What are the immediate management steps for complications post plasma exchange?

Immediate Management of Post-Plasma Exchange Complications

Monitor intensively for hypotension, citrate toxicity, and catheter-related complications, as these represent the most common and serious adverse events requiring immediate intervention. 1, 2

Immediate Assessment and Monitoring

Upon recognizing a complication post-plasma exchange, immediately assess:

• Vital signs: Blood pressure, heart rate, oxygen saturation, and temperature 2, 3
• Neurological status: Level of consciousness, new focal deficits, or worsening symptoms 4
• Vascular access site: Signs of bleeding, hematoma, or infection 1, 5
• Electrolyte status: Particularly calcium and potassium levels 1, 3

Management by Complication Type

Hypotension (Most Common: 8-21% of procedures)

Hypotension is the most frequently reported complication and correlates with low pre-procedure hematocrit. 2, 3

• Immediately slow or temporarily stop the plasma exchange procedure 2
• Administer intravenous normal saline bolus (250-500 mL) 2
• Place patient in Trendelenburg position if tolerated 4
• Monitor blood pressure every 5 minutes until stabilized 2
• Consider vasopressor support if fluid resuscitation inadequate 2

Citrate Toxicity (7.8% of procedures)

Citrate toxicity manifests as perioral tingling, muscle cramps, tetany, or cardiac arrhythmias, and is dramatically impaired in patients with hepatic insufficiency or hypoperfusion. 1, 6

• Immediately slow the infusion rate 6
• Administer intravenous calcium gluconate 10% (10-20 mL over 10 minutes) 1
• Monitor ionized calcium levels and ECG continuously 1
• Avoid plasma exchange in patients with severe liver disease or shock states 1

Allergic Reactions (Most common with plasma replacement)

Severe allergic reactions occur in 0.5% of procedures and represent a life-threatening complication requiring immediate intervention. 1, 4

Mild reactions (urticaria, pruritus):

• Slow or pause the procedure 2
• Administer antihistamines (diphenhydramine 25-50 mg IV) 2
• Resume at slower rate if symptoms resolve 2

Severe reactions (anaphylaxis):

• Immediately stop plasma exchange 1, 4
• Administer epinephrine 0.3-0.5 mg IM (1:1000 solution) 1
• Secure airway and provide supplemental oxygen 1
• Administer IV corticosteroids (methylprednisolone 125 mg) 2
• Consider switching replacement fluid from fresh frozen plasma to albumin for subsequent sessions 2

Catheter-Related Complications (Highest Risk of Serious Events)

Central venous catheter insertion and maintenance carry the highest risk of serious complications including pneumothorax, hemothorax, and line-related bacteremia, with 41% serious complication rate versus 4% with peripheral access. 1, 5

Immediate catheter complications:

• Pneumothorax/hemothorax: Obtain immediate chest X-ray if respiratory distress, decreased breath sounds, or chest pain develops 1
• Hemorrhage: Apply direct pressure, obtain coagulation studies, consider reversal agents if anticoagulated 1
• Air embolism: Place patient in left lateral decubitus Trendelenburg position, administer 100% oxygen 1

Line-related sepsis (0.3% of procedures):

• Obtain blood cultures from catheter and peripheral site 1, 4
• Immediately initiate broad-spectrum antibiotics (vancomycin plus gram-negative coverage) 1
• Remove catheter if sepsis suspected 1, 5

Coagulation Disorders

Fibrinogen levels decrease by 54% when albumin is used as replacement fluid versus only 4% with fresh frozen plasma. 2

• Monitor PT/INR, aPTT, fibrinogen, and platelet count 2
• Replace with fresh frozen plasma instead of albumin if active bleeding or recent procedure (kidney biopsy, surgery) 7, 2
• Administer cryoprecipitate if fibrinogen <100 mg/dL with bleeding 2
• Transfuse platelets if count <20,000/μL with bleeding risk 7

Electrolyte Imbalances

Hypokalemia and hypocalcemia are common laboratory complications requiring monitoring and replacement. 3

• Monitor potassium, calcium, and magnesium levels during and after each session 1, 3
• Replace potassium if <3.5 mEq/L (20-40 mEq IV over 2-4 hours) 3
• Replace calcium as described above for citrate toxicity 1

Filter Clotting (23% of filtration procedures)

Filter clotting is associated with higher prescribed exchange volumes and requires immediate recognition. 2

• Recognize by increased transmembrane pressure or decreased flow rates 2
• Discontinue procedure and replace filter/circuit 2
• Ensure adequate anticoagulation for subsequent sessions 2
• Consider reducing exchange volume to <4000 mL per session 2

Post-Procedure Monitoring Protocol

Intensive monitoring must continue after plasma exchange completion, as complications can occur in the recovery phase. 1

• Monitor vital signs every 15 minutes for first hour, then hourly for 4 hours 1, 2
• Assess vascular access site for bleeding or hematoma 1, 5
• Check electrolytes (calcium, potassium, magnesium) within 2 hours post-procedure 1, 3
• Monitor for delayed allergic reactions up to 24 hours 2

High-Risk Patient Populations Requiring Enhanced Monitoring

Patients with neurological diseases have significantly higher complication rates (P=0.013) compared to internal medicine patients. 4

• Neurological patients: Higher risk of hypotension due to autonomic instability 4, 5
• Hepatic insufficiency: Dramatically impaired citrate metabolism requiring calcium supplementation 1
• Hemodynamic instability: Consider plasma exchange contraindicated in shock states 1
• Renal failure, hypercoagulable states, active sepsis: Relative contraindications requiring risk-benefit assessment 1

Critical Pitfalls to Avoid

• Never perform plasma exchange without specialized apheresis expertise and equipment available 1
• Do not use central venous catheters when peripheral access is feasible (reduces serious complications from 41% to 4%) 1
• Avoid inadequate monitoring for citrate toxicity in patients with liver disease or hypoperfusion 1
• Do not fail to hold rituximab before plasma exchange sessions (results in wasted expensive medication) 1
• Never discharge patients immediately post-procedure without adequate observation period 1