Section Nineteen  Special Hematologic Procedures
PROCEDURE
123  
Apheresis and Therapeutic
Plasma Exchange (Assist)
Sonia M. Astle
PURPOSE:  Apheresis techniques are used to remove cells, plasma, and other
substances from blood. These procedures are used as adjunctive treatments in
many diseases, especially in antibody-mediated conditions that produce
autoantibodies.
PREREQUISITE NURSING
KNOWLEDGE
• Therapeutic apheresis is a technique for selective removal
of cells, plasma, and substances from the patient’s cir-
culation to promote clinical improvement. The different
apheresis techniques vary according to the component of
the blood removed or replaced or the substance removed.
❖ Cytapheresis is the selective removal of the cellular
components of blood. Blood is withdrawn from the
patient, and a specific cellular component is retained,
such as leukocytes (white blood cells); the remainder
of the blood components (erythrocytes, platelets, and
plasma) are returned to the donor or patient.
❖ Erythrocytapheresis is the process of removing erythro-
cytes (red blood cells) from whole blood.
❖ Extracorporeal photopheresis (ECP) uses apheresis
techniques to remove and return blood to the patient.
Whole blood is withdrawn into the ECP machine that
separates the leukocytes involved in the immune
response from the other blood components. The leuko-
cytes remain in the machine and the blood is returned
to the patient. While in the machine, the leukocytes are
exposed to the photosensitizing medication, methox-
salen, and are then treated with ultraviolet (UV) radia-
tion, which activates the methoxsalen. The leukocytes
are then returned to the patient. ECP induces cellular
changes that have been shown to be effective in certain
diseases such as cutaneous T-cell lymphoma, graft-
versus-host disease, post–bone marrow transplant, and
solid organ transplant rejection. Apheresis techniques
are also used for the procurement of peripheral stem
cells for bone marrow transplantation.
❖ Immunoadsorption (IA) is the removal of an antigen in
the blood by a specific antibody lining the surface of a
filter or cartridge.
❖ Leukocytapheresis is the removal of white blood cells
from the blood; the remaining blood components are
1100
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returned to the patient. It is most commonly used as a
therapeutic method for blast cell reduction in leuke-
mias (leukocytosis).
❖ Lymphoplasmapheresis is the separation and removal
of lymphocytes and plasma from the withdrawn blood,
with the remainder of the blood retransfused into the
donor.
❖ Red blood cell (RBC) exchange removes the patient’s
RBCs and replaces them with exogenous normal
RBCs.
❖ Rheopheresis is the process to change the viscosity of
blood by filtering out components such as fibrinogen
and low-density lipoprotein (LDL) cholesterol.
❖ Plasma adsorption/perfusion is the removal of plasma
with a hollow fiber filter. Blood is returned to the
patient, and the plasma is pumped over an adsorptive
column that removes certain proteins or pathogens.
The treated plasma is then returned to the patient.
❖ Therapeutic plasma exchange (TPE) is the process of
replacing the plasma removed with an equal amount of
either plasma or fluid (most commonly a combination
of 5% albumin and normal saline solution).
❖ Thrombocytapheresis is the selective removal of plate-
lets (thrombocytes).
• During plasma exchange procedures, the plasma removed
must be replaced; the most common replacement fluids
are 5% albumin, fresh frozen plasma (FFP), thawed
plasma (derived from thawed FFP and maintained at low
temperatures for use within 1 to 5 days), and normal
saline.1 Because clotting factors are transiently reduced by
plasma exchange, FFP can also be used as a fluid replace-
ment in patients when bleeding is an issue.
• Plasma volume is an estimate of the patient’s total volume
based on gender, height, weight, and hematocrit value.
Exchange volume is the ratio of the patient’s plasma
volume to be removed and replaced; this is usually 1:1 or
1.5:1 of the patient’s estimated plasma volume.4
• In plasma exchange, an average of 3 to 5 L of plasma is
removed and replaced.4
 123  Apheresis and Therapeutic Plasma Exchange (Assist) 1101
Figure 123-1  COBE Spectra Apheresis System. (© Caridian-
BCT, Inc. 2010. Used with permission.)
Figure 123-2  The B. Braun Diapact CRRT system can also be
used for therapeutic plasma exchange and plasma adsorption/
perfusion. (Photo courtesy B. Braun Medical, Inc.)
• Treatments can be done with two different systems.4
❖ Centrifugal: Separates plasma and other blood compo-
nents with use of a centrifuge (Fig. 123-1).
❖ Filtration: A hollow-fiber cell separator, permeable to
plasma proteins, is used to remove the patient’s plasma
via an apheresis machine or continuous renal replace-
ment machines adapted for apheresis (Fig. 123-2).
• Treatment length and frequency vary according to the
disease being treated, rate of production of the substance
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being removed, and the patient’s response to treatment.
Acute conditions, such as thrombotic thrombocytopenia
purpura or graft-versus-host disease, usually require daily
treatments for 5 to 7 days, depending on the response to
the treatment.6,7 Other conditions usually require plasma
exchanges two or three times weekly for up to 6 weeks.2,5–7
The total amount of plasma to be exchanged is used as a
guide for treatment. A single treatment, referred to as a
plasma exchange, usually takes 2 to 3 hours with a cen-
trifugal machine and 2 to 6 hours with filtration methods.4
• Apheresis procedures are performed by healthcare profes-
sionals, such as registered nurses or blood bank personnel,
with special knowledge and skills in apheresis. These
procedures are commonly performed both in critical care
units and on an outpatient basis, depending on the type of
disease being treated and on the patient’s condition.
• The most commonly used apheresis access systems use
either two large-bore peripheral venous catheters, double
lumen vascular access catheters (VAC), vortex ports or a
dialysis graft/fistula. Peripherally inserted central venous
catheters do not provide adequate blood flow and are not
acceptable for use.4
• The system should be primed with an anticoagulant (e.g.,
heparin or citrate) to prevent clotting. If citrate is used,
the patient must be monitored closely for hypocalcemia.
Citrate works as an anticoagulant by binding calcium
(Ca++), therefore decreasing the amount of Ca++ available
for normal clotting.4
• Plasma exchange is used to treat antibody-mediated dis-
orders because the pathogenic antibodies are contained in
the plasma. Removal of these antibodies through plasma
exchange reduces the number of circulating antibodies,
temporarily decreasing the patient’s symptoms.
• Conditions treated by plasma exchange may include the
following2,5–7:
❖ Myasthenia gravis
❖ Guillain-Barré syndrome
❖ Various hematologic disorders
❖ Nephrologic disorders
❖ Rheumatologic disorders
❖ Poisoning
❖ Drug overdose/drug toxicity
❖ Acute liver failure
❖ Solid organ transplantation for ABO incompatibility
and rejection
❖ Cytokine-mediated injury, such as sepsis, burns, and
multisystem organ dysfunction syndrome (MODS);
• Current indication categories for therapeutic apheresis, as
endorsed by the American Association of Blood Banks
(AABB) and the American Society for Apheresis (ASFA),
are listed in Table 123-1.
• If the patient is taking angiotensin-converting enzyme
(ACE) inhibitors, contact with certain filters or mem-
branes in the apheresis system can cause an anaphylactic
reaction and severe hypotension as a result of increased
levels of bradykinin, a potent vasodilator. ACE inhibitors
are recommended to be withheld for 48 to 72 hours before
treatment.
• Invasive procedures should be delayed until the treatment
is completed unless FFP is used as a replacement fluid.
1102 Unit VI  Hematologic System

