Baxter International Inc. · NYSE:BAX
Baxter International — Technical Presentation (June 2020)
26 slides from Baxter International's technical presentation, June 2020
Slide 1: Therapeutic Plasma Exchange Part II: Treatment Considerations
Therapeutic Plasma Exchange Part II: Treatment Considerations Tena Griffin, DNP, CRNP Renal Clinical Educator Baxter Healthcare
Slide 2: Overview
Overview • TPE selection criteria, treatment goals, and plan • Factors influencing TPE treatment dose and schedule • Vascular access and blood flow rate • TPE replacement fluids • Anticoagulation • Complications • TPE and medications • Influence of TMPa, blood flow rate, and patient hematocrit USMP/
Slide 3: TPE: Standard Medical Treatment
TPE: Standard Medical Treatment Treatment Goals • Early treatment to halt inflammatory response • Modulation of the abnormal immune response • Remove the causative factor Treatment Plan • Immunosuppressant medications (i.e., steroids) to inhibit inflammatory response • Chemotherapy/immunomodulators
Slide 4: TPE Treatment Schedule
TPE Treatment Schedule The TPE treatment schedule is prescribed by the physician based upon the patient-specific disease state TPE treatment schedule and patient outcomes are influenced by the plasma protein kinetics of the targeted substance: • Volume of distribution • Rebound / resynthesis • Half-
Slide 5: Volume of Distribution
Volume of Distribution Intravascular vs. extravascular • Is the substance targeted to be removed primarily in the intravascular or extravascular space? The extent of removal of a substance during TPE depends on:1,2 • The volume of the patient’s plasma removed in relation to total plasma volume • The
Slide 6: Plasma Rebound
Plasma Rebound TPE is an intermittent therapy • Intervals between treatments will be determined by the time it takes for plasma levels to rebound • Plasma rebound is defined by the length of time it takes for the targeted substance to return to near pre-treatment value • Plasma rebound is governed b
Slide 7: Plasma Half-Life
Plasma Half-Life Half-life (t½ ): the amount of time it takes for a substance to be reduced to half of its initial value The half-life of a substance plays a role in TPE prescription because it predicts how long it takes for plasma rebound to occur IgM as an example: • IgM t½ = 5 days – It takes 5 d
Slide 8: TPE Prescription and Dose
TPE Prescription and Dose After the patient- and disease-specific treatment schedule has been determined, the physician must make a few more prescription and TPE dose decisions: • Vascular access and blood flow rate • Estimated total blood volume (TBV) and plasma volume (PV) • Plasma exchange volume
Slide 9: Vascular Access & Blood Flow Rate
Vascular Access & Blood Flow Rate Vascular Access1,2 Blood Flow Rate – Central Venous Catheter: • Range: 100 – 250 ml/min3 • Internal Jugular • Minimum: 100 ml/min3 • Femoral • Lower rates can be delivered • Subclavian for low weight patients, if – Arteriovenous fistula/graft necessary; lower BFR ma
Slide 10: Volume Calculations: Total Blood, Plasma & Total Exchange
Volume Calculations: Total Blood, Plasma & Total Exchange Several steps are involved in determining the volume of plasma to be exchanged per treatment Necessary values and common formulas to determine TPE volume Patient’s weight In kg Patient lab results Pre-treatment HCT % Estimated TBV Weight (kg)
Slide 11: Step 1: Estimating Total Blood Volume (TBV)
Step 1: Estimating Total Blood Volume (TBV) Formulas: Weight (kg) x 70 ml/kg for normal male adults = TBV Weight (kg) x 65 ml/kg for normal female adults= TBV Weight (kg) x 80/70 ml/kg for normal infant/child= TBV Example: (normal adult male) 100 kg x 70 ml/kg = 7000 ml TBV (Note: Some facilities ma
Slide 12: Step 2: Estimating Plasma Volume (PV)
Step 2: Estimating Plasma Volume (PV) Formula: TBV x (1.0 – Hct %) = PV Example: 7000 ml x (1.0 - 0.42) 7000 ml x 0.58 = 4060 ml PV (Note: Hct of 42% = 0.42) Kiss JE. In Kellum J, et al. (Eds.) Continuous Renal Replacement Therapy 2nd edition. 2016; 49–173 Kiprov DD, et al. in Daugirdas JT et al. (E
Slide 13: Step 3: Calculating Plasma Exchange Volume
