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Role of Therapeutic Apheresis and Phlebotomy Techniques in Anaesthesia and Critical Care

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Role of Therapeutic Apheresis and Phlebotomy Techniques in Anaesthesia and Critical Care Review Article Role of therapeutic apheresis and phlebotomy techniques in anaesthesia and critical care Address for correspondence: Neeta Bose, Hitendra Kanzariya1 Dr. Neeta Bose, Department of Anesthesia, Gujarat Medical Education and Research Society, Gotri, Vadodara, 1Department 7, Laxminarayan Duplex, of Anaesthesia, PSMC, Karamsad, Anand, Gujarat, India Opp. Vipul Vatika, Nr Rajesh Towers, Ellora Park, Vadodara - 390 023, ABSTRACT Gujarat, India. E-mail: neetabosenayak@ Therapeutic transfusion techniques such as apheresis and phlebotomy are frequently used in hotmail.com intensive care units. Use of the apheresis technique for the treatment of various diseases in critically ill patients is growing day by day. There are increasing evidences for using apheresis Access this article online as a primary therapy or as an adjunct to other therapies for various diseases such as thrombotic Website: www.ijaweb.org thrombocytopenic purpura, haemolytic uremic syndrome, drug toxicities, autoimmune disease, sepsis and fulminant hepatic failure. Apheresis is an invasive procedure. It has significant DOI: 10.4103/0019-5049.144685 physiologic consequences, so the care of these patients requires continuous supervision. Quick response code Phlebotomy is performed as an intervention for some disease management. Its use is nowadays restricted to conditions such as polycythaemia, haemochromatosis and porphyria cutanea tarda. In this review, we have looked at various indications, procedure and complications of apheresis and phlebotomy in critical care unit. Key words: Apheresis, phlebotomy, plasmapheresis INTRODUCTION [Table 1] This allows disease resolution or decrease in morbidity.[1,2] The procedure was first Therapeutic transfusion techniques consist of successfully used for the treatment of Waldenstrőm removal of a blood component from a patient macroglobulinemia in 1959.[3,4] Since then, the using apheresis technology for removing defective efficacy of plasmapheresis has been documented in cells or disease mediators. The terminology numerous diseases of various organ systems. “Apheresis” stems from Greek verb apairesos or Roman aphairesis meaning to take away by force Sixty three articles were reviewed using keywords or withdraw.[1] Apheresis (or Haemapheresis) is the such as, therapeutic apheresis, plasmapheresis and collection of blood from a donor or patient followed therapeutic plasma exchange (TPE), starting from 1952 by separation and removal of a cellular component(s) till date, accessed through search engines PubMed, and/or plasma and return of the remaining blood Google, Google scholar and Medscape. components to the donor or patient. Cytapheresis is the procedure by which cellular elements of the Role in intensive care unit blood, platelets, leucocytes, lymphocytes, red blood Apheresis therapy like plasma exchange and plasma cells (RBC’s), are selectively removed from the adsorption is emerging as a therapeutic tool in blood. Plasmapheresis is a process in which plasma critical care. Apheresis therapy frequently used in is selectively removed. It is used to collect plasma intensive care unit (ICU) patients for thrombotic from healthy donor (without any fluid replacement) or to exchange plasma from a patient to remove thrombocytopaenic purpura (TTP), haemolytic a constituent (antibody, immune complexes, uraemic syndrome (HUS), autoimmune disease and inflammatory mediator, paraproteins, lipoproteins sepsis. Apheresis therapy is also useful in patients with and toxins, excess cells) which is causing harm. fulminant hepatic failure for artificial liver support.[2] How to cite this article: Bose N, Kanzariya H. Role of therapeutic apheresis and phlebotomy techniques in anaesthesia and critical care. Indian J Anaesth 2014;58:672-8. 672 Indian Journal of Anaesthesia | Vol. 58 | Issue 5 | Sep-Oct 2014 Bose and Kanzariya: Therapeutic transfusion techniques Table 1: TPE this procedure by one or more blood volumes, a Plasmapheresis TPE significant amount of pathologic components is Removal of plasma without Removal of a large proportion of removed. Anticoagulation of the circuit is required. fluid replacement patient plasma that is replaced with crystalloid, colloid fluids, FFP or This includes the collection of Centrifugation apheresis instruments use either a plasma from normal donors occasionally with coagulation factors TPE – Therapeutic plasma exchange; FFP – Fresh frozen plasma continuous or an intermittent flow method to drive the blood to the separation device. Continuous flow Description of apheresis methods draw blood into the extracorporeal circuit, Apheresis consists of the following: separate blood into components in the centrifugation • Circulating blood components can be chamber, channelizes the unwanted portion into a removed, either cells (cytapheresis) or plasma collection bag, and thereafter return the nonpathologic solutes (plasmapheresis). elements back to the patient without interruption. • Circulating substances responsible for certain Dual venous access is required for this. Intermittent diseases are removed. Some cells and plasma flow methods have the same steps but with a discrete components are mobilized from their tissue volume of blood at a time. This takes a longer time but depots and removed. requires only single venous access.