TABLE 123-1  American Society for Apheresis (ASFA) 2013 Indication Categories for
Therapeutic Apheresis
Disease Name TA Modality Disease Condition Category Grade
Acute disseminated encephalomyelitis TPE II 2C
Acute inflammatory demyelinating TPE After IVIG I 1A
polyneurophathy (Guillain-Barré syndrome) TPE III 2C
Acute liver failure TPE III 2B
Age-related macular degeneration, dry Rheopheresis I 1B
Amyloidosis, systemic TPE IV 2C
Amyotrophic lateral sclerosis TPE IV 1C
ANCA-associated rapidly progressive TPE Dialysis dependence III 2B
glomerulonephritis (Granulomatosis with TPE DAH I 1C
polyangiitis; Wegener’s granulomatosis) TPE Dialysis independence I 1B
Antiglomerular basement membrane disease TPE Dialysis dependence and no DAH III 2B
(Goodpasture’s syndrome) TPE DAH I 1C
TPE DAH Dialysis independence I 1B
Aplastic anemia; pure red cell aplasia TPE Aplastic anemia III 2C
TPE Pure red cell aplasia III 2C
Autoimmune hemolytic anemia: WAHA; cold TPE Severe WAHA III 2C
agglutinin disease TPE Severe cold agglutinin disease II 2C
Babesiosis RBC exchange Severe I 1C
RBC exchange High-risk population II 2C
Burn shock resuscitation TPE III 2B
Cardiac transplantation ECP Refection prophylaxis II 2A
ECP Cellular or recurrent rejection II 1B
TPE Desensitization, positive cross-match III 2C
due to donor-specific HLA antibody
TPE Antibody-mediated rejection III 2C
Catastrophic antiphospholipid syndrome TPE II 2C
Chronic focal encephalitis (Rasmussen TPE III 2C
encephalitis) IA III 2C
Chronic inflammatory demyelinating TPE I 1B
polyradiculoneuropathy
Coagulation factor inhibitors TPE Alloantibody IV 2C
IA Alloantibody III 2B
TPE Autoantibody III 2C
IA Autoantibody III 1C
Cryoglobulinemia TPE Symptomatic/severe I 2A
IA Symptomatic/severe II 2B
Cutaneous T-cell lymphoma; mycosis ECP Erythrodermic I 1B
fungoides; Sézary syndrome ECP Nonerythrodermic III 2C
Dermatomyositis or polymyositis TPE IV 2A
Leukocytapheresis IV 2A
Dilated cardiomyopathy, idiopathic TPE NYAH II-IV III 2C
IA NYHA II-IV II 1B
Familial hypercholesterolemia LDL apheresis Homozygotes I 1A
LDL apheresis Heterozygotes II 1A
TPE Homozygotes with small blood II 1C
volume
Focal segmental glomerulosclerosis TPE Recurrent in transplanted kidney I 1B
Graft-versus-host disease ECP Skin (chronic) II 1B
ECP Skin (acute) II 1C
ECP Nonskin (acute/chronic) III 2B
HSCT, ABO incompatible TPE Major HPC, Marrow II 1B
TPE Major HPC, Apheresis II 2B
RBC exchange Minor HPC, Apheresis III 2C

