Standardized protocol to identify high-risk patients undergoing therapeutic apheresis procedures

As the scope of therapeutic apheresis (TA) expands and more procedures are requested for critically ill patients, adverse reactions (AR) associated with TA become a major concern for physicians, nurses, patients and their families. To assess the risks for ARs associated with patients' underlying diseases, we developed a preprocedure assessment tool with a set of high-risk criteria which included: (1) unstable vital signs, (2) active nonphysiological bleeding, (3) evidence of severe bronchoconstriction, (4) severe anemia, (5) projected extracorporeal volume (ECV) >15% of total blood volume (TBV) in adults or >10% of TBV in pediatric patients, (6) pregnancy, and (7) conditions requiring continuous nursing support. A standard operating procedure with a "Request for Apheresis Procedure on High-Risk Patient" form and protocol were developed to identify patients as high-risk before initiation of a TA procedure. Here we report our experience in the 3-year period following the implementation of this protocol. During this period, a total of 3,254 TA procedures were performed, 44 of which were for patients identified as high-risk by the protocol. The incidence of overall ARs was 8% for all TA procedures and 45.5% for procedures performed for high-risk patients. The incidence of moderate-to-severe ARs was 3.7% for all TA procedures and 36.4% for procedures performed for high-risk patients. The protocol identified a group of patients with an increased risk for ARs, especially moderate-to-severe reactions during and/or immediately following TA.