(M) Apheresis Flashcards
It is a procedure in which whole blood is taken from the body and passed through an apparatus that separates out one or more constituents, then returns the remainder of constituents back to the body circulation.
Apheresis
Apheresis comes from the Greek term “aphairesis” meaning ____
taking away
Performed on a donor to collect a SPECIFIC blood component (e.g. Red blood cells, Plasma, Platelets, Stem cells, etc.), needs to be a healthy donor
donor apheresis
Performed on a patient to remove a PARTICULAR blood component for ____
- Removing antibodies in autoimmune disorders
- Removing excess ions on hemochromatosis
- Treating a sickle cell disease by removing the Red blood cell
therapeutic apheresis
What are the three components collected through apheresis?
- platelets
- RBCs
- Stem cells
Process of removing apheresis
- removing of plasma =
- removing platelets =
- removing red blood cells =
- removal of white blood cells =
- plasmapheresis
- plateletpheresis
- erythropheresis
- leukapheresis
Identify the blood component:
- 55% of the blood volume
- 1% of the blood volume
- 45% of the blood volume
- plasma
- buffy coat
- red blood cells
Identify the percentage in the plasma composisiton
- water
- proteins
- other solutes
- 91.5%
- 7%
- 1.5%
primary anticoagulant in apheresis
citrate
Citrate
Works by binding two ____ ions, preventing blood clotting
calcium
Released in response to decreased ionized calcium level.
It will help regulate calcium levels by stimulating the release of calcium from the bones and increasing the calcium reabsorption in the kidneys
Parathyroid hormone (PTH)
Methodology
- separatese the blood components based on their density
- Separates the blood components based on size and molecular weight.
- centrifugation
- membrane filtration
Centrifugation
- The separation of blood components is based on blood constituents’ ____ or ____.
- Duration of procedure: _____
- The separation of blood components is based on blood constituents’ specific gravity or weight.
- 45 to 120 minutes
Variables considered in apheresis procedure
- centrifuge ____ and ____
- Duration of ____ of the blood in the centrifuge
- Type of solutions added
- Cellular ____ or plasma ____
- centrifuge speed and diameter
- Duration of dwell time of the blood in the centrifuge
- Type of solutions added
- Cellular content or plasma volume
T or F
- The higher the centrifuge speed the better the separation, thus higher speeds are usually used for apheresis.
- Shorter dwell times have no risk for cell damage or activation
- EDTA is the anticoagulants of choice for apheresis
- Citrate or heparin can be added to enhance for sedimenting agents (hydroxyethyl strach) to enhance the separation of blood components
- False (Really high speeds are not advisable because they pose a risk for cell damage)
- True (longer dwell times are better for separation but has a risk for cell damage)
- False (citrate or heparin)
- True
A. Intermittent Flow Centrifugation (IFC)
B. Continuous Flow Centrifugation (CFC)
- Blood is processed in batches or cycles
- Performed as a single-needle procedure
- Blood withdrawal, processing and reinfusion are performed in an ongoing manner
- Dual-lumen central venous catheter can be used in therapeuitic procedures
- Two venipuncture sites are needed
- A
- A
- B
- B
- B
A. Intermittent Flow Centrifugation (IFC)
B. Continuous Flow Centrifugation (CFC)
- Greater blood volume is needed
- Smaller blood volumes (for pediatrics and elderly)
- Lesser time of collection
- Smaller equipment, more mobile
- Longer duration (fixed speed)
- Causes discomfort
- A
- B
- B
- A
- A
- B
- composed of bundles of hollow fibers or flat plate membranes with specific pore sizes.
- The pore size of the membrane determines the type of component that can pass through
- It is used only for plasma collection
Membrane filtration
What is the pore size used in membrane filtration
0.2 to 0.5 micrometers
- The instrument combines centrifugation and membrane filtration technology by using a small rotating cylindrical filter.
- The instrument uses a dual-stage process, with centrifugation as the initial separation and membrane filtration for further purification.
