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Developing a Protocol for Therapeutic Plasma Exchange in Tandem With Continuous Renal Replacement Therapy (CRRT) and
Cyril Jacquot1,2, Maria Di Mola3, Reuben Jacob4
1Department of Laboratory Medicine, Children's National Hospital, Washington, DC, USA.
Insights
Therapeutic plasma exchange (TPE) in critically ill children requires careful management of extracorporeal volume (ECV) and calcium levels. Integrating TPE with continuous renal replacement therapy (CRRT) or extracorporeal membrane oxygenation (ECMO) is feasible but demands close team communication.
Area of Science:
- Pediatric critical care medicine
- Extracorporeal therapies
- Nephrology and critical care
Background:
- Therapeutic plasma exchange (TPE) in pediatric patients poses unique challenges, particularly managing large extracorporeal volumes (ECV) and potential hypocalcemia.
- Critically ill children on continuous renal replacement therapy (CRRT) or extracorporeal membrane oxygenation (ECMO) may require TPE for conditions like sepsis or liver failure.
- Disconnecting CRRT or ECMO for TPE can be detrimental; integrating these circuits is a complex but necessary consideration.
Purpose of the Study:
- To explore the feasibility and challenges of performing therapeutic plasma exchange (TPE) in pediatric patients already on extracorporeal support.
- To highlight the critical need for managing extracorporeal volume (ECV) and electrolyte balance during combined TPE and CRRT/ECMO.
- To emphasize the importance of interdisciplinary communication for safe and effective TPE in critically ill children.
Main Methods:
- Review of principles for integrating TPE devices with existing CRRT or ECMO circuits.
- Discussion of strategies for monitoring and mitigating adverse events related to large ECV and calcium replacement.
- Emphasis on collaborative care models involving multiple clinical teams.
Main Results:
- Connecting TPE to established CRRT or ECMO circuits is technically feasible.
- Careful management of circuit flow, ECV, and calcium levels is essential to prevent complications.
- Effective communication protocols are vital for successful implementation.
Conclusions:
- Therapeutic plasma exchange can be safely performed in conjunction with CRRT or ECMO in pediatric patients.
- Successful integration requires a thorough understanding of extracorporeal circuit dynamics and vigilant patient monitoring.
- Interprofessional collaboration is paramount for optimizing patient outcomes in complex extracorporeal therapy scenarios.
Abstract:
Therapeutic plasma exchange (TPE) in pediatric patients presents many challenges, including management of a large extracorporeal volume (ECV) and calcium replacement for patients who may not be able to express signs of hypocalcemia or other associated adverse events with a large ECV. Pediatric patients who are critically ill on continuous renal replacement therapy (CRRT) and/or extracorporeal membrane oxygenation (ECMO) may have indications for TPE, such as sepsis or liver failure anticipating transplant. It may be difficult or clinically detrimental to take the patient off the CRRT or ECMO circuit to perform TPE. Connecting the TPE device into the preexisting circuit is feasible with the understanding of the principles of the circuit flow set up and monitoring to mitigate adverse events. Effective communication among clinical teams managing distinct extracorporeal circuits is critical to ensuring coordinated patient care.
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