| Complication | Prevention/mitigation strategy |
Hypocalcemia: - Due to citrate, which chelates calcium
| - Pretreatment with prophylactic calcium administration. The calcium formulation (oral, intravenous push, or continuous infusion) and dose are based on patient and procedure factors including:
- The patient's preprocedure calcium level
- Whether the patient has known citrate sensitivity or conditions that can affect calcium metabolism
- Duration of the apheresis procedure
- Volume of citrate-containing fluids administered
- Perform cardiac monitoring during continuous calcium infusion.
- Consider monitoring intraprocedural calcium levels.
- Use of plasma as a replacement fluid should only be done for specific indications.*
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| Other electrolyte fluctuations | - Evaluate electrolytes prior to the procedure.
- Manage abnormalities as indicated.
|
Vascular complications: - Peripheral veins
- Indwelling intravascular catheters and vascular access devices
| - Select optimal vein for accessibility, size, and location, based on the number and length of procedures.
- For indwelling devices:
- Follow standards of practice and institutional best practices for insertion and care.
- Confirm placement radiologically prior to apheresis procedures, in compliance with standards of practice and AABB standards.
- Evaluate coagulation parameters before removing the catheter.
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Transfusion reactions: - Includes anaphylactoid, allergic, hypotensive, septic, or hemolytic reactions; and TRALI or TACO
- Due to plasma as the replacement fluid or RBCs during RBC exchange transfusion, or other blood products
| - Follow PBM guidelines and institutional guidelines (if based on PBM guidelines) for blood product use.
- Avoid or minimize blood product exposure by only using blood products if indicated (especially plasma*).
- Monitor for transfusion complications; evaluate and manage per institutional policies and procedures and standards of care.
- If there is a history of anaphylaxis, check IgA and anti-IgA levels preprocedure; if results are consistent with IgA deficiency, provide blood products obtained from known IgA-deficient donors (may be available from special registries or inventories).
- For minor allergic reactions, consider premedication with an antihistamine if tolerated and not contraindicated.
|
Volume overload: - Increased intravascular volume prior to the procedure
- Underlying heart, kidney, or liver disease
- Rapid fluid shifts
- TACO
| - Manage overload (eg, administer diuretics) before, during, or after the procedure if indicated.
- Monitor fluid status during the procedure.
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Hypotension: - Underlying heart, kidney, or liver disease
- Low intravascular volume before the procedure
- Transfusion reactions
- ACE inhibitor-associated hypotension
- Membrane incompatibility with plasma membrane separation
- Other causes
| - Clinical evaluation and treatment for the underlying cause.
- Optimize volume status prior to apheresis and monitor volume status during apheresis.
- Consider discontinuation of the ACE inhibitor (and possibly substitution of an alternate medication) 24 to 48 hours before the procedure; change to a different albumin lot if the reaction recurs.
- For plasma membrane separation, change the membrane or use a therapy other than apheresis.
- For other causes, manage as needed.
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Removal/clinically relevant decrease in certain proteins or medications: - Coagulation factors
- Endogenous immunoglobulins
- Therapeutic monoclonal antibodies
- Other medications
| - Measure preprocedure PT and aPTT.
- Measure levels of immunoglobulins if hypogammaglobulinemia is a concern.
- Administer immune globulin as indicated.
- Administer clotting factors or plasma if bleeding is a significant concern; hematologist consultation is advised.
- Perform preprocedure medication review.
- Delay medications that are removed by apheresis; administer after the apheresis procedure is completed.
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