Fenwal autopheresis-C
Donation frequency
2RBC
16 weeks
Donation frequency
Plasma (frequent)
Every 2 days, no more than 2 times in 7 days
Donation frequency
Plasma (Infrequent)
Every 4 weeks (no more than 13 times/year)
Donation frequency
Platelets, single apheresis unit
Every 2 days (no more than 2 times in 7 dyas; no more than 24 times in 12 months)
Donation frequency
Platelets, double or triple apheresis unit
every 7 days
Donation Frequency
Granulocytes
Every 2 days
T or F: Donation frequency will vary based on red cell gain and if more than one type of component is collected concurrently.
F (red cell loss)
Enumerate the nine (9) requirements for an apheresis program unit.
- Qualified licensed physician
- Good equipment
- Well-trained and motivated staff
- Written form consent
- Standardized protocols and policies for component collection and therapeutic procedure
- QC of equipment and apheresis product
- Management of adverse reactions
- Post-apheresis care
- Proper record-keeping and documentation
What are the four (4) components under apheresis?
- RBCs
- Plasma
- Platelets
- Granulocytes
- Typically collected as a double unit
RBCs
RBCs Component Collection
This is the clinical advantage of collecting apheresis RBCs
Reduced donor exposure for recepient (since RBCs are collected as double units)
RBCs Component Collection
The hematocrit must be at least ____ regardless of the gender.
40%
RBCs Component Collection
It should be determined by (qualitative/quantitative) method
Quantitative
RBCs Component Collection
T or F: The use of copper sulfate is acceptable.
F
Component collection
- It can be used to augment the inventory of fresh frozen
plasma (FFP) of a particular ABO group, especially group
AB. - for direct patient use
PLASMA
Component collection: Plasma
- What ABO type is considered to be the universal donor?
- What is the maximum allowable volume donated per year according to the FDA guidelines?
- AB
- 12L or 14.4L (for donors >175 lbs)
Component collection
- Platelet obtained by apheresis provides the equivalent of ____ units of whole blood - derived platelets (random-donor platelets), significantly decreasing a patient’s donor exposure.
- The platelets are suspended in ____ in a collection bag specificallly designed for platelet storage
- Platelet obtained by apheresis provides the equivalent of 6 to 8 units of whole blood - derived platelets (random-donor platelets), significantly decreasing a patient’s donor exposure.
- The platelets are suspended in donor plasma in a collection bag specificallly designed for platelet storage
Component collection: platelets
- A platelet procedure usually takes ____ minutes
- The interval between plateletpheresis procedures must be at least ____ days with no more than two procedures in a ____ day period
- 45 to 90 minutes
- 2 days, 7 day period
Component collection: platelets
- A donor may undergo no more than ____ plateletpheresis procedures in a rolling 12-month period
- The total plasma volum collected during any one procedure cannot exceed ____ mL or ____ mL (if donor weighs >175 lbs)
- What is the minimum platelet count required for a platelet donor?
- 24
- 500mL or 600mL
- 150,000/µL
Antiplatelet medications deferral time
a. 48 hours
b. 14 days
- Aspirin
- Clopidogrel (Plavix)
- Ticlopidine (Ticlid)
- Aspirin-containing medications
- a
- b
- b
- a
Antiplatelet medications deferral time
a. 48 hours
b. 14 days
- Ticagrelor (Brilinta)
- Anti-inflammatory drug Feldene
- Prasugrel (Effient)
- b
- a
- b
Component collection
- beneficial to some severely neutropenic patients
- has shown favorable results in treating neturopenic neonatees with sepsis
granulocytes
Component collection
What is the minimum therapeutic dose of granulocytes?
1 × 10^10 granulocytes
Component Collection: Granulocytes
Donors are stimulated with either a ____ or a ____ prior to the procedure and utilize a red blood cell sedimenting agent during the collection process
- corticosteroids or colony stimulating factor
Component Collection: Granulocytes
What is the red blood cell sedimenting agent used?
Hydroxyethyl starch (HES)
Therapeutic apheresis category according to the blood component removed
- procedure may be used to selectively remove RBCs, WBCs, or platelets.
- procedure is used to remove plasma when the pathological substance is found in the circulation.
- cytapheresis
- plasma pheresis
INDICATION CATEGORIES FOR THERAPEUTIC APHERESIS
- Apheresis is standard and acceptable, either as primary therapy or as a first-line adjunct to other initial therapies.
- Apheresis is generally accepted in a supportive role or as second-line therapy, rather than first-line therapy
- Apheresis has been demonstrated to lack efficacy or be harmful and should be discouraged in these disorders. Clinical applications should be undertaken only under an approved research protocol.
