Best practices for Red Blood Cell Exchange procedures on ...€¦ · Best practices for Red Blood...
Transcript of Best practices for Red Blood Cell Exchange procedures on ...€¦ · Best practices for Red Blood...
Best practices for Red Blood Cell Exchange procedures on the Spectra Optia apheresis system to treat Sickle Cell Disease patients
Bridget Hughes - Nurse Practitioner Therapeutic ApheresisServices Leeds2017
Content
• Procedure management
• Custom prime
• Depletion/ exchange procedures
NICE Guidelines
And then...
Procedure ManagementFCR, replacement fluid volume, target HCT, target fluid balance,replacement fluid HCT
Red Blood Cell Exchange
• Known as automated exchange or exchange-transfusion
• Defective RBC are removed and normal RBC are simultaneously infused
• Can rapidly adjust the HCT% and HbS% concentration of the patient
• Avoids fluid overload, increased viscosity and iron overload associated with transfusions
Defective red cells removed
Blood warmer
Blood pumps
Donor red cells infused
Patient Information• Sex
• Height Total blood volume
• Weight
• HCT%
Patients who are <25 kg require a manual calculation of the TBV
Procedural Parameters to Order• Pre/ target HBS% or FCR
• Final (desired) patient HCT%
• Fluid balance
• The replacement fluid HCT%
• The final (post-procedure) patient HCT%
Final HCT- Iron Overload• Every unit of packed RBC contains approximately 200mg heme iron
• Every increase of 3 points in the patient’s final HCT% = 1 additional unit of RBC transfused to the patient
• The transfusion of as few as 10 to 20 RBC units can cause iron overload
• RBCX avoids iron overload by balancing the removed RBC with the infused RBC ie it is iron neutral
Final HCT- Other Factors • Blood viscosity
• Blood Usage
FCR% V HbS% V Replacement Fluid Volume
• The Spectra Optia system operator needs to know one of the following data points:
– FCR%– Patient’s current HbS% and desired final HbS%– Replacement fluid volume of RBC
Which one to use and when?
What is Fraction of Cells Remaining (FCR%)?
Patient RBC
FCR
Donor RBCRBCX
The percentage of the original RBC remaining in the patient’s body at the end of the procedure
A lower FCR results in a lower final
HbS% and a greater
volume of RBC
exchanged
Relationship between FCR% and HBS%
Starting HbS(Pre Procedure)
Desired HbS(Post Procedure)
40% 10%
Post HbS%
Pre HbS%=
10%40%
25%
FCR%
=
Pre + Post procedure HBS%• It is generally accepted that the pre-procedure HbS%
(+HbC%) should be maintained at or below 30% to minimise morbidity and mortality associated with SCD
Fluid Balance• Fluid balance during an RBCX procedure is generally
set at 100% (isovolemic) ; if that is the case, isovolemia is maintained throughout the procedure
• The Spectra Optia system also allows the operator to run the procedure with a positive (>100%) or negative (<100%) fluid balance if required by the ordering physician
Custom PrimeAlbumin or RBC
Custom Prime• Custom prime consists of replacing the normal saline
(NS) used to prime the device with either RBC, 5% albumin or plasma
• It is an option to be used whenever the extracorporeal volume (ECV) of the apheresis device exceeds a pre-set maximum percentage of the patient’s TBV
• Used in paediatrics <25kg
Exchange DepletionProcedure, protocol, efficiency
Protocol• Phase 1: Isovolemic Depletion
• Phase 2: Exchange
• The overall result is a more efficient procedure, where fewer RBC are needed to reach the same end points
Efficiency� Lower FCR (final HbS%)
� The same volume of blood is used
� Lower FCR attained
� Fewer RBC required
� Same FCR targeted
� 1 unit less RBC needed
RCX Programme at Leeds
• 9 Adults & 9 Paediatrics
– 5-7 weekly– Attend the unit for procedure, Leeds Children’s Hos pital or
Hull– Attend 2 days pre RBCX for cross matching– Memos sent out in advance– 4 require CVC insertion, we have 1 patient with a v ortex port
and all others including the children have peripher al access– In the process of training to Deep Vein Cannulate th ose that
currently have regular line insertions– Ages 5-45
• Performed over 20 Acute RCX last year
Lovely Laura at Paediatric RCX Clinic
Thank you for listening
Any questions?