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 123  Apheresis and Therapeutic Plasma Exchange (Assist) 1103

TABLE 123-1  American Society for Apheresis (ASFA) 2013 Indication Categories for
Therapeutic Apheresis—cont’d
Disease Name TA Modality Disease Condition Category Grade
Hemolytic uremic syndrome, atypical TPE Complement gene mutations II 2C
TPE Factor H antibodies I 2C
TPE MCP mutations IV 1C
Hemolytic uremic syndrome, infection TPE Shiga toxin associated IV 1C
associated TPE Streptococcus pneumoniae III 2C
associated
Henoch-Schonlein purpura TPE Crescentric III 2C
TPE Severe extrarenal disease III 2C
Heparin-induced thrombocytopenia TPE Precardiopulmonary bypass III 2C
TPE Thrombosis III 2C
Hereditary hemochromatosis Erythrocytapheresis I 1B
Hyperleukocytosis Leukocytapheresis Leukostasis I 1B
Leukocytapheresis Prophylaxis III 2C
Hypertriglyceridemic pancreatitis TPE III 2C
Hyperviscosity in monoclonal gammopathies TPE Symptomatic I 1B
TPE Prophylaxis for rituximab I 1C
Immune complex rapidly progressive TPE III 2B
glomerulonephritis
Immune thrombocytopenia TPE Refractory IV 2C
IA Refractory III 2C
Immunoglobin A nephropathy TPE Crescentric III 2B
TPE Chronic progressive III 2C
Inclusion body myositis TPE IV 2C
Leukocytapheresis IV 2C
Inflammatory bowel disease Adsorptive cytapheresis Ulcerative colitis III/II 1B/2B
Adsorptive cytapheresis Crohn’s disease III 1B
ECP Crohn’s disease III 2C
Lambert-Eaton myasthenic syndrome TPE II 2C
Lipoprotein (a) hyperlipoproteinemia LDL apheresis II 1B
Liver transplantation, ABO incompatible TPE Desensitization, live donor I 1C
TPE Desensitization, deceased donor III 2C
TPE Humoral rejection III 2C
Lung allograft rejection ECP Bronchiolitis obliterans syndrome II 1C
TPE Antibody-mediated rejection III 2C
Multiple sclerosis TPE Acute CNS inflammatory II 1B
demyelinating disease
IA Acute CNS inflammatory III 2C
demyelinating disease
TPE Chronic progressive III 2B
Myasthenia gravis TPE Moderate to severe I 1B
TPE Prethymectomy I 1C
Myeloma cast nephropathy TPE II 2B
Nephrogenic systemic fibrosis ECP III 2C
TPE III 2C
Neuromyelitis optica (Devic’s syndrome) TPE Acute II 1B
TPE Maintenance III 2C
Overdoses, envenomation, and poisoning TPE Mushroom poisoning II 2C
TPE Envenomation III 2C
TPE Natalizumab and PML III 2C
RBC exchange Tacrolimus III 2C
Paraneoplastic neurological syndromes TPE III 2C
IA III 2C
Continued

