**3. Contraindications to plasma exchange: complications**

#### **3.1. Contraindications to PEX**

The major contraindications to PEX are hemodynamically unstable patients, sepsis, history for allergy to human albumin or FFP.

obstruction and anemia [14]. In addition, the complications are significantly more in PEX with

Plasma Exchange in Clinical Practice http://dx.doi.org/10.5772/intechopen.76094 65

Similar results were observed in our institution. In 51 PEX procedures no life-threatening complications were detected. Two episodes of hypotension were established, not requiring vasopressor agents. Two patients developed paraesthesia. Laboratory results prior and after PEX remained stable (hemoglobin level, white blood cell count, platelet count and potassium and calcium levels). An expected drop in fibrinogen, immunoglobulin A and G levels, was

In conclusion, though the procedure is relatively safe, due to the risk for serious complica-

The basic clinical parameters should be monitored prior to and after the procedure—blood pressure, heart rate and body temperature. Clinical assessment can be performed at shorter

Full blood count, plasma calcium, plasma potassium, fibrinogen levels and prothrombin time should be evaluated after each procedure. Other laboratory tests can be performed prior to

PEX was prescribed with different volume, duration, frequency, number of performed procedures and different concomitant (immunosuppressive) therapy over the years. This is the reason for the relatively small number of randomized controlled trials (RCTs) concerning

In order to evaluate the present data for the effectiveness of PEX in the treatment of different diseases, the American Society for Apheresis (ASFA) has classified the indications into four

• *ASFA category 1: Disorders for which apheresis is accepted as first-line therapy, either as a primary* 

• *ASFA category 2: Disorders for which apheresis is accepted as second-line therapy, either as a stand-*

categories, according to the possible beneficial effect of PEX [16, 17]:

*stand-alone treatment or in conjunction with other modes of treatment*.

*alone treatment or in conjunction with other modes of treatment*.

detected, without bleeding or infection episodes, associated with the procedure [15].

FFP substitution, compared to human albumin only.

tions, it should be performed by experienced personnel.

intervals of time during the procedure in unstable patients.

and after PEX treatment, including antibody titers.

**4. Plasma exchange: clinical indications**

**4.1. Clinical indications: classification**

**3.3. Indicators to monitor during PEX treatment**

*3.3.1. Clinical indicators*

*3.3.2. Laboratory indicators*

plasma exchange.

#### **3.2. Complications**

Generally, the procedure is safe, and though the incidence of all complications peaks to 40%, the risk for life-threatening adverse events (defined as death, hypotension-requiring vasopressor agent, arrhythmias, medical intervention and hemolysis) is low, ranging between 0.025 and 4.75% [11, 12]. There are three groups of complications in PEX, which are summarized in **Table 1**.

As the most serious complication, death has incidence of up to 0.05%, though most of the patients were with severe pre-existing conditions [2]. However, the complication rate varies across registries, as mortality was 0% in the Swedish apheresis data base, encompassing more than 20,000 procedures. Yet the same trend was observed—overall complications' rate reached 4.3%, of which just 0.9% were serious adverse events [13].The highest risk for complications was detected in unstable patients, hypotension, active bleeding, bronchial


FFP: fresh frozen plasma, ACE inhibitors: angiotensin-converting enzyme inhibitors, LDL: low-density lipoprotein.

**Table 1.** Complications in plasma exchange.

obstruction and anemia [14]. In addition, the complications are significantly more in PEX with FFP substitution, compared to human albumin only.

Similar results were observed in our institution. In 51 PEX procedures no life-threatening complications were detected. Two episodes of hypotension were established, not requiring vasopressor agents. Two patients developed paraesthesia. Laboratory results prior and after PEX remained stable (hemoglobin level, white blood cell count, platelet count and potassium and calcium levels). An expected drop in fibrinogen, immunoglobulin A and G levels, was detected, without bleeding or infection episodes, associated with the procedure [15].

In conclusion, though the procedure is relatively safe, due to the risk for serious complications, it should be performed by experienced personnel.

#### **3.3. Indicators to monitor during PEX treatment**

#### *3.3.1. Clinical indicators*

**3. Contraindications to plasma exchange: complications**

The major contraindications to PEX are hemodynamically unstable patients, sepsis, history

Generally, the procedure is safe, and though the incidence of all complications peaks to 40%, the risk for life-threatening adverse events (defined as death, hypotension-requiring vasopressor agent, arrhythmias, medical intervention and hemolysis) is low, ranging between 0.025 and 4.75% [11, 12]. There are three groups of complications in PEX, which are summa-

As the most serious complication, death has incidence of up to 0.05%, though most of the patients were with severe pre-existing conditions [2]. However, the complication rate varies across registries, as mortality was 0% in the Swedish apheresis data base, encompassing more than 20,000 procedures. Yet the same trend was observed—overall complications' rate reached 4.3%, of which just 0.9% were serious adverse events [13].The highest risk for complications was detected in unstable patients, hypotension, active bleeding, bronchial

**3.1. Contraindications to PEX**

Vascular access-associated Hematoma

Other Hypotension

**Table 1.** Complications in plasma exchange.

Infection/sepsis Pneumothorax

Coagulopathy Blood-borne infections Hypocalcaemia Hypokalemia

Dyspnea

Low platelet count Hemolysis

Drug and vitamin removal

dextran sulfate systems for LDL apheresis

FFP: fresh frozen plasma, ACE inhibitors: angiotensin-converting enzyme inhibitors, LDL: low-density lipoprotein.

Death, due to cardiac arrest, pulmonary edema and pulmonary embolism

Anaphylactoid reactions, hypotension, flushing due to ACE inhibitors and the use of

Anaphylaxis to FFP Death, due to anaphylaxis

**3.2. Complications**

rized in **Table 1**.

Substitution therapy-associated

for allergy to human albumin or FFP.

64 Plasma Medicine - Concepts and Clinical Applications

The basic clinical parameters should be monitored prior to and after the procedure—blood pressure, heart rate and body temperature. Clinical assessment can be performed at shorter intervals of time during the procedure in unstable patients.

#### *3.3.2. Laboratory indicators*

Full blood count, plasma calcium, plasma potassium, fibrinogen levels and prothrombin time should be evaluated after each procedure. Other laboratory tests can be performed prior to and after PEX treatment, including antibody titers.