- Apheresis is not clearly indicated based on insufficient evidence, conflicting results, or inability to document a favorable risk-to-benefit ratio. Decision-making should be individualized.
- Cattegory I
- Category II
- Category IV
- Category III
The published guidelines by ____ is routinely updated but the decision should be individualized especially for Category III.
American Society for Apheresis
What are the two (2) vascular consideration?
- Vascular Access
- Physiological Consideration
- Considered to ensure safe and effective treatment
Vascular Access
Vascular Access
- Most common access site
Peripheral Vein (arm)
Vascular Access
- Veins in the neck, chest or arm
Central Vein
Vascular Access
T or F: Both the peripheral vein and central vain may be collected from either simultaneously or sequentially.
T
Vascular Access
- Mandatory during therapeutic apheresis as larger volumes of blood are processed and the duration of the procedure is longer than for donor apheresis
Adequate vascular access
Vascular Access
What are the gauge/s used?
16 to 18 gauge needles
Vascular Access
Poor vascular access may lead to what four (4) complications?
- Inadequate blood flow
- Hematoma formation
- Infection
- Nerve damage
Physiological Considerations
Less than 15% of the total blood volume (TBV) to minimize risk of hypovolemia (low blood volume)
Extracorporeal Blood Volume
What are the three (3) hypovolemia risks?
- Decreased blood pressure
- Reduced cardiac output
- Increase the risk of shock
Physiological Considerations
Familiarize yourself with the prevention for the physiological considerations.
- Extracorporeal blood volume should be less than 15%
- Monitoring patient’s vital signs
- Adjust the procedure as needed
- Fluid intake to maintain the blood volume
The removal and retention of the plasma, with return of all cellular components to the patient
Therapeutic Plasma Exchange
- Most common therapeutic apheresis procedure performed
- Purpose: To remove agents in the plasma that is causing clinical conditions such as autoantibodies, immune complexes, toxins, and inflammatory mediators
- Effectiveness relative to volume of plasma removed and concentration of pathological substance in the blood
Plasmapherisis
Plasmapherisis
1 volume exchange = ?
approximately 3L
Reduce the unwanted plasma component to approximately 30%
- Used to treat patients who have abnormally elevated platelet counts
- Platelet count will be decreased by 30% to 60%
- The blood is extracted from the patient and is separated using centrifuge or membrane filtration to remove the excess platelets before the rest of the components are transfused back to the patient.
- Can help reduce the risk of thrombotic and hemorrhagic complications
Plateletpheresis
Match the following.
- Myeloproliferative disorders, polycythemia vera, essential thrombocythemia, CML, or as reactive process in response to splenectomy, infection, chronic inflammation, or malignancy
- The patient is at risk for developing thrombotic or hemorrhagic complication
A. 1,000,000/uL
B. 500,000/uL
- B
- A
- Reduces abnormally elevated leukocyte count
- Used to treat patients with hyperleukocytosis, blast count of over 100,000/uL
- A single procedure should reduce the WBC count by 30% to 60%
- Reduces complications associated with hyperleukocytosis
Leukapheresis
Leukapheresis
May be used to improve the separation of WBCs and other blood components
Hydroxyethyl Starch
- Removes large number of RBCs from the patient and returns the patient’s plasma and platelets
- Performed in patients with sickle cell disease
- Goal: To decrease the level of hemoglobin S to less than 30%
- Treatment of overwhelming malaria or Babesia infections
- Treating patients when the parasite load is greated than 10%
- Removes incompatible RBCs from a patient’s circulation
Erythrocytapheresis
- Used to maintain fluid and electrolyte balance
- Maintains blood volume to prevent hypotension
Fluid Replacement
Fluid Replacement
The most common replacement fluid for TPE
Human Serum Albumin as a 5% solution
Fluid Replacement
Replaces fluid in certain situations such as clotting factor replacement, thrombocytopenia purpura, hemolytic uremic syndrome
Fresh Frozen Plasma (FFP)
Match the following.