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1104 Unit VI  Hematologic System

TABLE 123-1  American Society for Apheresis (ASFA) 2013 Indication Categories for
Therapeutic Apheresis—cont’d
Disease Name TA Modality Disease Condition Category Grade
Paraproteinemic demyelinating TPE IgG/IgA I 1B
polyneuropathies TPE IgM I 1C
TPE Multiple myeloma III 2C
IA IgG/IgA/IgM III 2C
PANDAS; Sydenham’s chorea TPE PANDAS exacerbation I 1B
TPE Sydenham’s chorea I 1B
Pemphigus vulgaris TPE Severe III 2C
ECP Severe III 2C
IA Severe III 2C
Peripheral vascular diseases LDL apheresis III 2C
Phytanic acid storage disease (Refsum’s TPE II 2C
disease) LDL apheresis II 2C
Polycythemia vera and erythrocytosis Erythrocytapheresis Polycythemia vera I 1B
Erythrocytapheresis Secondary erythrocytosis III 1C
POEMS syndrome TPE IV 1C
Post transfusion purpura TPE III 2C
Psoriasis TPE Disseminated pustular IV 2C
Adsorptive cytapheresis III 2C
Lymphocytapheresis III 2C
ECP III 2B
Red cell alloimmunization in pregnancy TPE Before IUT availability III 2C
Renal transplantation, ABO compatible TPE Antibody-mediated rejection I 1B
TPE Desensitization, living donor, positive I 1B
cross-match due to donor-specific
HLA antibody
TPE Desensitization, high PRA deceased III 2C
donor
Renal transplantation, ABO incompatible TPE Desensitization, live donor I 1B
TPE Humoral rejection II 1B
TPE Group A2/A2B into B, deceased IV 1B
donor
Schizophrenia TPE IV 1A
Scleroderma (Progressive systemic sclerosis) TPE III 2C
ECP III 2B
Sepsis with multiorgan failure TPE III 2B
Sickle cell disease, acute RBC exchange Acute stroke I 1C
RBC exchange Acute chest syndrome, severe II 1C
RBC exchange Priapism III 2C
RBC exchange Multiorgan failure III 2C
RBC exchange Splenic sequestration; hepatic III 2C
sequestration; intrahepatic
cholestasis
Sickle cell disease, nonacute RBC exchange Stroke prophylaxis/iron overload II 1C
prevention
RBC exchange Vaso-occlusive pain crisis III 2C
RBC exchange Preoperative management III 2A
Stiff person syndrome TPE III 2C
Sudden sensorineural hearing loss LDL apheresis III 2A
Rheopheresis III 2A
TPE III 2C
Systemic lupus erythematosus TPE Severe II 2C
TPE Nephritis IV 1B
Thrombocytosis Thrombocytapheresis Symptomatic II 2C
Thrombocytapheresis Prophylactic or secondary III 2C

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 123  Apheresis and Therapeutic Plasma Exchange (Assist) 1105

