What are the potential complications to monitor for within 24 hours after plasma exchange?

Post-Plasma Exchange 24-Hour Complications

Within the first 24 hours after plasma exchange, monitor intensively for hypotension (most common, occurring in 8-15% of procedures), hypocalcemia (up to 20% of sessions), allergic reactions to replacement fluids (3-4.5%), coagulation abnormalities, and catheter-related complications including infection and bleeding. 1, 2

Immediate Monitoring Requirements (First 24 Hours)

Cardiovascular Complications

• Hypotension is the single most frequent complication, occurring in 8-15.2% of plasma exchange procedures, and is typically asymptomatic in 95.8% of cases 1, 2
• Hypotension correlates directly with low hematocrit levels before therapy and occurs more frequently when 4% albumin is used as replacement fluid (19.8%) compared to fresh frozen plasma (8.9%) 1, 2
• Monitor vital signs every 5-15 minutes during and immediately after the procedure, maintaining mean arterial pressure >65-70 mmHg with IV fluid resuscitation as needed 3
• Cardiac arrhythmias and myocardial infarction, though rare (0.3-0.7% severe events), represent life-threatening complications requiring continuous cardiac monitoring 4, 5

Metabolic and Hematologic Complications

• Hypocalcemia occurs in 19.6% of sessions, presenting as citrate toxicity (7.8% of procedures) with perioral tingling, muscle cramps, and paresthesias 1, 2, 4
• Hypocalcemia is significantly more frequent with fresh frozen plasma replacement (28%) compared to albumin alone (11.7%), requiring calcium supplementation monitoring 2
• Coagulation disorders depend critically on replacement fluid type: fibrinogen levels decrease by 54% with albumin 5% but only 4% with plasma frozen within 24 hours 1
• Monitor complete blood count, PT, aPTT, and Clauss fibrinogen levels immediately post-procedure and at 24 hours 3

Allergic and Immunologic Reactions

• Allergic reactions occur in 3-4.5% of sessions and are exclusively associated with fresh frozen plasma use, never with albumin alone 1, 2
• Most allergic reactions are mild and self-limited, but severe anaphylactic reactions requiring immediate intervention occur in 0.5% of procedures 5
• Monitor for urticaria, pruritus, bronchospasm, and respiratory distress during and for several hours after the procedure 3

Catheter-Related Complications

Vascular Access Issues

• Catheter-related complications are more frequent in neurological patients compared to those with internal medicine conditions 5
• Monitor for catheter-related hematoma (0.9%), bleeding at insertion sites, and thrombosis 6
• Infection risk is present but relatively low when procedures are performed by trained teams; monitor for fever, chills, and signs of catheter-related bacteremia 7, 1
• Unlike other patient populations, neurological patients undergoing plasma exchange have lower infection rates compared to those with renal insufficiency or hematologic disorders 4

Neurological Complications

• Visual scotomata occur in 1.3% of procedures and are typically transient 4
• Unconsciousness is rare (0.9%) but requires immediate assessment for hypocalcemia, hypotension, or cerebral hypoperfusion 6
• Patients with underlying neurological diseases have significantly higher overall complication rates (P = 0.013) compared to those with internal medicine conditions 5

Technical Complications

• Filter clotting occurs in 22.8% of filtration procedures and is associated with higher prescribed exchange volumes (4600 ml vs 3900 ml without clotting) 1
• Both centrifugation and filtration techniques have similar overall adverse reaction rates (23.9% vs 31.7%, P = 0.19) 1

High-Risk Patient Populations Requiring Enhanced Monitoring

• Patients with thrombotic thrombocytopenic purpura (TTP) or hemolytic uremic syndrome (HUS) have the highest complication risk among internal medicine patients 5
• Neurological patients require closer monitoring for hypotension and vascular access complications compared to other populations 5
• Patients with low pre-procedure hematocrit levels need aggressive monitoring for hypotension 1

Critical Pitfalls to Avoid

• Do not use diuretics for respiratory distress developing within 6 hours post-procedure, as this may represent TRALI rather than volume overload 3, 8
• Recognize that severe adverse events, while rare (0.3-0.7% of sessions), include sepsis and severe allergic reactions requiring immediate intervention 5
• Maintain a 1:2 nurse-patient ratio for intensive monitoring during the first 24 hours when clinically indicated 7
• Ensure immediate availability of calcium supplementation, vasopressors, and resuscitation equipment 3