BENEFIT OF TPE IN CRITICAL ILL PATIENT IN COVID-19

BASTIAN - 2021
OUT LINE
• BLOOD PURIFICATION
• PLASMAPHARESIS
• CRITICAL ILL PATIENT
• COVID 19
• CASES
• KESIMPULAN
 “Spanish Flu”

Pandemic
Early ‘90s

As of 26th January 2021, The total case of COVID-19 infection has reached 100 millions (100,297,653)
Blood Transfus 2014; 12: 14-21 DOI 10.2450/2013.0131-13

The Egyptians were known to take
blood baths to restore health and to
maintain youthfulness
Hippocrates (460-377 B.c.)
Introduction of bloodletting
Galen’s “humoral theory” Once
the humors were balanced through
the removal of blood, then the
individual was restored to health.
“Bad humors” were thought to be
responsible for ill health and
emotional states such as depression
and insanity
William Harvey, 1568-1637 Blood transfusion bottles used prior
the Circulation of Blood to 1965 for the scparation of plasma
Plasmapheresis is derived from a Greek word
meaning to take away by force.

A recent “state of the art” article cites over 50 diseases

treated by plasmapheresis worldwide
Introduction

In 1920 by G. H. Whipple

THEORY AND RATIONALE The goal of plasmapheresis is the removal of

pathogenic substances present in plasma. Pathogenic factors include
autoreactive antibodies, immune complexes, paraproteins,
lipoproteins, and infl ammatory mediators such as cytokines.
 Demand for therapeutic plasma
exchange (TPE) is rising as further new
indications for the procedure are added
to clinical guidelines.

TPE was first performed by the Yeh JH, et al. The most common indication of TPE nowadays :
Russian physicians Vadim A. Yurevich Neurological disorders (58.4%), mainly myasthenia gravis
and Nikolay Konstantinovich (34.9%) and Guillain-Barré syndrome (18.2%).
Rosenberg in 1913. Haematological disorders (19.3%),
Hepatic-pancreatic disorders (12.3%), and
Rheumatic disorders (7.1%)
Human donors and attempted as 1952
treatment in a patient with multiple
myeloma.
 Plasmapheresis was first reported as a 1968
treatment for hepatic coma
 Goodpasture’s syndrome 1975
 Thrombotic thrombocytopenic purpura 1977
 Meningococcal sepsis 1979

1983 plasmapheresis had been evaluated for use in immune-

mediated neurological diseases such as myasthenia gravis,
multiple sclerosis, acute and chronic-relapsing Guillain-Barré
syndromes, polymyositis, and dermatomyositis.
PASIEN KRITIS

Historical perspective on heart function: the Frank–Starling Law. Biophysical Reviews · November 2015
Lara Shekerdemian, Desmond Bohn. Cardiovascular effects of mechanical ventilation. Arch Dis Child 1999;80:475–480
SHOCK
CRITICAL ILL PATIENT
Imbalance oxygen delivery (DO2) and oxygen demand
(VO2).
BAHAYA
Shimabukuro-Vornhagen et al. Journal for ImmunoTherapy of Cancer (2018) 6:56
Immunopathogenesis and coagulopathy induced by SARS-CoV2 in susceptible patients
leads to cytokine storms and aberrant coagulation responses that can lead to high
mortality due to the occurrence of ARDS and MOD. Reducing the burden of cytokines
and abnormal coagulation agents by plasmapheresis can be very helpful in the
management of COVID-19
Halaman 14 – 37
5. DERAJAT BERAT ATAU KRITIS

Halaman 51 – 56
BAB V
STRATEGI MANAJEMEN DI ICU

CRRT-
CVVHDF
SLED HFR
TPE
 Hepatitis  (approximate diameter of 55-60 nm) to pass the
membrane so they can be eliminated, downregulating viral load,
Similarly SARS-CoV-2  has a diameter of 60-140 nm, also large
enough to be eliminated with DFPP.
PATHOMECHANISME Clin J Am Soc Nephrol 9: 181–190, 2014. doi10.2215/CJN.0468051

TPE
• The basic concept of TPE is to remove certain pathological substance
from the plasma to reverse the pathologic process.
• There are two types of TPE : Centrifugal and Membrane
• Centrifugal use the concept of Density & Gravity
• Membrane use the concept of Size
Types of TPE
Centrifugal Membrane