TABLE 123-1  American Society for Apheresis (ASFA) 2013 Indication Categories for
Therapeutic Apheresis—cont’d
Disease Name TA Modality Disease Condition Category Grade
Thrombotic microangiopathy, drug TPE Ticlopidine I 1B
associated TPE Clopidogrel III 2B
TPE Cyclosporine/Tacrolimus III 2C
TPE Gemcitabine IV 2C
TPE Quinine IV 2C
Thrombotic microangiopathy, HSCT TPE Refractory III 2C
associated
Thrombotic thrombocytopenic purpura TPE I 1A
Thyroid storm TPE III 2C
Toxic epidermal necrolysis TPE Refractory III 2B
Voltaged gated potassium channel antibodies TPE II 1C
Wilson’s disease TPE Fulminant I 1C
ANCA, antineutrophil cytoplasmic antibody; CNS, central nervous system; ECP, extracorporeal photopheresis; DAH, diffuse alveolar hemorrhage; HLA, human leukocyte
antigen; HSCT, hematopoietic stem cell transplant; IA, immunoadsorption; IgA, immunoglobulin A; IgG, immunoglobulin G; IgM, immunoglobulin M; IUT, intrauterine
transfusion; IVIG, intravenous immunoglobulin; LDL, low-density lipoprotein; MCP, membrane cofactor protein; NYHA, New York Heart Association; PANDAS, pediatric
autoimmune neuropsychiatric disorders associated with streptococcal infections; POEMS, polyneuropathy, organomegaly, endocrinopathy, M protein, and skin changes;
PML, progressive multifocal leukoencephalopathy; RBC, red blood cell; TPE, therapeutic plasma exchange; WAHA, warm autoimmune hemolytic anemia.
Categories:
I Disorders for which apheresis is accepted as first-line therapy, either as a primary standalone treatment or in conjunction with other modes of treatment.
II Disorders for which apheresis is accepted as second line therapy, either as a standalone treatment or in conjunction with other modes of treatment.
III Optimum role of apheresis therapy is not established. Decision making should be individualized.
IV Disorders in which published evidence demonstrates or suggests apheresis to be ineffective or harmful. Institutional review board approval is desirable if apheresis
treatment is undertaken in these circumstances.
Grades:
Grade 1A: Strong recommendation, high-quality evidence
Grade 1B: Strong recommendation, moderate-quality evidence
Grade 1C: Strong recommendation, low-quality or very low-quality evidence
Grade 2A: Weak recommendation, high-quality evidence
Grade 2B: Weak recommendation, moderate-quality evidence
Grade 2C: Weak recommendation, low-quality or very low-quality evidence
From Schwartz J, 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 sixth special issue, J Clin Apherisis 28(3):145–284, 2013.

• Potential complications of apheresis techniques include

the following: EQUIPMENT
❖ Bleeding
❖ Thrombocytopenia • Blood cell separator or filter machine
❖ RBC lysis/hemolysis • Blood cell separator or filter tubing set
❖ Air embolism • Replacement intravenous (IV) fluids
❖ Blood leak • Hemostats
❖ Circuit clotting • Vascular access dressings and flushes
❖ Hypovolemia • Nonsterile gloves
❖ Hypotension • Fluid shield face masks or goggles
❖ Hypothermia • Caps
❖ Vascular access complications Additional equipment, to have available as needed, includes
❖ Fever/chills the following:
❖ Shock • Laboratory specimen tubes
❖ Anaphylaxis • Sterile gloves if accessing central lines such as VAC or
❖ Allergic reactions vortex ports
❖ Transfusion reactions
❖ Electrolyte imbalances PATIENT AND FAMILY EDUCATION
❖ Dysrhythmias
❖ Citrate toxicity • Explain the procedure, including risks, length of treat-
❖ Infection ment, and patient positioning, and answer any questions