[5] • Lymphocytes from the spleen and lymph nodes in chronic lymphocytic leukaemia THERAPEUTIC CYTAPHERESIS • Low‑density lipoproteins (LDLs) in familial hypercholesterolaemia. The purpose was to deplete over-abundant or abnormal • Removal of platelets and lymphocytes. cellular components. • Reinfusion of a deficient plasma factor as in TTP. Common indications are as follows: • Increases clearance of immune complexes by • Erythrocytapheresis (the patient’s RBCs are the spleen, in certain autoimmune disorders. removed and replacement with donor red cells if required) Types of apheresis • Sickle cell disease: Goal of exchanging the • Collection of components for transfusion: sickle red cells for red cells containing • Platelets - Plateletpheresis haemoglobin A is to interrupt the vicious • Leucocytes - Leucocytapheresis cycle of stasis, sickling and hypoxia. • Plasma - Plasmapheresis This procedure has also been used • Peripheral blood stem cells (PBSCs) prophylactically in pregnancy with sickle • Removal of pathological components, that is, cell disease and prior to general anaesthesia therapeutic apheresis: in these patients[6] • Therapeutic cytapheresis • Hyperparasitaemia: To lower parasite loads • TPE. in Malaria, Babesiosis. • Leucocytapheresis The procedure involved in apheresis is more • Leukaemia with hyperleucocytosis extensively used to harvest platelets and plasma from syndrome: Leukostasis results from healthy donors than as a therapeutic modality. As a microvascular obstruction and therapeutic procedure, it is not curative and does not may lead to endothelial injury, change the natural course of the disease; however, it thrombosis and/or haemorrhage. can be life-saving in many situations and buys time to affect more definitive therapy. The main emphasis Once total leucocyte count is above 3 in this article is on various aspects of therapeutic 200,000/mm in acute myeloid leukaemia 3 apheresis. and above 300,000/mm in chronic myeloid leukaemia, organ dysfunction is likely: TECHNICAL ASPECT OF APHERESIS • Pulmonary dysfunction (hypoxemia, diffuse lung infiltrates) Apheresis instruments separate the blood into • Cerebral dysfunction (confusion, components, then selectively remove one component mental status changes, altered level of and return the remaining to the patient. By running consciousness). Indian Journal of Anaesthesia | Vol. 58 | Issue 5 | Sep-Oct 2014 673 Bose and Kanzariya: Therapeutic transfusion techniques • Cutaneous T‑cell lymphoma (CTCL): In volumes beyond 1.5 plasma volumes removes smaller the leukaemic phase, also known as Sezary amounts of pathologic substance while prolonging syndrome, repeated leucocytapheresis reduces the procedure and exposing the patient to more circulating malignant cells (sezary cells).[7,8] replacement fluid and anticoagulant. • Extracorporeal photopheresis is also a type of leukopheresis in which the white blood The theoretical efficacy of TPE is shown in cells are exposed to ultraviolet A light to Table 2.[2] Role of plasmapheresis in various disease induce an immunomodulatory effect. It can conditions/syndromes are enlisted along with the achieve sustained remission in CTCL.[9] factors to be removed in each: • PBSC collection • Anti‑glomerular basement membrane (anti‑GBM) • Thrombocytapheresis: Acute management of disease[16] - Anti GBM antibody patients with symptomatic thrombocythaemia • Guillain‑Barre syndrome (GBS) ‑ Antimyelin where a rapid reduction in platelet count is antibody[17] required. • Hyperviscosity syndrome - IgM • Thrombocytosis (platelet count > 450,000‑ • Cryoglobulinemia - Cryoglobulins 500,000/μl) like polycythaemia • Microangiopathic thrombocytopaenia (TTP/ vera (PV), essential thrombocythaemia, HUS) - Von Willebrand factor multimers/ idiopathic myelofibrosis or unclassified anti-endothelial cell antigen[18-20] myeloproliferative neoplasm, with • Homozygous familial hypercholesterolaemia ‑ an acute and severe thrombotic or LDL cholesterol[21] haemorrhagic event. Platelets are reduced • Myasthenia gravis (MG) crisis ‑ Ach receptor for symptomatic relief while waiting for antibody cytoreductive therapy to take effect. • Coagulation factor inhibitors ‑ Factor VIII • Useful in those who cannot tolerate
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