Background: Patients undergoing therapeutic plasma exchange (TPE) may present with risks for hemorrhage or thrombosis. Use of replacement fluids devoid of coagulation factors will decrease factor levels and platelet levels. There are no established guidelines for hemostasis management in these situations. Materials and methods: A survey to evaluate current hemostasis management practice during TPE was conducted using online survey software. One response per institution was analyzed based on a hierarchical algorithm, excluding membrane filtration users, resulting in a maximum of 107 respondents. Descriptive analysis was performed with results reported as the number and frequency (%) of respondents to each question. Results: Apheresis Medicine physicians, alone (59.4%) or jointly with the requesting provider (29.2%), choose the replacement fluid. Based on a theoretical patient case receiving five TPEs approximately every other day, the percent of respondents who would use albumin with or without normal saline was 94.7% with no history of a bleeding or clotting disorder, 1.1% with active bleeding, and 8.8% with hypofibrinogenemia (<100 mg/dL) due to recent TPE. More respondents would use albumin with or without normal saline for replacement fluid when a minor invasive procedure (49.5%) vs a major surgery (8.9%) was performed 1 day before TPE. Replacement fluid selection varied among respondents for several other clinical conditions. The most frequent use for cryoprecipitate by respondents (14.3%) was hypofibrinogenemia. Conclusions: These survey results demonstrate wide interinstitutional variation in replacement fluid selection to manage hemostasis in patients undergoing TPE. Further studies are needed to guide optimal hemostasis management with TPE.
Bibliographical noteFunding Information:
The authors would like to acknowledge the respondents who participated in our survey, the members of the ASFA Clinical Applications Committee who provided feedback during development and beta testing of the survey, and the ASFA head office staff for assistance with distributing the survey and administrative support throughout the project. NDZ: Research funding: Octapharma, Terumo BCT, Bayer HealthCare, Verax Biomedical; Financial interest: Endo International PLC, Boston Scientific. MBP: Research funding: Terumo BCT. MAR: Advisory Boards: Bayer and NovoNordisk. ECCW: Consultant: Comprehensive Care Services. YW: Consultant: Verax Biomedical. The other authors have no conflict of interest to disclose.