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1106 Unit VI  Hematologic System
the patient may have. Rationale: Explanation provides
information and may decrease patient anxiety.
• Explain the purpose of the apheresis procedure, why this
treatment is being performed, and the expected clinical
outcomes. Rationale: Knowledge about the procedure
helps the patient to understand the treatment plan and will
decrease anxiety.
• Explain the need for careful sterile technique for the dura-
tion of treatment. Rationale: Sterile technique is impor-
tant to decrease the chance of systemic infection because
pathogens can be transported throughout the entire body
via the circulation.
• Explain the need for careful monitoring of the patient for
complications. Rationale: Hypocalcemia, hypotension,
bleeding, and hypothermia are all potential complications
of apheresis.
• Explain the importance of the patient informing the nurse
how he or she is feeling during the treatment. Rationale:
Patient symptoms can be important signs of complications
related to the procedure. Examples include lightheaded-
ness as a sign of hypotension and numbness and tingling
as a sign of hypocalcemia.
• Explain the importance of preventing bleeding compli-
cations: pressure dressings at vascular sites, avoiding
shaving, and care of the access catheter. Rationale: Alter-
ations in blood composition and anticoagulation can put
the patient at risk for bleeding.
• Explain the apheresis circuit setup to the patient and family.
Rationale: Blood will be removed from the patient’s body
and will be visible during apheresis treatment.
PATIENT ASSESSMENT AND
PREPARATION
Patient Assessment
• Obtain baseline vital signs, body system assessment,
hemodynamic parameters (if appropriate), weight, and
pretreatment fluid balance. Rationale: Total body assess-
ment should be based specifically on the patient’s diagno-
sis and reason for treatment. Pretreatment assessment
provides a baseline for comparison once the treatment is
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started, allowing for appropriate modification of the inter-
vention as needed. Changes in weight during and after
treatment are an indicator of fluid balance.
• Review prescribed medications, and ensure that the patient
has not taken an ACE inhibiter within 48 hours. Ratio-
nale: Contact with certain fibers or membranes in the
apheresis system can cause an anaphylactic reaction and
severe hypotension.
• Assess pretreatment laboratory values. Rationale: Base-
line values are needed of the complete blood count (CBC)
with differential, platelet count, and electrolytes before
these are altered by treatment. Coagulation parameters are
particularly important: fibrinogen, prothrombin time (PT),
activated clotting time (ACT), and partial thromboplastin
time (PTT) if heparin is used, and ACT and ionized Ca++
if citrate is used. Serum sodium and serum bicarbonate
levels/pH also should be evaluated in patients when citrate
is used as the anticoagulant. Disease-specific tests should
also be obtained pretreatment as needed.
• Obtain vascular access. Rationale: A properly functioning
vascular access is necessary to perform plasmapheresis.
Patient Preparation
• Verify That the patient is the correct patient using two
identifiers. Rationale: Before performing a procedure, the
nurse should ensure the correct identification of the patient
for the intended intervention.
• Ensure that informed consent has been obtained. Ratio-
nale: Informed consent protects the rights of the patient
and makes a competent decision possible for the patient.
• Ensure that patient understands preprocedural instruc-
tions. Answer questions as they arise, and reinforce infor-
mation as needed. Rationale: Understanding of previously
taught information is evaluated and reinforced.
• Assist the patient to a position of comfort that also facili-
tates optimal blood flow through the vascular access.
Rationale: Facilitating patient comfort helps to minimize
the amount of patient movement during treatment. Move-
ment can change the blood flow through the access site.
Different access sites may require different patient posi-
tions to facilitate optimal blood flow.
 123  Apheresis and Therapeutic Plasma Exchange (Assist) 1107

Procedure for Assisting With Apheresis/Plasmapheresis

Steps Rationale Special Considerations
1. Verify apheresis orders. Familiarizes nurse with the
individualized patient treatment and
reduces the possibility of error.
2. HH
3. PE
4. Confirm access placement. Validates line is in correct placement.
5. Review the following with the Sets joint goals and actions to provide
apheresis nurse: for patient safety and optimize the
A. Exchange volume patient’s outcome.4
B. Anticoagulant
C. Replacement fluids
D. Baseline patient assessment,
including
i. Vital signs
ii. Jugular vein distention
iii. Presence of edema
iv. Intake and output
v. Neurological assessment
vi. Pulmonary assessment
vii. Renal assessment
viii. Parameters/treatment for
heart rate and blood
pressure
ix. Laboratory monitoring
x. Procedure for emergency
resuscitation
6. Gather supplies for vascular Prepares for the procedure. The process of vascular access
access. depends on whether the site is
central or peripheral.
7. Assist in gathering the supplies Prepares for the procedure. Obtaining and sending laboratory
for apheresis procedure. specimens may be part of the
apheresis setup as the vascular
system is accessed.
8. Ensure that appropriate Maintains correct electrolyte balance; Replacement fluids should be slightly
replacement fluid is available. avoids hypothermia.4 warmed before infusion unless
Warm replacement fluids as contraindicated (e.g., blood
prescribed. products should be maintained at a
specific temperature before infusion
to maintain viability of the
product). Never use a microwave to
warm fluids. Some patients also
may need an increase in the
ambient room temperature or
ventilator cascade and warming
blankets to avoid hypothermia.
Most apheresis systems have inline
blood warmers.
9. Infuse fluid boluses as needed Maintains hemodynamic stability.
before initiation.
10. Assist with setup and priming of Ensures safe and proper assembly and
the apheresis circuit as needed. complete removal of air from the
circuit.
11. Secure all connections. Prevents inadvertent disconnection of
the system.
12. Remove gloves and discard used
supplies.
13. HH
Procedure continues on following page

