What are the management strategies for post-plasma exchange complications, including infection, allergic reactions, and citrate toxicity?

Management of Post-Plasma Exchange Complications

Immediate Recognition and Treatment of Citrate Toxicity

Prevent citrate toxicity by administering continuous calcium gluconate infusion (10 mL of 10% calcium gluconate per liter of return fluid) throughout the plasma exchange procedure, which reduces citrate reactions from 35.6% to 8.6%. 1

Clinical Presentation and Risk Factors

• Citrate toxicity manifests as perioral tingling, paresthesias of hands and feet, and in severe cases, facial and extremity tetany 1, 2, 3
• Women under age 50 are at higher risk than older women (mean age 49.9 vs 57.9 years) 1
• Patients taking loop diuretics (e.g., bumetanide) or those with pre-existing hypocalcemia are at significantly elevated risk 3
• Citrate metabolism is dramatically impaired by hypoperfusion, hypothermia, and hepatic insufficiency 4

Treatment Protocol for Active Citrate Reactions

• First-line interventions: Slow whole blood flow rate, adjust ACD:whole blood ratio from 1:16, and administer oral calcium carbonate wafers 1
• If symptoms persist: Administer intravenous boluses of 10% calcium gluconate up to 25 mL during the procedure 1
• For severe tetany: Initiate empirical IV calcium gluconate immediately; muscle contractions typically resolve over 10-15 minutes 3

Prevention Strategy

• Screen all patients for medications causing hypocalcemia (loop diuretics, bisphosphonates) and measure pre-procedure serum calcium in high-risk patients 3
• Use continuous calcium gluconate infusion (10 mL/L return fluid) rather than reactive bolus dosing 1

Management of Allergic and Anaphylactic Reactions

For patients with history of anaphylactic reactions to plasma, substitute with Octaplas (solvent-detergent treated pooled plasma) or use albumin-based replacement with slow incremental plasma reintroduction. 5

Acute Allergic Reaction Management

• Mild allergic reactions (urticaria, pruritus) occur commonly and are generally self-limited 6
• Severe anaphylactic reactions require immediate cessation of plasma infusion and standard anaphylaxis treatment 6, 5
• TRALI (transfusion-related acute lung injury) is a rare but severe complication associated with leucocyte antibodies in donor plasma 4, 6

Alternative Strategies for Plasma-Allergic Patients

• Option 1: Switch to Octaplas (lot-batched, solvent-detergent treated, type-specific pooled plasma), which successfully prevents recurrent anaphylaxis 5
• Option 2: Use albumin as primary replacement fluid with gradual incremental exposure to standard plasma to achieve desensitization 5
• Both strategies have demonstrated success in achieving disease remission while preventing further anaphylactic events 5

Infection Risk Management

Plasma exchange increases serious infection risk by 19% (risk ratio 1.19,95% CI 0.99-1.42), particularly in patients receiving concurrent immunosuppression for ANCA-associated vasculitis. 4

Risk Stratification

• Infection is the leading cause of death (48%) within the first year in vasculitis patients receiving plasma exchange plus immunosuppression 7
• The infection risk must be weighed against potential benefits, particularly in patients with lower baseline risk of end-stage renal disease 4
• Neurological patients have lower infection rates compared to patients with renal insufficiency or hematologic disorders 2

Infection Prevention

• Minimize central venous catheter duration and use ultrasound guidance for placement to reduce mechanical complications and infection risk 4, 8
• Consider high-dose intravenous immunoglobulin in ICU patients with particularly high infection risk 9
• Avoid plasma exchange in patients without substantial bleeding or those with low risk of disease progression 4

Cardiovascular and Hemodynamic Complications

Monitoring and Management

• Transient hypotension occurs in 2.6% of procedures and is generally self-limited 2
• Cardiac arrhythmias and myocardial infarction are rare but serious complications requiring immediate cardiovascular support 2
• Fluid overload can occur with rapid or massive transfusion, particularly in patients with cardiac or renal dysfunction 6

Prevention Strategies

• Maintain whole blood flow rates at 70-80 mL/min to minimize hemodynamic instability 1
• Use albumin-based return fluid (4-5% human serum albumin in 0.9% NaCl) rather than plasma when possible to reduce allergic reactions 1
• Monitor for ABO incompatibility when using fresh frozen plasma as replacement fluid 4

Hematologic Complications

Recognition and Management

• Gross hemolysis is rare but requires immediate procedure cessation 2
• Thrombocytopenia can develop, particularly with hemoperfusion procedures 4
• Coagulation factor depletion occurs with plasma exchange; avoid procedures in patients without substantial bleeding 4

Special Considerations

• Plasma exchange nonselectively removes medications, including rituximab; administer rituximab after plasma exchange completion 8, 9
• Visual scotomata occur in 1.3% of procedures and are typically transient 2
• Bleeding diathesis risk is higher in patients with underlying hematologic disorders 2

Critical Pitfalls to Avoid

• Never use plasma exchange as monotherapy for antibody-mediated rejection; always combine with immunosuppression 8
• Do not delay empiric treatment in suspected immune-mediated disease while awaiting diagnostic confirmation, as delayed treatment dramatically worsens outcomes 7
• Avoid plasma exchange in dialysis-dependent vasculitis patients without extrarenal manifestations after 3 months of treatment 8
• Do not use fixed volumes without weight-based calculation (45-60 mL/kg depending on indication) 8