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Plasma Exchange
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Sample Consults
Hemolytic
Uremic Syndrome
Multiple Myeloma0
TTP / HUS
Coagulopathy
Vascular Rejection
Guillain' Bar
Hemolytic Uremic Syndrome (HUS)1) Diagnosis - HUS
2) Obtain Vascular Access
a. If IJ or subclavian line is placed verify catheter tip placement is in
SVC not right atrium by X-ray
3) Check ionized CA+
4) Premedicate with Benadryl (25 mg PO or IV) and Tylenol (650 mg PO or PR)
5) One Volume Plasma Exchange Today with every day replacement until increase in
platelets and increase in renal fxn.
6) Replace with FFP
7) Replace Ca+ as needed (1-2 gms PRN), may need Ca++ drip Gluconate drip
8) Risks and Benefits explained to patient, informed consent obtained &
witnessed
9) May need to replace protein bound meds or hold until after procedure
Multiple Myeloma
1) Diagnosis – Multiple Myeloma with Hyperviscosity syndrome
2) Obtain Vascular Access
a. If IJ or subclavian line is placed verify catheter tip placement is in
SVC not right atrium by X-ray
3) Check ionized Ca+
4) Premedicate with Benadryl (25 mg PO or IV) and Tylenol (650 mg PO or PR)
5) One Volume Plasma Exchange Today
6) Replace with ½ 5% albumin and ½ FFP
7) Replace Ca+ as needed (1-2 gms PRN), may need Ca++ drip Gluconate drip
8) Risks and Benefits explained to patient, informed consent obtained &
witnessed
9) May need to replace protein bound meds or hold until after procedure
10) Check viscosity after TPE
11) Check 24 hr urine for Bence Jones proteins
Thrombic Thrombocytopenic Purpura / Thrombotic Microangiopathy / HUS
1) Diagnosis –
2) Obtain Vascular Access
a. If IJ or subclavian line is placed verify catheter tip placement is in
SVC not right atrium by X-ray
3) Check ionized Ca+
4) Premedicate with Benadryl (25-50 mg PO or IV) and Tylenol (650 mg PO or PR)
5) 1-1.3 Volume Plasma Exchange Today with every day replacement until increase
in platelets to normal level for 2-3 days
6) Replace with FFP
7) Replace Ca+ as needed (1-2 gms PRN), may need Ca++ drip Gluconate drip
8) Risks and Benefits explained to patient, informed consent obtained &
witnessed
9) May need to replace protein bound meds or hold until after procedure
Coagulopathic
1) Diagnosis –
2) Obtain Vascular Access
a. If IJ or subclavian line is placed verify catheter tip placement is in
SVC not right atrium by X-ray
3) Check ionized Ca+
4) Premedicate with Benadryl (25 mg PO or IV) and Tylenol (650 mg PO or PR)
5) 1 Volume Plasma Exchange Today
6) Replace with FFP
7) Replace Ca+ as needed (1-2 gms PRN), may need Ca++ drip Gluconate drip
8) Risks and Benefits explained to patient, informed consent obtained &
witnessed
9) May need to replace protein bound meds or hold until after procedure
10) Do not heparinize vascular access
Vascular Rejection S/P Transplant
1) Diagnosis – Vascular Rejection S/P Transplant
2) Obtain Vascular Access
a. If IJ or subclavian line is placed verify catheter tip placement is in
SVC not right atrium by X-ray
3) Check ionized Ca+, Coags and Fibrinogen
4) Premedicate with Benadryl (25 mg PO or IV) and Tylenol (650 mg PO or PR)
5) 1 Volume Plasma Exchange Today and for the next 2 days or QOD (total 3)
6) Replace with 5% albumin unless
a. Fibrinogen low:
i. <120 – 1:1 FFP:Albumin
ii. 120-150 – 4 units of FFP with 5% albumin
iii. 150-180 – 2 units of FFP with 5% albumin
7) Replace Ca+ as needed (1-2 gms PRN), may need Ca++ drip Gluconate drip**
8) Risks and Benefits explained to patient, informed consent obtained &
witnessed
9) May need to replace protein bound meds or hold until after procedure
** Calcium – 6 amps (1 gm each) in 250 cc of NS to be run over course of the
procedure
Guillain Barre’
1) Diagnosis – Guillain Barre’
2) Obtain Vascular Access
a. If IJ or subclavian line is placed verify catheter tip placement is in
SVC not right atrium by X-ray
3) Check Fibrinogen, CBC and BMP
4) 1 Volume Plasma Exchange Today and QOD x 5 (total 6 exchanges)**
5) Replace with 5% albumin unless
a. Fibrinogen low:
i. <120 – 1:1 FFP:Albumin
ii. 120-150 – 4 units of FFP with 5% albumin
iii. 150-180 – 2 units of FFP with 5% albumin
6) If FFP or a blood prime will be utilized, premedicate with Benadryl (25 mg
PO or IV) and Tylenol (650 mg PO or PR).
7) If only 5% albumin utilized supplement with Calcium gluconate otherwise
replace Ca+ as needed (1-2 gms PRN)
8) Risks and Benefits explained to patient, informed consent obtained &
witnessed
9) If patient receiving IV Ig it will need to be removed by the procedure.
10) May need to replace protein bound meds or hold until after procedure
** Number of exchanges dependant on pt. condition.
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