With respect to plasma exchange therapy:
- (a) What are the physical principles of plasma exchange therapy?
- (b) What substances can plasma exchange effectively remove?
- (c) List 5 acute conditions where therapeutic plasma exchange is indicated.
- (d) List 4 common complications of this therapy, excluding catheter-related complications
Answer and interpretation
(a) What are the physical principles of plasma exchange therapy?
- Separation of plasma from blood cells by centrifugation or membrane filtration
- Reinfusion of cells plus autologous plasma or another replacement solution eg albumin
- Removes large molecular weight substances
(b) What substances can plasma exchange effectively remove?
- Pathogenic auto-antibodies
- Immune complexes
- Myeloma light chains
- Cholesterol-containing lipoproteins /triglycerides
(c) List 5 acute conditions where therapeutic plasma exchange is indicated.
- Myasthenic Crisis
- Goodpasture’s Syndrome with pulmonary haemorrhage
- Hyperviscosity syndromes
— Waldenstrom’s Macroglobulinaemia
- Wegener’s Granulomatosis with pulmonary haemorrhage
- Guillain-Barre Syndrome/Acute Inflammatory Demyelinating Polyradiculopathy
- Antiphospholipid Antibody Syndrome
- HELLP syndrome
- Multiple sclerosis
- HIV-related neuropathy
- Paraneoplastic syndromes
- Rapidly progressive glomerulonephritis
- Renal transplant rejection
- Coagulation inhibitors
- Auto-immune haemolytic anaemia
- Overwhelming sepsis syndromes eg meningococcaemia
- Reye’s syndrome
- Paraquat poisoning
(d) List 4 common complications of this therapy, excluding catheter-related complications
- Hypotension due to excess fluid removal +/ inadequate volume replacement
- Citrate-induced hypocalcaemia
- Anaphylactic/transfusion reactions to fresh frozen plasma replacement solution
- Coagulation abnormalities due to removal of clotting factors not replaced when albumin replacement used.
- Removal of useful immunoglobulins and complement which can in theory lead to an immunodeficient state.
- Drug removal – especially drugs with high protein-binding and low volume of distribution. Potential problems in the diseases in which therapeutic plasma exchange is used are cyclophosphamide and azathioprine.
- Pyrogenic reactions
- Vasovagal reactions
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.