Intensive plasma exchange in small and critically ill pediatric patients: Techniques and clinical outcome

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Abstract
Standard apheresis techniques require modification of use in children, particularly those with serious concurrent medical problems, as they are prone to apheresis‐induced disturbances of volume, metabolism, and coagulation. We report 112 plasma exchanges (TPE) on 11 children, 9 of whom weighed less than 20 kg and 7 of whom were critically ill. All were treated on continuous flow apparatus; seven on centrifugal systems (CS), two on a membrane filtration system (MFS), and two on both. Perturbations of blood and red blood cell (RBC) volume were prevented by priming the extracorporeal circuits with a red cell saline mixture having an hematocrit equal to or greater than the patient's hematocrit. Priming volume and minimal flow rates were 170 ml and 40 cc/min (MFS) and 350 ml and 10 cc/min (CS). TPE dose varied from 1.3 to 3 plasma volumes. Immunoglobulins fell by the following amounts: IgG 43.7%, IgA 36.7%, and IgM 41% per plasma volume. Platelets fell by 20–90% (CS) and 5–7% (MFS). Vascular access was obtained by various means including Thomas shunts, dialysis catheters, and standard 16–19 gauge butterflies and angiocaths. Bleeding in patients with coagulopathies was prevented by using repeated small boluses of heparin to maintain a clotting time of 2.5–3 minutes. Morbidity from TPE was limited to citrate toxicity (2 patients) and transient pulmonary edema (1 patient).Treatment outcome was successful in 8 out of 11 patients. We have shown that if PEX is otherwise indicated, it should not be withheld solely for patient size or the complexity of concurrent medical problems.

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