1. THERAPEUTIC PLASMA EXCHANGE OUR EXPERIENCE AT SALEM
Dr. Aswin Kumar. S
II year M.D., Immunohematology & Blood Transfusion
Vinayaka Mission Medical College, Salem

2. INTRODUCTION
APHERESIS, The Greek word ‘Pheresis’ meaning “to take away,” involves the selective removal of blood constituents from donors or patients.
Desired components
Red blood cell
Platelets
Plasma
Whole blood

3. INTRODUCTION Therapeutic plasma exchange (TPE),is an
extracorporeal blood purification technique used
to remove large molecular weight substance like
Pathogenic autoantibodies (e.g. Myasthenia Gravis: autoantibody)
Cryoglobulins or other abnormal plasma proteins (e.g. Waldenstorm's macroglobulinemia)
Immune complexes (e.g. Goodpasture's syndrome)

4. INDICATIONS
Approximately 300,000 plasma exchange procedures are performed worldwide for various indications like
Neurological - GBS,MG
Renal -Good pasture syndrome
Hematological-TTP, Sickle cell crisis
Dermatology –Pemphigus vulgaris
Toxins-Amanita phalloids, OPC

5. OUR EXPERIENCE
We started TPE in Jan 2011 till date we have done 110 procedures on 36 patients

6. CASE DISTRIBUTION
Total no of patients : 36

7. Guillain barre syndrome
DIAGNOSIS
No of Patients
Category of Indication
(AABB/ASFA)
Number of procedure per patient
Total procedures
Guillain barre syndrome 12 I 5 60
Myasthenia gravis 4 20
Motor neuron disease 1
Parainfectious demyelinating spondyloarthropathy
Paraquat poisoning 18
III

9. AGE DISTRIBUTION

10. GENDER DISTRIBUTION
Total patients = 36

11. PROCEDURE Instrumentation : Hemonitics cell separator (MCS+)
Done at : ICU under the supervision of emergency physician
IV access : Central venous catheter (femoral or internal jugular vein)
Anticoagulant : Acid citrate dextrose (ACD) anticoagulant is used in 1:16 ratio

12. KEEP AN EYE ON Pulse Blood pressure Urine output Blood flow
Signs of citrate toxicity

13. VOLUME OF PLASMA EXCHANGE
Formula: The volume of plasma to be exchanged is determined by patients estimated plasma volume (EPV) and hematocrit (hct) EPV = 0.07 x weight(kg) X (1-hct) in liters

14. PLASMA VOLUME EXCHANGE
Percent Removed 0%
0.5
39.3%
1.0
63.2%
1.5
77.7%
2.0
86.5%
2.5
91.8%
3.0
95.0%

15. Efficiency of removal is greatest early in the procedure and diminishes progressively during the exchange.

16. NUMBER OF PROCEDURES Neuro-immunological cases
Approximately 5 procedures were done on alternate days
Paraquat poisoning
Single large volume exchange (1-1.5 plasma volume exchange) 1 2 3 4 5

17. REPLACEMENT FLUIDS
These r the various replacement fluids available, each one has its own advantages n disadvantages.

18. REPLACEMENT FLUIDS Fresh frozen plasma (30 – 40%)
Colloids(6% hydroxyethyl starch) (30%)
Crystalloids (30%)
In our center we generally replace with normal saline,6 %HES n FFP in the ratio 1;1;3. That is one point of ns ,one point of 6% HES n 3 units of FFP each containing approx 200 ml

19. ADVERSE REACTIONS 27
Out of 36 patients 9 patient had a manageable adverse reaction 9

20. ADVERSE REACTIONS 1 patient 2 patients
Hypotension was most commonly observed reaction
Out of our 36 patients 3 patients became hypotension 2 pt. had fever n chills, catheter plugging was noticed in 2 pt n jst one pt showed the signs of citrate toxicity
2 patients

21. SIGNS OF RECOVERY In Neuro-immnological cases recovery is assessed by
Recovery from assisted ventilator support
Improvement in muscle power and early mobilization
The outcome of neuroimmunological cases were assessed on the basis of
Recovery from assisted ventilatory support
Improvement in muscle power and early mobilization

22. CLINICAL DATA
Most of the patients undergoing this procedure were under mechanical ventilation

23. NEURO-IMMUNOLOGICAL MORTALITY
Unfortunately one of our patients could not been extubated n he expired due to respiratory failure

24. MORTALITY IN PARAQUAT POISONING
8 patients
Out 18 pt procedure was successful on 10 patients and wasn’t on 8 patients.
To mention paraquat is a herbicide.
It is highly toxic, fatal compound with no specific antidote avaliable
Consumption of paraquat poison for suicidal attempt increased in recent years ,consumption of 15 ml or more is considered to be a lethal dose , n main modality of treatment is charcoal hemoperfusion Wch is not avaliable in most of the centers in india. . TPE is indicated when all the treatment modalities fails.

25. CONCLUSION
The efficacy of plasma exchange in various clinical indications are categorized as follows Category I – Standard acceptable therapy Category II – Sufficient evidence to suggest efficacy usually as adjunctive therapy Category III – inconclusive evidence of efficacy or uncertain risk/benefit ratio Category IV – Lack of efficacy in controlled trials
Conclusive discussion

26. CATEGORY - I INDICATIONS (first line therapy )
Neurological:
Guillain Barre synd
Myasthenia Gravis
CIDP
Demyelinating polyneuropathy with IgG & IgA
Hematological:
TTP
Sickle cell crisis
ABO mismatch Marrow transplant
Cryoglobinemia
Others:
Cutaneous T cell Lymphoma
Good pasteur synd
Hypercholestrolemia
Phytanic acid storage disease
Amanita phalloides poisoning
Chronic inflammatory demyelinating polyradiculoneuropathy

27. CATEGORY - II INDICATIONS
Renal & Others:
RPGN
Acute renal failure due to cast nephropathy
Graves disease
Digitalis toxicity
Pemphigus vulgaris
Bullous pemphigoid
Toxic epidermonecrolysis
Neurological:
Lambert -Eaton synd
Acute CNS inflamatory demyelinating disease
Sydenham’s chorea
PANDAS
Refsum’s diseases
Hematological:
ITP
Maternal-fetal Rh incompatability
Coagulation factors inhibitors
Pediatric autoimmune neropsychiatry disorder PANDAS
Rapidly progressively glomular nephritis

28. CONCLUSION
TPEs are successfully performed worldwide but implementation of plasma exchange in our country is still lacking
The risks and complications associated with this procedure are minimal and manageable
Utilization of this procedure in large scale will prove beneficiary to patients

29. CONCLUSION Therapeutic plasma exchange is Safe Cost effective and
Efficacious
when performed with expertise in appropriate indications
TPE
To conclude

30. Thank you