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1108 Unit VI  Hematologic System

Expected Outcomes Unexpected Outcomes

• Therapeutic goals achieved • Complications related to the treatment (e.g.,
• Optimal fluid balance is maintained hypotension, hypocalcemia, hypothermia,
• Laboratory values are maintained within expected hypokalemia, hypernatremia, metabolic alkalosis, air
range embolism, blood leak, bleeding, infection)
• Properly functioning access site • Poor blood flow through the vascular access
• Patient remains pain free or has pain controlled to an • Bleeding from the access site
acceptable goal • Dislodgment of the access catheter
• Therapeutic medication levels will be maintained • Hematoma formation at the access site
• Patient/family will verbalize understanding of the • Technical problems with apheresis circuit
procedure • Hemolysis

Patient Monitoring and Care

Steps Rationale Reportable Conditions
These conditions should be reported if
they persist despite nursing
interventions.
1. Monitor the patient during and Patients can experience complications, • Hypotension
after the apheresis treatment: such as hypotension, hypothermia, • Hypertension
A. Vital signs blood leak, air embolism, • Tachycardia/bradycardia
B. Hemodynamic parameters transfusion reactions, hypocalcemia, • Tachypnea/bradypnea
C. Jugular vein distention RBC hemolysis, thrombocytopenia, • Fever
D. Presence of edema citrate toxicity, and bleeding, that • Hypothermia
E. Intake and output may need intervention.1,3,4 • Jugular vein distention
F. Neurological assessment • Crackles
G. Pulmonary assessment • Edema
H. Renal assessment • Change in level of consciousness
I. Apheresis circuit • Dizziness
J. Laboratory values as prescribed • Change in cardiac rhythm
(if plasma is removed, include • Blood leak
prothrombin time/international • Hemolysis
normalized ratio [INR], • Thrombocytopenia
fibrinogen, platelet count) • Dysrhythmias
• Coagulopathies
• Allergic reaction
• Transfusion reaction
2. Monitor serum ionized Ca++, Citrate binds with Ca++ and can cause • Hypocalcemia
magnesium, serum sodium, and hypocalcemia. It also metabolizes • Hypernatremia
serum bicarbonate levels/pH (if to sodium and bicarbonate, which • Metabolic alkalosis
citrate is used as an anticoagulant). may cause hypernatremia, • Increased anion gap
metabolic alkalosis, and citrate
toxicity.4
3. Monitor ACT/PTT (if heparin is These values primarily reflect the • Prolonged ACT/PTT
used as an anticoagulant). activity of the intrinsic clotting
pathway.
4. Administer replacement fluid as Replacement fluids are important • Hypotension
prescribed and needed. during the treatment to maintain • Tachycardia
adequate intravascular volume. • Decreased central venous and
pulmonary artery pressures
• Decreased urine output

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 123  Apheresis and Therapeutic Plasma Exchange (Assist) 1109

Patient Monitoring and Care —Continued

Steps Rationale Reportable Conditions
5. Hold medication administration as Many medications are withheld • Medications needed (e.g.,
prescribed. during treatment, including analgesics, antipyretics)
vasopressors and pain medications, • Transfusion reaction
especially those that are protein-
bound.8 Some medications, such as
antihypertensive agents,
anticholinergic agents, and Ca++
supplements, may be withheld
during treatment.4 Analgesics and
antipyretics may be indicated
during a treatment, although these
medications may mask the
symptoms of a transfusion
reaction.8
6. Monitor the access and dressing Bleeding or signs or symptoms of • Bleeding
sites after the termination of the infection can be complications of • Redness, tenderness, pain, or
apheresis procedure. the vascular access.9 warmth at the access insertion site
• Generalized bleeding or fever
7. Appropriately label VACs that Prevents the infusion of anticoagulant • Bleeding
contain indwelling anticoagulant. into the patient. • Bruising
• Oozing
8. Review the following with the For proper patient evaluation and
apheresis nurse, including: documentation.
A. Amount and type of fluids • Unexpected volume
removed
B. Amount and type of fluids given • Unexpected volume
C. Exchange volume and fluid • Unexpected volume
balance
D. Patient reactions during • Flushing
treatment • Dysrhythmias
• Tachypnea
E. Medications given during • Unexpected side effects
treatment
9. Follow institutional standards for Identifies need for pain interventions. • Continued pain despite pain
assessing pain. Administer interventions
analgesia as prescribed.

