Best practices for Red Blood Cell Exchange procedures on ...€¦ · Best practices for Red Blood...
Transcript of Best practices for Red Blood Cell Exchange procedures on ...€¦ · Best practices for Red Blood...
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Best practices for Red Blood Cell Exchange procedures on the Spectra Optia apheresis system to treat Sickle Cell Disease patients
Bridget Hughes - Nurse Practitioner Therapeutic ApheresisServices Leeds2017
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Content
• Procedure management
• Custom prime
• Depletion/ exchange procedures
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NICE Guidelines
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And then...
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Procedure ManagementFCR, replacement fluid volume, target HCT, target fluid balance,replacement fluid HCT
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Red Blood Cell Exchange
• Known as automated exchange or exchange-transfusion
• Defective RBC are removed and normal RBC are simultaneously infused
• Can rapidly adjust the HCT% and HbS% concentration of the patient
• Avoids fluid overload, increased viscosity and iron overload associated with transfusions
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Defective red cells removed
Blood warmer
Blood pumps
Donor red cells infused
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Patient Information• Sex
• Height Total blood volume
• Weight
• HCT%
Patients who are <25 kg require a manual calculation of the TBV
Procedural Parameters to Order• Pre/ target HBS% or FCR
• Final (desired) patient HCT%
• Fluid balance
• The replacement fluid HCT%
• The final (post-procedure) patient HCT%
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Final HCT- Iron Overload• Every unit of packed RBC contains approximately 200mg heme iron
• Every increase of 3 points in the patient’s final HCT% = 1 additional unit of RBC transfused to the patient
• The transfusion of as few as 10 to 20 RBC units can cause iron overload
• RBCX avoids iron overload by balancing the removed RBC with the infused RBC ie it is iron neutral
Final HCT- Other Factors • Blood viscosity
• Blood Usage
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FCR% V HbS% V Replacement Fluid Volume
• The Spectra Optia system operator needs to know one of the following data points:
– FCR%– Patient’s current HbS% and desired final HbS%– Replacement fluid volume of RBC
Which one to use and when?
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What is Fraction of Cells Remaining (FCR%)?
Patient RBC
FCR
Donor RBCRBCX
The percentage of the original RBC remaining in the patient’s body at the end of the procedure
A lower FCR results in a lower final
HbS% and a greater
volume of RBC
exchanged
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Relationship between FCR% and HBS%
Starting HbS(Pre Procedure)
Desired HbS(Post Procedure)
40% 10%
Post HbS%
Pre HbS%=
10%40%
25%
FCR%
=
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Pre + Post procedure HBS%• It is generally accepted that the pre-procedure HbS%
(+HbC%) should be maintained at or below 30% to minimise morbidity and mortality associated with SCD
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Fluid Balance• Fluid balance during an RBCX procedure is generally
set at 100% (isovolemic) ; if that is the case, isovolemia is maintained throughout the procedure
• The Spectra Optia system also allows the operator to run the procedure with a positive (>100%) or negative (<100%) fluid balance if required by the ordering physician
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Custom PrimeAlbumin or RBC
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Custom Prime• Custom prime consists of replacing the normal saline
(NS) used to prime the device with either RBC, 5% albumin or plasma
• It is an option to be used whenever the extracorporeal volume (ECV) of the apheresis device exceeds a pre-set maximum percentage of the patient’s TBV
• Used in paediatrics <25kg
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Exchange DepletionProcedure, protocol, efficiency
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Protocol• Phase 1: Isovolemic Depletion
• Phase 2: Exchange
• The overall result is a more efficient procedure, where fewer RBC are needed to reach the same end points
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Efficiency� Lower FCR (final HbS%)
� The same volume of blood is used
� Lower FCR attained
� Fewer RBC required
� Same FCR targeted
� 1 unit less RBC needed
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RCX Programme at Leeds
• 9 Adults & 9 Paediatrics
– 5-7 weekly– Attend the unit for procedure, Leeds Children’s Hos pital or
Hull– Attend 2 days pre RBCX for cross matching– Memos sent out in advance– 4 require CVC insertion, we have 1 patient with a v ortex port
and all others including the children have peripher al access– In the process of training to Deep Vein Cannulate th ose that
currently have regular line insertions– Ages 5-45
• Performed over 20 Acute RCX last year
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Lovely Laura at Paediatric RCX Clinic
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Thank you for listening
Any questions?