatible liver transplantation



                              Therapeutic Apheresis 6(6):478-483
• Table 1. Bridge therapy to liver transplantation
                       P’t   Encephalopathy    BE     PE      PE+CHDF       CHDF
Survivor               23            6          5     15           3           0
Nonsurvivor            22            5          5     9            5           3
Total                  45            11         10    24           8           3




• Table 2. Supplement to the graft until the recovery of postoperative
  hepatic function
                 P’t         BE/PE            BE+PE        CHDF/CHF     PE+CHDF
   Survivor      21            7                1             1           12
   Nonsurvivor   56           29                2             10          15
   Total         77           36                3             11          27
                   Case Report
• Plasma Exchange for Hypertriglyceridemic Acute
  Necrotizing Pancreatitis : Two case report
   – Hypertriglyceridemia : Cause of acute pancreatitis
      • TG to lipase  hydrolytic formation of free fatty acids  Local
        tissue injury
      • Release pancreatic enzymes
      • Consequent autodigestion
   – Combined CVVH, continuous nafamostat mesilate,
     Selective digestive decontamination, enteral feeding via
     jejunal tube
• Plasmapheresis in Streptococcal Toxic Shock
  Syndrome
   Combination of Therapeutic Apheresis and Therapeutic

 Ventricular Assistance for End-Stage Heart Failure Patients

• A VAD can be inhibit the heart failure compensatory
  mechanism by extreme ventricular unloading
• A Apheresis can be inhibit the vicious cycle in heart
  failure by removing factors that are produced by the
  activated neurohormonal/autocrine-paracrine
  compensatory mechanisms
   – Anti-ß1-adrenoceptor autoantibodies ( A-ß1-AABs )in a p’t with
     dilated cardiomyopathy has been reported ß-adrenergic agonist
   – Apheresis therapy with a VAD can be reduce the level A-ß1-
     AABs , LDL, cytokines
•   Question ?
•   Choose Machine ?
•   Plasma exchange or Double Filtration ?
•   Protocol ?
•   Blood Purification Physician ?
Effectiveness of Combining Plasma Exchange and
Continuous Hemodiafiltration in the Treatment of
        Patients with Acute Hepatic Failure
• Plasma Exchange
  –   IL-6, IL-8
  –   Blood Citrate level: ACD solution
  –   Hypernatremia: HAES, FFP
  –   Metabolic alkalosis:Anticoagulant
  –   Colloid osmotic pressure :Short time Large FFP
       • Cerebral edema
       • Lung edema
•  Plasma Exchange + CHDF
                                     Crit Care Med 2001 Vol. 29, No.7
                                     Therapeutic Apheresis
                  Plasma exchange
150                                              35
           33.1                           148
145                                              30
                                          26.3
140                                              25
           138
           20.9                           20.5
135                                              20

130                                              15
      92年2月14日          92年2月15日    92年2月16日


                   Na      HCO3     Bil
                  Plasma exchange

150                                        25     25
           23.9
                                           146
145        19.5                                   20

140        140                                    15
                                           13.4
135                                               10
      92年2月26日         92年2月27日     92年2月28日

                  Na       HCO3      Bil
                      PE + CVVH


145                                             20
          18.3
                                         17.3
140                                      139
                                                15
          136
135                                             10
          6.01                           6.01
130                                             5
      92年5月5日           92年5月6日   92年5月7日


                 Na        HCO3    Bil
6/7
       30
            40
                 50
                           60

11:14:11

11:33:55

11:53:44

12:19:22

12:39:03

12:58:50

13:18:37

13:38:21
                      R-rSO2




13:58:06

14:17:55

14:37:45

14:57:32

15:17:22

15:37:11

15:56:57
       30
            40
                               50
                                    60
                                          70
09:53:30
10:01:47
10:10:07
                                                 rSO2


10:18:26
10:26:45
10:35:06
10:43:25
10:51:43
11:00:01
11:08:21
11:16:40
11:25:00
11:33:22
            Manitol infusion




11:41:43
                                         LEFT
                                         RIGHT
                                                         20
                                                              40
                                                                   60
                                                   10:01:28
                                                   10:17:12
                                                                        80