- Systemic Lupus Erythematosus
- Guillain-Barre Syndrome, Goodpasture Syndrome
- Waldenstrom’s Macroglobulinemia
- Amanita Mushroom Poisoning, Barbiturate Poisoning
- Familial hypercholesterolemia, hypertriglyceridemia
- Refsum’s Disease
A. Phytanic Acid
B. Lipoproteins
C. Protein-bound Toxins
D. Immunoglobulins causing hyperviscosity
E. Alloantibodies
F. Immune Complexes
- F
- E
- D
- C
- B
- A
- Also referred to as peripheral blood stem cells
- Can be collected by apheresis from an autologous or allogeneic donor
- Each procedure lasts 4 to 6 hours
- Collected by apheresis which involves stimulating the bone marrow and releasing HPCs in the bloodstream using growth factors
- Collecting is done with a machine
Hematopoietic Progenitor Cells
Advantages of HPCs
- ____ is avoided, procedures can be performed in the outpatient setting
Anasthesia
Advantages of HPCs
T or F: There is a shorter period of cytopenia, decreased transfusion requirements, fewer infectious complications, and decreased length of hospitalization for autologous HPC donors.
T
Adverse Effects of HPCs
- Complications such as dizziness or fainting can occur especially for donors at higher risks for ____ or ____
Presyncopal or syncopal reactions
- Observed during cytapheresis component collections when anticoagulated plasma is returned at a rate
- Can be clinically detected using Chvostek’s sign or Trousseau’s sign
Citrate Toxicity
Citrate Toxicity
Twitching of the patient’s muscles when the cheek is tapped
Chvostek’s Sign
Citrate Toxicity
Spasmodic contraction of muscle in the forearm when blood pressure cuff is inflated
Trousseau’s sign
- Large intravenous catheter can lead to bleeding, lung puncture, if the catheter is left in too long, infection may occur
- Due to catheter insertion or removal
Vascular Access
Is a fainting episode mediated by the vagus nerve
Vasovagal Reactions
Vasovagal Reactions
Most common type of fainting
Vasovagal Syncope
Vasovagal Reactions
Results in a decrease in blood pressure
Hypovolemia
- Hypovolemia = IFC
- Allegic reactions are related to the replacement fluids such as albumin
- Hemolysis
- Air embolism and clotting factor deficiencies are not
commonly observed
Miscellaneous Reactions
Familiarize yoruself with the prevention and management in plasma procedures
● Watch for signs of vasovagal reactions, hypovolemic
reactions, and others
● Ensure adequate fluid replacement to prevent hypovolemia
● Use of appropriate replacement fluids to minimize allergic reactions
● Ensure that patients are suitable for plasmapheresis and monitor them closely.
● Follow and establish protocols to minimize risk
● Monitor and provide supportive care if necessary
● Be prepared to respond to emergency situations such as cardiac arrest and respiratory distress
- Concentration of most plasma substances is
reduced by 50% to 60% after one standard
plasmapheresis treatment - Removes plasma proteins such as
immunoglobulins, complements, coagulation
factors,and lipoproteins
Plasma Protein Interactions
Major causes of fatalities in apheresis?
- Circulatory Complications
- Respiratory Complications
Familiarize yourself with the adverse effects of apheresis.
● Citrate toxicity
● Vascular access complications: hematoma, sepsis, phebitis, neuropathy
● Vasovagal reactions
● Hypovolemia
● Allergic reactions
● Hemolysis
● Air embolus
● Depletion of clotting factors
● Circulatory and respiratory distress
● Transfusion-transmitted diseases
● Lymphocyte loss
● Depletion of Proteins and immunoglobulins
Match the following.
Timing of Donation/Deferral
1. 48 days/2 days
2. 4 weeks
3. 48 hours
4. 16 weeks
A. Platelet
B. Plasma (occassional)
C. Plasma (serial)
D. Double RBC (autologous allogenic)
- A
- B
- C
- D
Match the following.
- M = at least 130 lbs, 5’1, 40% HCT
- F = at least 150 lbs, 5’5, 40% HCT
- Not exceed > 2x per week with normal TP
- HES, corticosteroids, or growth factor (GCSF)
- Not exceed > 2x per week or 24x per year
- PC = 150,000/uL if < 4 weeks interval
A. Platelet
B. Plasma (occassional)
C. Plasma (serial)
D. Double RBC (autologous allogenic)
- D
- D
- B
- C
- A
- A
