CH14 Apheresis PDF

Modern Blood Banking & Transfusion Practices
6th Edition
Chapter 14
Apheresis
Copyright © 2012 F.A. Davis Company

6th Edition
History and Development

 Early developments in apheresis began some 60
years ago when Dr. Edwin J. Cohn devised a
method, based on a dairy centrifuge (the “Cohn
centrifuge”), for purification of albumin from
pooled human plasma.
 Developments in the 1960s
 Developments in the 1970s

6th Edition
History and Development (cont’d)

 Apheresis today still consists of withdrawing a
small volume of whole blood from a donor or
patient and separating into its components.
 One (or more) of the components is collected
and retained, and the remaining components
are recombined and returned to the individual.

6th Edition

 Apheresis can be performed on a donor to
collect a specific blood component (donor
apheresis).
 It can be performed on a patient to remove a
particular blood component for therapeutic
purposes (therapeutic apheresis).

6th Edition

 The process of removing plasma is termed
plasmapheresis.
 In a similar manner, platelets (plateletpheresis),
red blood cells (erythrocytapheresis), or
leukocytes (leukapheresis) can be removed (or
collected) using apheresis technology.
< Insert Figure 14-1>

6th Edition
Physiology of Apheresis
 Impact of the manipulation of the removed
blood, and subsequent reinfusion of portions
of the blood back to the donor’s body
 Effects of anticoagulation
 Effects of fluid shifts
 Effects of cellular loss
 Procedures to track annual cell losses are
required

6th Edition
Methodology
 Modern apheresis instruments utilize a
computerized control panel, allowing the
operator to select the desired component to be
collected or removed.
 Onboard optical sensors
 Use of disposable equipment
 Duration of the procedure varies
 Goals determine instrument selection

6th Edition
Methodology (cont’d)
 By manipulating certain variables on an
apheresis instrument, the operator can harvest
plasma, platelets, WBCs, or RBCs.
 Centrifuge speed and diameter
 Dwell time of the blood in the centrifuge
 Type of solutions added, such as anticoagulants or
sedimenting agents
 Cellular content or plasma volume of the patient or
donor
6th Edition
Methods of Centrifugation
 Two common methods of centrifugation
 Intermittent Flow Centrifugation (IFC)
 Continuous Flow Centrifugation (CFC)
 Advantages and disadvantages of IFC and CFC
 Combined platforms with both methods

6th Edition
Methods of Centrifugation
(cont’d)
< Insert Figures 14-3 and 14-4>

6th Edition
Membrane Filtration
 Membrane separators are typically composed of
bundles of hollow fibers or flat plate membranes
with specific pore sizes.
 Pores can be sized to prevent the passage of even
small cellular elements during plasma collection.
 There are advantages over centrifugation methods.

6th Edition
Component Collection
 A specific blood component is obtained that
will be transfused to a patient.
 General and apheresis-specific donor
requirements
 Collection of each apheresis blood component
carries with it a different deferral period.

6th Edition
Component Collection (cont’d)

 A qualified, licensed physician must be
responsible for all aspects of the apheresis
program.
 Other staff requirements
 Written, informed consent must be obtained
from the donor, including statements of risk.

6th Edition
Red Blood Cells

 Typically collected as a double unit (termed a
2RBC or double RBC procedure)
 Clinical advantage: reduced donor exposure for
the recipient because the patient can potentially
receive two units from the same individual
 2001 FDA donor selection criteria

6th Edition
Plasma
 Plasmapheresis: collection of plasma by apheresis
 Each apheresis unit (“jumbo” plasma) is the volume
equivalent of at least two whole-blood-derived plasma units.
 Varied purposes for collection of apheresis plasma
 For donor purposes, collection divided into frequent
and infrequent plasmapheresis
 Applicable FDA guidelines for plasmapheresis

6th Edition
Platelets
 Apheresis platelets provide the equivalent of
6 to 8 units of random-donor platelets.
 This significantly decreases the patient’s
donor exposure.
 Additional donor selection criteria for the
plateletpheresis donor.

6th Edition
Platelets (cont’d)
 Plateletpheresis collections should not be
performed on potential donors taking
antiplatelet medications.
 Recommended intervals between
plateletpheresis procedures according to
regulatory guidelines established by the FDA
and the AABB.

6th Edition
Granulocytes
 Patient populations that may benefit
 Provides a higher yield product than whole
blood
 Minimum therapeutic dose considerations
 Side effects of the addition of the red cell
sedimenting agent, hydroxyethyl starch (HES)

6th Edition
Granulocytes (cont’d)
 Use of oral corticosteroids to mobilize marginal pool
granulocytes and increase circulating cells
 Considerations for administration of granulocyte-
colony stimulating factor (G-CSF)
 Consideration of GVHD in severely
immunocompromised patients
 Compatibility testing requirements

6th Edition
Therapeutic Apheresis (TA)

 The rationale is based on
 A pathologenic substance exists in the blood that
contributes to a disease process or its symptoms.
 The substance can be more effectively removed by
apheresis than by the body’s own mechanisms.
 Cytapheresis procedures
 Plasmapheresis procedures

6th Edition
Therapeutic Apheresis (TA) —

General Considerations
 Clearly defined policies must delineate the
responsibility of the blood bank physician and
the patient’s attending physician(s).
 American Society for Apheresis (ASFA) guidelines
for Therapeutic Apheresis