                                              開始
                                                   10:32:59
                                                   10:48:52
                                                   11:04:49
                                                   11:20:36




Cerebral edema ?
                                                   11:36:20
                                                   11:52:16
                                                   12:08:12
                                                   12:24:02
                                                   12:39:48
                                                                                rSO2




                                                   12:55:33



                   不平衡症候群(Disequilibria) ?
                                                   13:11:30
                                                   13:27:22
                                                   13:43:11
                                                   13:58:54
                                             結束



                                                   14:14:46
                                                                             Left
                                                                             Right
                                  LEFT
           plasma-exchange        RIGHT

                rSO2

100
 80
 60
 40   開始
                             結束
 20
      1
TCD Fig.1
      Hemanetics Vs HF400
Centrifugal Separator   Membrane Separator
Complicated Operation   Automatic Operation

Anticoagulant           Anticoagulant : Free

Cost : $ 5200元          Cost : $6000元

Fixed person            Person available
Hypothermia             Warmer
4C1-8-1 Acute hepatic failure
       Blood flow    Plasma/Blood   Pre-Hct   MX-2 Post-Hct     TMP              Ca +                   K+
1 st   150 c.c/min      20%          30%         32%           90 ~ 95           0.81                   3.7
2 rd   150c.c/min       30%          29%         34%          110 ~ 115 0.54 : vicatal 1amp       3.1 : KCl 20 meq

end    150c.c/min       30%          29%         34%             110       0.35 : vicatal 2amp    3.1 : KCl 20 meq



1 st   150 c.c/min      20%          30%         32%             100      0.74:Vicatal 20c.c/hr    3.3:KCl
2 rd   150c.c/min       30%          29%         34%          105 ~ 110
end    150c.c/min       30%          29%         34%             110              0.8                   3.2
               Protocol

•   One to two Plasma volume
•   Replaced HALES and FFP
•   ACD solution 1 : 12 ratio ?
•   2% Vitacal 20 c.c/hr
     Plasma Exchange Volume
• Plasma交換80 c.c/Kg計算
• 以Hb及Hct計算
  – e.g. 50Kg P’t, Hb :10gm/dl, Hct : 30%
  – 50 X 80 c.c  4000 c.c (Total Blood Volume )
  – 4000 c.c X 0.65  2600 c.c ( one volume plasma )
• HAES + 24 U FFP  5000 c .c
  The most frequent complication
• Hypocalcemia
  – Infusion CaCl2 : 2% 20 c.c/hr
• Hypokalemia
  – Add potassium
• Anaphylactic reactions
• Hypothermia
  – Hyperthermia blanket , Warm lamp, Warmer
• Others
                         Plasma Exchange Note
• Date:__年__月__日Duration:__時__分至__時__分,Total :____min
• Indication:_________________________________________
Pre-Exchange
• GCS:____, HR:____, BP:_____mmHg, CVP:__mmHg
• Bil T/D:______, GOT/GPT:____, NH3:____, Platelet : ______
• HCO3:_______, Sodium:______, rSO2 :Left____, Right_____
Double Lumen:R’t_____, L’t_____
   Jugular vein_____, Subclavian vein_____, Femoral vein_____
Blood Flow:_____c.c, Plasma/Blood :____%, ACD Ratio:____
Replacement Fluid:
• FFP:______c.c, HAES:_______c.c, Ringer:_______c.c
Add Volume:ACD Solution:________ c.c, Vitacal:________ c.c
Exchange Volume:
• Intake:_______ c.c, Output:_______c.c, Balance:_______
Complication:
                                        Performed :
            Plasma-exchange

•   健保碼(58008C00)  $ 2475
•   耗材碼含tubing、0.9% N/S × 1 : $ 5200
•   ACD Solution另計費
•   HAES:$700元/bottle, FFP :300元/1unit
•   Total : $17675元 ( 24 u FFP+ 4 bottle HASE )
          Double Filtration

•   健保碼(58008C00)  $ 2475
•   耗材碼(20210512)  $ 6000 × 2
•   20211003管線:自費($1100)
•   0.9% N/S 1000 c.c × 2
•   Total $15575元 + ?

				
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