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Best Practices for Red Blood Cell Exchange Procedures on the Spectra Optia Apheresis System to Treat Sickle Cell Disease Patients

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Best Practices for Red Blood Cell Exchange Procedures on the Spectra Optia Apheresis System to Treat Sickle Cell Disease Patients 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 Apheresis Services Leeds 2017 Content • Procedure management • Custom prime • Depletion/ exchange procedures NICE Guidelines And then... Procedure Management FCR, 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 Donor red cells warmer infused Blood pumps 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%)? The percentage of the original RBC remaining in the patient’s body at the end of the procedure Patient RBC RBCX Donor RBC A lower FCR results in a lower final HbS% and a FCR greater volume of RBC exchanged Relationship between FCR% and HBS% Post HbS% = FCR% Pre HbS% 10% = 25% 40% 40% 10% Starting HbS Desired HbS (Pre Procedure) (Post Procedure) 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 Prime Albumin 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 Depletion Procedure, 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 Hospital 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 vortex port and all others including the children have peripheral access – In the process of training to Deep Vein Cannulate those 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?.
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