Keywords

These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

FormalPara Main Points

  • Complications frequently occur during apheresis and should be detected as early as possible.

  • Technicians or operators should fully understand the function and applications of all equipment used and the possible complications of the apheresis procedure.

  • It is important that physicians understand the cause of any complications and manage them quickly.

1 Introduction

Complications frequently occur during apheresis, but they can be prevented from becoming serious if the technicians or operators understand their causes and how to manage them. We will review the complications associated with the apheresis equipment and those associated with the treatment.

2 Complications Associated with Apheresis Equipment

2.1 Clotting in the Circuit

Blood takes a longer time to pass through the circuit during apheresis than during hemodialysis due to the lower blood flow rate and higher priming volume of the circuit. Therefore, more extensive anticoagulation should be used during apheresis than during hemodialysis. This is especially true during double filtration plasmapheresis (DFPP), where endogenous anticoagulants are removed, and even more anticoagulation is necessary. It is essential that coagulation is monitored by tests such as activated partial thromboplastin time (APTT) or prothrombin time (PT) during apheresis. When pressure in the circuit becomes elevated, even if adequate anticoagulation has been administered, the problem must be quickly remedied because clots can begin to form. The pressure in the circuit needs to be continuously monitored and it is important to prevent loss of blood in the circuit.

2.1.1 Cause

Clotting in the circuit can be caused by a deficiency of anticoagulants, formation of white thrombi through platelet activation, frequent blood removal failure, or other reasons.

2.1.2 Management

Management of these complications depends on where the clots form in the circuit (Table 21.1) [1].

Table 21.1 Management according to location of clotting within the circuit
Full size table

2.2 Equipment Malfunction

Blood purification equipment must have regular maintenance and inspection, as required by the revised Medical Care Act (Act No. 84 of 2006). The operation of these machines should be tested once a month even if they are rarely used.

2.2.1 Management

If the therapy cannot continue due to equipment malfunction, we manually return the blood in the circuit to the body with the hand-powered handle, or through other procedures. If there is a spare apparatus, we continue the therapy with a transfer of the circuit.

2.3 Human Errors

It is important that operators become skilled in the procedures and use of blood purification equipment. More than one person should monitor all procedures because a delay in the detection of an error could possibly cause serious harm to the patient. In our hospital, we utilize checklists designed according to the type of therapy and machine. They are used after priming, upon starting the machine, before beginning therapy, and before the initiation of plasma separation.

2.3.1 Cause

Problems with the procedure can occur due to technician carelessness, insufficient monitoring lack of knowledge, or an oversight such as forgetting to lock or unlock Kocher clamp. Problems can also arise from the mistaken entry of air, damage of the circuit, or incorrect setting of the flow rate.

2.3.2 Management

The therapy should be interrupted until the patient’s safety has been assured. This can involve assessing whether the error has done harm to the patient, sterile conditions have been maintained, and whether an exchange of circuits is necessary, among other considerations. The hospital’s risk management plan should be followed.

3 Complications Associated with the Apheresis Treatment

Complications affecting the patient’s clinical condition should be detected as early as possible thorough monitoring of vital signs and other methods. It is also essential that operators and technicians are trained to manage complications and emergencies that occur during treatment.

3.1 Hypotension

Hypotension can occur frequently, and the cause can often be deduced by examining when it occurred. Causes and management of hypotension according to onset time are shown in Table 21.2 [1]

Table 21.2 Causes and management of hypotension according to onset time
Full size table

(See Chap. 17).

3.2 Paresthesias (Citrate Toxicity)

3.2.1 Cause

Citrate toxicity results from a temporary reduction in plasma ionized calcium concentration due to exposure to citrate that is contained in anticoagulants used during centrifugal leukocytapheresis or in fresh frozen plasma (FFP) used as replacement fluid in plasma exchange (See 20.2 Calcium).

3.2.2 Management

The citrate delivery rate can be lowered (usually along with the blood flow rate) and prophylactic calcium preparations can be infused via the venous return line. The rate of clearance of citrate, which is metabolized by the liver, varies among individuals, and a change of therapy type or combined plasma exchange and dialysis should be considered in patients with both hepatic and renal dysfunction.

3.3 Other Complications

Other characteristic complications are shown in Table 21.3. We should be familiar with the package inserts of each device used because there are different kinds of complications associated with particular devices.

Table 21.3 Complications during apheresis other than hypotension
Full size table