Further Detailed Management of Complications (Therapeutic Apheresis)

Complication

Symptoms

Management

Citrate Toxicity

Circumoral paraesthesia

Muscle twitching

Nausea and/or vomiting

Chills

Syncope

Tetany (rare)

Palpitations/arrhythmia

Avoidance:

Warn patient of symptoms
Oral calcium supplements before/during procedure
Use the recommended anticoagulant solution in the correct proportions
Slow infusion rate

Treatment:

Stop or slow infusion
Oral calcium supplements
10% calcium gluconate 5 ml slow infusion if serious reaction

Inadequate Citrate

Clotting in extracorporal circuit

DIC

Haemolysis

Avoidance:

Use the recommended anticoagulation solution in the correct proportions
Monitor:
- delivery of anticoagulant
- return IV line for clotting
- colour of plasma (red = haemolysis)

Heparin related

Bleeding

Allergy/anaphylaxis

Thrombocytopenia

Treatment:

Protamine Sulphate – to reverse heparin.
Side effects: chills, light headedness, allergy and/or anaphylaxis, dyspnoea, and/or chest pain, flushing.

Thrombocytopenia

Petechiae, Bleeding

Avoidance:

Monitor platelet count 20-30% decrease expected

Treatment:

Platelet transfusion if platelets<50 x 10⁹/L

Transfusion reactions to blood and blood products

Allergic Anaphylaxis

hives, itch facial oedema, dyspnea

Treatment:

Antihistamine ± hydrocortisone

Transfusion transmitted infection

Hepatitis B/C, HIV, CMV

ABO incompatible reaction

Delayed adverse reaction Haemolysis

Specific to virus transmitted.

Avoidance:

Use ABO compatible products.

Treatment:

Stop infusion – supportive care, IV fluids – contact TMS/ Haematologist

Transfusion related acute lung injury

Severe dyspnea, hypoxia

Supportive care/ICU ± hydrocortisone

Hypervolaemia

Dyspnea

Oedema

Avoidance:

Monitor fluid balance – judicious use of albumin; finish with a small negative fluid balance. Must replace at least 75% of total calculated plasma volume

Hypovolaemia

Hypotension

Syncope

Avoidance:

Use colloid solutions (albumin, HES etc.)

Treatment:

Give IV fluids – colloids or normal saline

Abnormal electrolytes

Low calcium

Others, uncommon

See above

Adjust composition of electrolyte solutions to correct these.

Hypothermia

Chills

Use blood warmer
Warm replacement fluids
At risk patient groups:
- sickle cell disease
- cold haemagglutinin disease
- paraproteinaemia
- cryoglobulinaemia
- children

Complication of venous access

See previous comments

See previous comments

Haemolysis

Fever, red urine, red plasma

Renal impairment

Avoidance:

Use ABO compatible blood and blood products. Monitor:
Pressure in returning line.
Ensure no kinking or twisting of lines and that these are fitted correctly into the machine.
Monitor colour of plasma.

Treatment:

Stop and resolve cause – see above

Air Embolus

Dyspnea, chest pain

Avoidance:

Monitor drip chambers and returning line

Treatment:

Procedure, turn patient onto their left side head down.
Notify TMS/Haematologist

Equipment Contamination

Septic type

Do not prime equipment more than 1 hour before the procedure.

Bacterial contamination

Septic shock

Avoidance:

Inspect all replacement fluids to ensure no evidence of microbial contamination or defects in the container.

Treatment:

Stop procedure, call TMS/Haematologist.
Give IV fluids to maintain BP.
Administer IV antibiotics.


