Transcript Folie 1 - ООО "ЭМСИПИ

Apheresis Procedures
1
Definition
From greek „Apheresis“, i.e. „separation“
of plasma through membran filter or centrifuge
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Overview
Plasmapheresis
Preparative Plasmapheresis
Conserved Plasma
Plasma Fractions
Therapeutic Plasmapheresis
Blood cells
non- selective
semi- selective
selective
Plasma Protein Concentrate
Coagulation Factors
Leucocyte Concentrates
Therapeutic Plasma Exchange
Cascade Filtration
Enzym Adsorption (Bioreaction)
Fresh- frozen- Plasma (FFP)
Human Albumine
Erythrocyte Concentrate
Activated Charcoal Adsorption
Cryo Filtration
Immuno Adsorption
Thrombocyte Concentrate
Ion Exchange Adsorption
Immuno Adsorption
Protein A
Phenylalanin
LDL- Apheresis
Tryptophan
Heparin Prezipitation
Dextransulfat Adsorption
Immuno Adsorption
Thermo Filtration (?)
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Plasmapheresis
Preparat ive Plasmapheresis
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Therapeut ic Plasmapheresis
Blood Cells
selekt ive
Plasma Fract ions
semi- selekt ive
Conserved Plasma
non- selekt ive
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Therapeut ic Plasmapheresis
non- selekt ive
Ion Exchange Adsorpt ion
Activated charcoal Adsorpt ion
Plasma Exchange
semi- selekt ive
selektive
Cascade Filtration
Enzym Adsorpt ion (Bioreaction)
Cryo-Filtration
Immuno- Adsorpt ion
Immuno- Adsorpt ion
Phenylalanin
Tryptophan
Protein A
LDL- Apheresis
Heparin Prezipit at ion
Dext ransulf at Adsorpt ion
Immuno- Adsorpt ion
Thermo- Filt rat ion (?)
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Cryo-Filtration
Cascade FiltrationDextransulfat Adsorption
Therapeutic
Heparin Precipitation
Immuno-Adsorption
Plasma Exchange
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Membrane Plasma
Separation
Centrifuge Plasma
Separation
Application
Therapeutic Plasma
Pheresis
Preparative Plasma
Pheresis
Anticoagulation
Kont.
Heparinisation
Citrate with Heparin
Initialbolus
Side Effects
Filter Clotting, mech. Thrombocytopenia,
Hemolysis
mech. Hemolysis
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Membrane Filter Separation
Filtration Rate <1/3 of Blood Flow Rate
Hemocompatibility
TMP <100 mmHg
Sterilisation:
ETO
Steam
Gamma
Secundary Membrane
Pore Size 0.2-0.6 µm
Sueface 0.13-0.6 m²
Material:
Polypropylen
Polysulfon
Cellulosediacetat
Cut-off 3 BiDa
Sieving Coefficient >0.8
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Thrombocytes 2-3.5 µm
Albumine 69 kDa
IgG 150 kDa
IgA 160 kDa
IgM 900 kDa
Fibrinogen 340 kDa
LDL 2000-4500 kDa
0.02 µm
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Membrane Pores 0.2-0.6 µm
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Sieving Coefficient
Concentration ratio of a certain component in
separated plasma to the Concentration in plasma before seperation
Plasma Component
Total Protein
Albumine
IgG
IgA
IgM
Fibrinogen
Cholesterol
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Sieving Coefficient
0.9
0.95
0.9
0.85
0.8
0.95
0.8
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optimal plasma separation
1. plasma/blood flow 1/3
2. low TMP
3. high blood flow
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TPE - Therapeutic Plasma Exchange
Heater
PV
PPL
BLD
SAC
Heparin
V
V
Plasma Filter
SAD
PA
Advantages
Disadvantages
rel. simple technic
bride spectrum of
indication
rel. low
costs
non- selective
substitution
complications
no chronic
application
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Pl.
