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Intensive plasma exchange in small and critically ill pediatric patients: techniques and clinical outcome
Insights
Therapeutic plasma exchange (TPE) is safe and effective in children, even those critically ill or underweight. Modified apheresis techniques prevent complications, making TPE a viable option for pediatric patients when indicated.
Area of Science:
- Pediatric Nephrology
- Pediatric Critical Care
- Apheresis Medicine
Background:
- Standard apheresis techniques require modifications for pediatric patients, especially those with critical illnesses.
- Children are susceptible to volume, metabolic, and coagulation disturbances during apheresis.
Purpose of the Study:
- To evaluate the safety and efficacy of therapeutic plasma exchange (TPE) in pediatric patients, including those with low body weight and critical medical conditions.
- To demonstrate that TPE can be safely performed in children without withholding treatment due to size or complexity of illness.
Main Methods:
- 112 TPE procedures were performed on 11 children (9 < 20 kg, 7 critically ill) using continuous flow apparatus (centrifugal or membrane systems).
- Extracorporeal circuits were primed with a red cell saline mixture to maintain hematocrit and prevent volume perturbations.
- Heparin was used cautiously for anticoagulation in patients with coagulopathies, and various vascular access methods were employed.
Main Results:
- Immunoglobulin levels decreased significantly per plasma volume (IgG 43.7%, IgA 36.7%, IgM 41%).
- Platelet reduction varied by system: 20-90% with centrifugal systems (CS) and 5-7% with membrane filtration systems (MFS).
- Treatment was successful in 8 out of 11 patients, with limited morbidity (citrate toxicity, pulmonary edema).
Conclusions:
- Therapeutic plasma exchange can be safely adapted for pediatric patients, irrespective of size or concurrent medical problems.
- Modified apheresis protocols, including appropriate priming and anticoagulation, mitigate risks associated with TPE in children.
- TPE should not be withheld from pediatric patients when clinically indicated, as demonstrated by successful outcomes in this cohort.
Abstract:
Standard apheresis techniques require modification of use in children, particularly those with serious concurrent medical problems, as they are prone to apheresis-induced disturbances of volume, metabolism, and coagulation. We report 112 plasma exchanges (TPE) on 11 children, 9 of whom weighed less than 20 kg and 7 of whom were critically ill. All were treated on continuous flow apparatus; seven on centrifugal systems (CS), two on a membrane filtration system (MFS), and two on both. Perturbations of blood and red blood cell (RBC) volume were prevented by priming the extracorporeal circuits with a red cell saline mixture having an hematocrit equal to or greater than the patient's hematocrit. Priming volume and minimal flow rates were 170 ml and 40 cc/min (MFS) and 350 ml and 10 cc/min (CS). TPE dose varied from 1.3 to 3 plasma volumes. Immunoglobulins fell by the following amounts: IgG 43.7%, IgA 36.7%, and IgM 41% per plasma volume. Platelets fell by 20-90% (CS) and 5-7% (MFS). Vascular access was obtained by various means including Thomas shunts, dialysis catheters, and standard 16-19 gauge butterflies and angiocaths. Bleeding in patients with coagulopathies was prevented by using repeated small boluses of heparin to maintain a clotting time of 2.5-3 minutes. Morbidity from TPE was limited to citrate toxicity (2 patients) and transient pulmonary edema (1 patient). Treatment outcome was successful in 8 out of 11 patients. We have shown that if PEX is otherwise indicated, it should not be withheld solely for patient size or the complexity of concurrent medical problems.