6th Edition

General Considerations (cont’d)
 The indication categories for therapeutic
apheresis include
 Category I
 Category II
 Category III
 Category IV

6th Edition

Physiologic Considerations
 The patient’s extracorporeal blood volume (ECV)
should be <15% of the total blood volume (TBV) in
order to minimize the risk of hypovolemia.
 Calculation of the patient’s plasma volume (PV)
 Consideration of the patient’s medications
 The number of TA procedures performed varies
with the disease/disorder and the individual patient.
 Use of a blood warmer during TA
6th Edition
Therapeutic Plasma Exchange

(TPE)
 Removal and retention of the plasma, with return of
all cellular components
 Removal of an offending agent in the plasma
 Replace a normal factor or substance that may be
missing or deficient in the patient’s plasma
 Because of the diminishing effect of increased
plasma removal, it is recommended that
approximately 1 to 1.5 plasma volumes be
exchanged per procedure.
6th Edition
Plateletpheresis
 Therapeutic plateletpheresis is used to treat
thrombocythemia with related symptoms.
 Risk of thrombotic or hemorrhagic complications
 Use of medications versus plateletpheresis
 There are no specific guidelines as to the level the
platelet count must be reduced or a standardized
procedure to reach a particular target platelet count.

6th Edition
Leukapheresis
 Used to treat patients with hyperleukocytosis
(defined as a WBC or circulating blast count of
>100,000/µL)
 Risk for organ dysfunction from microthrombi in the
pulmonary and cerebral microvasculature
 Prediction of required blood volume is difficult
 Monitor with WBC counts
 Use of a red cell sedimenting agent, such as HES,
may be of benefit

6th Edition
Erythrocytapheresis
(Red Cell Exchange)
 Removes a large number of RBCs from the patient
and returns the patient’s plasma and platelets with
compatible allogeneic donor RBCs.
 Most commonly performed to reduce complications of
sickle cell disease
 Therapeutic goal: removal of incompatible RBCs from
patient's circulation
 Less common indications for red cell exchange
 Requirements for allogeneic donor red cells
6th Edition
Fluid Replacement
 In therapeutic plasmapheresis, large volumes of the
patient’s plasma are retained.
 Replacement is necessary to maintain appropriate
intravascular volume and oncotic pressure.
 Several options are available, determined by the disease
being treated, the condition of the patient, and the
preference of the institution.
 Use of 5% human serum albumin vs. FFP.

6th Edition
Special Procedures
 New technology has allowed the collection of
very specialized components as well as the
removal of specific plasma constituents.
 Hematopoietic Progenitor Cells (HPCs)
 Immunoadsorption/Selective Absorption
Photopheresis
< insert Figure 14-10>

6th Edition
Adverse Effects of Apheresis

 Citrate toxicity
 Vascular access difficulties
 Vasovagal reactions
 Hypovolemia
 Allergic reactions
 Hemolysis

6th Edition
Plasma Protein Interactions

 The concentration of most plasma substances
is reduced by 50% to 60% after one standard
plasmapheresis treatment, with the rate of
return to steady state concentrations varying
among analytes.

6th Edition
Fatalities
 Rare fatalities during therapeutic apheresis
procedures have been reported.
 Most caused by circulatory (cardiac arrest or arrhythmia)
or respiratory complications (acute pulmonary edema or
adult respiratory distress syndrome)
 FFP recommended only in cases of TTP or hemolytic
uremic syndrome (HUS)
 There is a possibility of disease transmission with use of
FFP

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Modern Blood Banking & Transfusion Practices

Copyright © 2012 F.A. Davis Company

History and Development

Copyright © 2012 F.A. Davis Company

History and Development (cont’d)

Copyright © 2012 F.A. Davis Company

History and Development (cont’d)

Copyright © 2012 F.A. Davis Company

History and Development (cont’d)

Copyright © 2012 F.A. Davis Company

Copyright © 2012 F.A. Davis Company

Copyright © 2012 F.A. Davis Company

Copyright © 2012 F.A. Davis Company

Copyright © 2012 F.A. Davis Company

Copyright © 2012 F.A. Davis Company

Copyright © 2012 F.A. Davis Company

Component Collection (cont’d)

Copyright © 2012 F.A. Davis Company

Red Blood Cells

Copyright © 2012 F.A. Davis Company

Copyright © 2012 F.A. Davis Company

Copyright © 2012 F.A. Davis Company

Copyright © 2012 F.A. Davis Company

Copyright © 2012 F.A. Davis Company

Copyright © 2012 F.A. Davis Company

Therapeutic Apheresis (TA)

Copyright © 2012 F.A. Davis Company

Therapeutic Apheresis (TA) —

Copyright © 2012 F.A. Davis Company

Therapeutic Apheresis (TA) —

Copyright © 2012 F.A. Davis Company

Therapeutic Apheresis (TA) —

Therapeutic Plasma Exchange

Copyright © 2012 F.A. Davis Company

Copyright © 2012 F.A. Davis Company

Copyright © 2012 F.A. Davis Company

Copyright © 2012 F.A. Davis Company

Adverse Effects of Apheresis

Copyright © 2012 F.A. Davis Company

Plasma Protein Interactions

Copyright © 2012 F.A. Davis Company

Copyright © 2012 F.A. Davis Company

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