Step 3: Calculating Plasma Exchange Volume Formula: PV x Number of exchanges prescribed = Total Exchange Volume Example: • 4060 ml x 1.5 (or 150%) = 6090 ml • Total plasma volume to exchange: 6090 ml (Note: The total replacement volume ordered will reflect the total plasma volume to exchange.) Kiss
Slide 14: Number of PV Exchanges
Number of PV Exchanges The number of PV exchanges is prescribed by the physician based on treatment goals • The relationship between plasma volume exchanged and concentration of substances is illustrated below: Plasma Volume Volume Amount of Substances Exchanged Exchanged Removed (macromolecule redu
Slide 15: TPE Calculation Practice
TPE Calculation Practice Patient characteristics Results Patient’s weight 100 kg Patient’s lab result: 34% or 0.34 Pre-treatment HCT % TPE prescription: 1.5 Number of exchanges TBV: Weight (kg) x 70 mL/kg for adults = TBV PV: TBV x (1.0 – HCT %) = PV Total exchange volume: PV x number of exchanges =
Slide 16: TPE Calculation Practice - Answers
TPE Calculation Practice - Answers Patient characteristics Results Patient’s weight 100 kg Patient’s lab result: 34% or 0.34 Pre-treatment HCT % TPE prescription: 1.5 Number of exchanges TBV: 7000 mL Weight (kg) x 70 mL/kg for adults = TBV PV: 4620 mL TBV x (1.0 – HCT %) = PV Total exchange volume:
Slide 17: TPE Replacement Fluids
TPE Replacement Fluids Purpose Most Common Types • Restore vascular volume • Colloid solution (albumin and/or fresh frozen plasma) • Restore oncotic pressure • Combination of crystalloid/colloid solution • Supply coagulation factors Kiprov DD, et al. in Daugirdas JT et al. (Eds.) Handbook of Dialysi
Slide 18: Albumin (5%)
Albumin (5%) Limitations Benefits • Occasional hypotension • Most commonly used • Pulmonary edema following rapid increase • No viral transmission in albumin • Less expensive than FFP • Clotting factor depletion or Coagulopathy • Maintains stable blood volume • Immunoglobulin depletion • Allergic re
Slide 19: Fresh Frozen Plasma (FFP)
Fresh Frozen Plasma (FFP) Selection Criteria • Fibrinogen level <125mg/dl • Coagulation factors below normal value • Reduced platelet count Benefits Limitations • Replaces plasma clotting • Anaphylactic reactions factors • ABO matching • No post-pheresis • Viral transmission (rare) coagulopathy • Ci
Slide 20: Anticoagulation
Anticoagulation • Recommended for use in TPE if no contraindication exists • Heparin (systemic): preferred method for membrane filtration • Citrate (regional): preferred method for centrifugal devices (but can be used for membrane devices) • Follow hospital standard protocol Kiprov DD, et al. in Dau
Slide 21: Potential Complications
Potential Complications Adverse effects of TPE may include: • Anaphalactoid reactions (with FFP) • Fluid imbalance: hypovolemia or overload • Hypothermia • Convective electrolyte loss • Hemolysis* • Clotting* * Risk of clotting and hemolysis can be minimized by closely monitoring TMPs and filtration
Slide 22: Medications and TPE
Medications and TPE ACE inhibitors1 Antibiotics, other medications2,3 Risk Risk • Anaphylactic reactions if albumin is used for • May be removed during TPE based on the replacement solution during TPE volume of distribution of the drug in the body • Bradykinin release resulting in vasodilation • Dru
Slide 23: Factors Influencing Plasmafiltration
Factors Influencing Plasmafiltration TMPa Return – Access Transmembrane Pressure pressure – Machine calculated – Alarm limit varies with BFR Effluent pressure Blood flow rate (BFR) – Minimum of 100 ml/min – Maximum of 250 ml/min Patient’s hematocrit (Hct) To decrease the TMPa and filtration fraction
Slide 24: Knowledge Check
Knowledge Check • Can you identify the common TPE therapeutic goals? • Can you identify the basic TPE prescription components? • Can you cite nursing considerations when administering TPE? Please refer to your facility's protocols before performing this treatment. USMP/MG120/19-0022 09/19 24
Slide 25: References
References USMP/MG120/19-0022 09/19
Slide 26: References
References • Gambro. Introduction to Therapeutic Plasma Exchange. Renal Intensive Care – Self-learning Moduler (Version 2). 2004. • Gambro. Prismaflex Operator’s Manual (for use with software versions 7.xx). Order Number G5039110. 2005-2014. • Gashti CN. Membrane-based Therapeutic Plasma Exchange: A
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