Management of Hypertension During Therapeutic Plasma Exchange (TPE)
Immediately discontinue TPE if severe hypotension or hemodynamic instability occurs, and withhold angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) on the day of the procedure to prevent bradykinin-mediated cardiovascular collapse.
Pre-Procedure Medication Management
Critical medication considerations:
Discontinue ACE inhibitors and ARBs on the day of TPE 1. These medications potentiate bradykinin accumulation when plasma contacts extracorporeal membranes, leading to severe hypotension and potential hemodynamic collapse requiring vasopressor support and intubation 1.
Evaluate all antihypertensive medications prior to TPE, as the procedure itself can cause hypotension in 3.5-3.6% of cases 2, 3.
Monitoring During TPE
Essential hemodynamic surveillance:
Monitor blood pressure continuously throughout the procedure, as hypotension is one of the most common complications (3.5-3.6% of sessions) 2, 3.
Watch for early signs of cardiovascular compromise including tachycardia, which occurs in approximately 4% of cases when related to blood pressure changes 4.
Maintain adequate vascular access through central venous catheters (66% of cases) or large peripheral veins to minimize hemodynamic stress 3.
Management of Hypertension During TPE
If hypertension develops during the procedure:
For severe hypertension requiring immediate IV treatment, use labetalol or nicardipine as first-line agents 5. These medications are recommended for acute severe hypertension and are compatible with ongoing TPE.
Nicardipine IV can be initiated at 5 mg/hr and titrated by 2.5 mg/hr every 5-15 minutes up to 15 mg/hr to achieve blood pressure control 4.
Labetalol IV is an alternative first-line option for acute blood pressure management during procedures 5.
Oral methyldopa or nifedipine can be used for less urgent blood pressure elevation 5.
Management of Hypotension During TPE
If hypotension occurs (the more common scenario):
Immediately discontinue the TPE infusion 4. Hypotension occurs in 3.5-3.6% of TPE sessions and is the most frequent cardiovascular complication 2, 3.
Administer fluid boluses as initial management 1.
Once blood pressure and heart rate stabilize, restart TPE at low infusion rates (3-5 mg/hr if using nicardipine) and titrate carefully 4.
If hypotension is severe and unresponsive to fluids, vasopressor support may be required, particularly in patients who received ACE inhibitors or ARBs 1.
Post-Procedure Blood Pressure Management
After TPE completion:
Resume chronic antihypertensive medications cautiously, as patients may remain hemodynamically labile for several hours post-procedure 1.
ACE inhibitors and ARBs can be restarted 24 hours after TPE once hemodynamic stability is confirmed 1.
Target blood pressure should be <140/90 mmHg for most patients, or 120-129/<80 mmHg for those at high cardiovascular risk, once the acute procedure period has passed 5.
Common Pitfalls to Avoid
Critical errors in TPE blood pressure management:
Never continue ACE inhibitors or ARBs on the day of TPE - this is associated with life-threatening bradykinin-mediated hypotension requiring intensive care 1.
Do not use small peripheral veins (dorsum of hand/wrist) as this increases vascular complications and hemodynamic instability 4.
Change peripheral IV infusion sites every 12 hours to minimize venous irritation and maintain adequate access 4.
Do not abruptly discontinue beta-blockers in patients receiving them, as TPE does not provide protection against withdrawal effects 4.
Special Considerations
Patient-specific factors:
In patients with congestive heart failure, monitor closely during blood pressure adjustments as they are at higher risk for hemodynamic complications 4.
For patients with impaired hepatic or renal function, use lower initial doses of IV antihypertensives and titrate more gradually 4.
Complications occur in approximately 18.3% of patients overall, with hypotension being among the most common alongside catheter-related issues 3.