Documentation
Documentation should include the following:
• Patient and family education • Patient’s response to apheresis and daily progress
• Completion of informed consent toward treatment goals
• Date and time of treatment initiation • Unexpected outcomes
• Condition of vascular access • Nursing interventions
• Intake/output/fluid balance • Laboratory assessment data
• Vital signs throughout the apheresis treatment • Pain assessment, interventions, and effectiveness.
• Daily weight

References and Additional Readings

For a complete list of references and additional readings for
this procedure, scan this QR code with any freely available
smartphone code reader app, or visit
http://booksite.elsevier.com/9780323376624.

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 123  Apheresis and Therapeutic Plasma Exchange (Assist) 1109.e1
References
1. Garner S, et al: Apheresis donors and platelet function:
Inherent platelet responsiveness influences platelet quality.
Transfusion 48:673–680, 2008.
2. Neunert C, et al: The American Society of Hematology
2011 evidenced-based practice guidelines for immune
thrombocytopenia. Blood 117:4190–4207, 2011.
3. Ontaneda D, et al: New insights in pathogenesis and novel
therapeutics. Annu Rev Med 63:389–404, 2012.
4. Rohe RM, et al: Therapeutic plasma exchange. In Counts
C, editor: Core curriculum for nephrology nursing, ed 5,
Pitman, NJ, 2008, American Nephrology Nurses’
Association, pp 277–308.
5. Magana SM, et al: Beneficial plasma exchange response in
central nervous system inflammatory demyelination. Arch
Neurol 68:870–878, 2011.
6. Szczepiorkowski ZM, et al: Guidelines on the use of
therapeutic apheresis in clinical practice–evidenced-based
approach from the American Society of Apheresis. J Clin
Apher 25:83–177, 2010.
7. Schwartz J, 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 sixth special issue. J Clin Apher 28(3):
145–284, 2013.
8. Tobian A, et al: Transfusion premedications: A growing
practice not based on evidence. Transfusion 47:1089–1096,
2007.
9. McLeod B, et al: Apheresis: Principles and practice,
Bethesda, MD, 2010, AABB Press.
Downloaded for Cathy Arnold (cathylee.arnold@health.nsw.gov.au) at Illawarra Shoalhaven Local Health District from ClinicalKey.com.au/nursing by
Elsevier on August 05, 2021. For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. All rights reserved.
Additional Readings
Bardin T, et al: Nephrogenic systemic fibrosis. Curr Opin
Rheumatol 22:54–58, 2010.
Cortese I, et al: Evidence-based update: Plasmapheresis in
neurologic disorders: Report of the therapeutics and
technology assessment subcommittee of the American
Academy of Neurology. Neurology 76:294–300, 2011.
Heddle NM, et al: Comparing the efficacy and safety of
apheresis and whole blood-derived platelet transfusions:
A systematic review. Transfusion 48:1447–1458, 2008.
Kandiah P, et al: Emerging strategies for the treatment of
patients with acute hepatic failure. Curr Opin Crit Care
22(2):142–151, 2016.
Lee G, et al: Anticoagulation techniques for apheresis: From
heparin to citrate and beyond. J Clin Apher 27(3):
117–125, 2012.
Li Q, et al: Plasmapheresis is associated with better renal
outcomes in lupus nephritis patients with thrombotic
microangiopathy: A case series study. Medicine
(Baltimore) 95(18):e3595, 2016.
Thompson GR, et al: Recommendations for the use of LDL
apheresis. Atherosclerosis 198:247–255, 2008.
Van de Watering L: The intention-to-treat principle in clinical
trails and meta-analyses of leukoreduced blood
transfusions in surgical patients. Transfusion 47:573–581,
2007.