About this Canterbury DHB document (38131):
Document Owner:	Not assigned (see Who's Who)
Last Reviewed:	June 2019
Next Review:	June 2022
Keywords:
Note: Only the electronic version is controlled. Once printed, this is no longer a controlled document. Disclaimer The Haematology Department Protocols and Guidelines (the Red Book) are intended as a guide for registered health professionals to communicate guidelines and share best practices with supporting health professionals within New Zealand district health boards. They are not intended to be provided to or used as a reference for patients or non-registered health professionals. All health professionals must exercise their own clinical judgement and use pertinent clinical data when treating patients. The authors and editors of this publication have checked with sources believed to be reliable in their effort to provide information that is complete and in accord with the standards accepted at the time of publication. However, in view of the possibility of human error or changes in medical science, neither the authors, editors, publisher, nor any other party who has been involved in preparing or publishing this work warrants that the information contained in it is accurate or complete in every respect. They therefore have no liability (whether in tort (including negligence) or otherwise) for any loss or damage arising out of any reliance on this information. This publication has been compiled by the staff and contractors of Canterbury District Health Board (CDHB) and as such CDHB has copyright for this book. Amendments must be authorised in accordance with the documented process. No release of part of, or all of, this publication to any other party or organisation is permissible without the prior approval of the designated document owner.
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Topic Code: 38131


Complication	Symptoms		Management
Citrate Toxicity	Circumoral paraesthesia Muscle twitching Nausea and/or vomiting Chills Syncope Tetany (rare) Palpitations/arrhythmia		Avoidance: Warn patient of symptoms Oral calcium supplements before/during procedure Use the recommended anticoagulant solution in the correct proportions Slow infusion rate Treatment: Stop or slow infusion Oral calcium supplements 10% calcium gluconate 5 ml slow infusion if serious reaction
Inadequate Citrate	Clotting in extracorporal circuit DIC Haemolysis		Avoidance: Use the recommended anticoagulation solution in the correct proportions Monitor: delivery of anticoagulant return IV line for clotting colour of plasma (red = haemolysis)
Heparin related	Bleeding Allergy/anaphylaxis Thrombocytopenia		Treatment: Protamine Sulphate – to reverse heparin. Side effects: chills, light headedness, allergy and/or anaphylaxis, dyspnoea, and/or chest pain, flushing.
Thrombocytopenia	Petechiae, Bleeding		Avoidance: Monitor platelet count 20-30% decrease expected Treatment: Platelet transfusion if platelets<50 x 10⁹/L
Transfusion reactions to blood and blood products
Allergic Anaphylaxis		hives, itch facial oedema, dyspnea		Treatment: Antihistamine ± hydrocortisone
Transfusion transmitted infection Hepatitis B/C, HIV, CMV ABO incompatible reaction		Delayed adverse reaction Haemolysis		Specific to virus transmitted. Avoidance: Use ABO compatible products. Treatment: Stop infusion – supportive care, IV fluids – contact TMS/ Haematologist
Transfusion related acute lung injury		Severe dyspnea, hypoxia		Supportive care/ICU ± hydrocortisone
Hypervolaemia		Dyspnea Oedema		Avoidance: Monitor fluid balance – judicious use of albumin; finish with a small negative fluid balance. Must replace at least 75% of total calculated plasma volume
Hypovolaemia		Hypotension Syncope		Avoidance: Use colloid solutions (albumin, HES etc.) Treatment: Give IV fluids – colloids or normal saline
Abnormal electrolytes Low calcium Others, uncommon		See above		Adjust composition of electrolyte solutions to correct these.
Hypothermia		Chills		Use blood warmer Warm replacement fluids At risk patient groups: sickle cell disease cold haemagglutinin disease paraproteinaemia cryoglobulinaemia children
Complication of venous access		See previous comments		See previous comments
Haemolysis		Fever, red urine, red plasma Renal impairment		Avoidance: Use ABO compatible blood and blood products. Monitor: Pressure in returning line. Ensure no kinking or twisting of lines and that these are fitted correctly into the machine. Monitor colour of plasma. Treatment: Stop and resolve cause – see above
Air Embolus		Dyspnea, chest pain		Avoidance: Monitor drip chambers and returning line Treatment: Procedure, turn patient onto their left side head down. Notify TMS/Haematologist
Equipment Contamination		Septic type		Do not prime equipment more than 1 hour before the procedure.
Bacterial contamination		Septic shock		Avoidance: Inspect all replacement fluids to ensure no evidence of microbial contamination or defects in the container. Treatment: Stop procedure, call TMS/Haematologist. Give IV fluids to maintain BP. Administer IV antibiotics.