Can perform separation of Dialysis equipment that has

all blood compartments: additional functionality –
plasmapheresis, PLASMAPHERESIS ONLY
leukapheresis, RBC Plasma is separated from
exchange, platelet other cellular components
depletion based on size via membrane
Kits designed to remove with large pores (0.3–0.5
specified cell layer based um)
on specific gravity.
Centrifugal Plasma Exchange
Membrane Plasma Exchange
 mTPE Procedure
Filter AN69 ST100 (CRRT) TPE1000 TPE2000

• Filter: TPE 1000/2000

Material Acrylonitrile & MS copolymer polypropylene polypropylene

• Surface are
Effective Surface area
Internal diameter
1m2
240microm
0.15m2
330microm
0.35m2
330microm

Priming volume
a 69ml 23ml 41ml

Sieving coefficient <0.01 0.97/1/0.92 0.97/1/0.92

Albumin/IgG/IgM

Plasma filtration rate at

blood flow
100ml/min 29ml/min 42ml/min
200ml/min 49ml/min 79ml/min
Diagram of
Centrifugal and
Membrane PE
 Plasma Volume Calculation
• Total Blood Volume (TBV) is estimated to be 5,5 - 7,5% of Body weight or
70ml/kg for males and 65 ml/kg for females

• Total Plasma Volume (TPV) to be removed =

Total blood volume (TBV) x (100%-HCT)

Or

0.07 x Body Weight x (1 - HCT)

• Plasmapheresis can remove What is Being Removed?
• Proteins
• Cytokines
• Toxins
• Antibodies
• Ag-Ab complexes
• More specifically, it is removing autoantibodies in these autoimmune
disorders:
• Acute Inflammatory Demyelinating Polyradiculoneuropathy/ Guillain Barre Syndrome
• Myasthenia Gravis
• Immune Thrombocytopenia Purpura
• Autoimmune hemolytic anemia
• Etc
Ward DM, Conventional Apheresis Therapies: A Review.
J Clin Apheresis, 26:230-238, 2011
 Rational Use of TPE
Volume : 1 – 1.5x TPV
Typical Regimen : 20-25ml/Kg
Replacement Fluid : Albumin
Frequency : every one day or two days
Duration : Depends upon clinical scenario. Some
patients may require long-term maintenance TPE.

Schwartz J, Padmanabhan A, Aqui N, et al. Guidelines on the use of therapeutic apheresis in clinical
practice–evidence‐based approach from the Writing Committee of the American Society for Apheresis: the
seventh special issue. Journal of clinical apheresis. 2016;31(3):149-338.
 CASE
THERAPI
PLASMA
EXCHANGE
 BLOOD
TOTAL REPLACMENT
REPLACMENT FLUID
PBP
PLASMA LOSS
HEPARIN 1 KALI SIKLUS m TPE

LK 55 kg BV = 70 ml/KG = 3850 ml = 3.85 L

PV = BV (1- Hct/100) = 3.85 L X 66 % = 2.541 L ~
1-1,5 PV = 2.5 L-3.75 L

PASIEN PINDAH KE BANGSAL

KASUS 1
COVID
HFNC
 KASUS 2
Covid 19
Plasmaphareresis

LOW PERFUSION IN BRAIN IN SPITE

GOOD MAP
KASUS 3
COVID
HFNC

1 KALI SIKLUS m TPE

1.5 x BV KALI SIKLUS m TPE

3. 500 ml
KASUS 4
COVID
INTUBATION

1 KALI SIKLUS m TPE

1.5 x BV KALI SIKLUS m TPE

2.300 ml
KASUS 5
COVID
INTUBATION

1 KALI SIKLUS m TPE

1.5 x BV KALI SIKLUS m TPE

2.300 ml
KASUS 6
COVID
CPAP

LK 60 kg BV = 70 ml/KG = 4.2 L
PV = BV (1- Hct/100) = 4,2 L X 70 % = 2.91 L
PV = 1.5 X 2,9 L = 4.3 L

2 x BV KALI SIKLUS m TPE

4.000 ml
1.5 x BV KALI SIKLUS m TPE
2.300 ml
Conclusion
SEVERITY

KRITIS RINGAN
21% 16%

BERAT SEDANG
27% 36%

BLOOD PURIFICATION TPE

LEBIH BANYAK LAKI DARI PERMPUAN  8 : 2 ORANG
COVID DERAJAT BERAT  SEVERE ARDS
SURVIVER  30 PERSEN
MORTALITY DERAJAT BERAT  70 PERSEN
EARLY TPE  OUT COME LEBIH BAIK
EARLY TPE)

TOO LATE
BROOOOO…….