S
Balance
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Blood Access
Vessel Access
 periferal vein
V. jugularis
interna
V. subclavia
 arterio-venous fistula
 central-venous access
V. cubitalis
V. femoralis
Cimino Fistula
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Anticoagulation
initial
Heparin
Citrate
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continuous
40-60
IU/kg BW
1000-3000
IU Heparin
10-20 IU/kg/h
1:15-1:25
ACD/Blood
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Coagulation Cascade
Defect
Injury
X
Tissue
Endothel
Endogen System
XII
XI
XIIa
XIa
Exogen System
IX
IXa
Tissue Factor (III) +
Ca2+ (IV) + VII
VIII
Ca2+ (IV)
TF3
TF3 + Xa + V + Ca2+ (IV)
Thrombocytes
XIII
Citrate
Thrombin
Heparin
Prothrombin (II)
AT III
Fibrin Monmers
Fibrinogen (I)
XIIIa
Fibrin
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Substitution
Clinical
Requirement
•isovolemic, isotonic, isooncotic
•allergen and pyrogen free, sterile
•containing coagulation factors and
immunoglobulins
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Substitution
Remarcs
1. Plasma Expander
Dextrane, Hydroxyethylstarch (HES), Gelatine Preparation. Short
Half Life Time
2. Conserved Plasma
Protein
3. Fresh Frozen Plasma
(FFP)
4. Human Albumine
Solution
Contain E’lytes, Albumine, Globulins. Expensive, Incompatibility
Reactions
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AB0-Compatibility, Indikation for TTP und Goodpasture-Syndrom,
Allergic Reactions, Viral Infections, Hypocalcemia
Albumine + Hemofiltration Solutions with Lactate or Bicarbonate,
Low Rate of Side Effects
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Hemofiltration Solution
Na+
mmol/l
K+
mmol/l
Ca2+
mmol/l
Mg2+
mmol/l
Clmmol/l
Lactate
mmol/l
Glucose
g/l
Osmol.
mmol/l
135-150
0-4
1.6-2.0
0.50-0.75
100-113
35-45
0-2.0
285-312
Na+
mmol/l
K+
mmol/l
Ca2+
mmol/l
Mg2+
mmol/l
Clmmol/l
Bicarbon.
mmol/l
Glucose
g/l
Osmol.
mmol/l
140
0-4
1.5
0.5
109-113
35
1.0
290-300
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Human Albumine Electrolyte Solution
3%
3.5%
4%
4.5%
5%
5.5%
6%
Solution Solution Solution Solution Solution Solution Solution
HF-Solution (ml)
850
825
800
775
750
725
700
Human Albumine 20% (ml)
150
175
200
225
250
275
300
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Albumine Solution
HF Solution
Albumine
i.g. 2 Liters 4%-Solution = 400 ml Albumine 20% + 1600 ml HF Solution
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Exchange Volume
Plasma Volume ½ - 2 PV
Ratio
1:1
Therapy Time 1 – 3 h
acute: 1x day for 3 days lang, then every 2 days
Frequency
chronic: 1-4 monthly
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Dilution Kinetics
0
10
20
Reduct ion %
30
40
50
60
70
80
90
100
PV
Reduction %
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0
0
1/3
2/3
28
49
1
1 1/3
1 2/3
74
81
63
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86
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Intracellular Space = 40%
Extracellular Space = 20%
Interstitial Space = 16%
Intravascular Space = 4%
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Distribution Volume
Plasma Component Molekular Weight
Dalton
Intrav. Distribution Half Life Time
%
Days
Normal value
g/l
Albumine
69 000
40
19
35-50
IgG
150 000
50
20-23
8-18
IgA
160 000
50
5-6
0.9-4.5
IgM
900 000
80
5-6
0.6-2.8
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Complications
technical
medical
Access Problems
Hypotension
Plasma Filter Clotting
Allergy
Blood Leak
Fever
Hemolysis
Hypocalcemia
Arrhythmia
Edema
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Indications
Dessease
ThromboticThrombocytopenic
Purpura (TTP)
Hyperviscosity
Syndrome
Cryoglobulinemia
Goodpasture
Syndrome
Myasthenia gravis
Guillain-BarréSyndrome
Systemic Lupus
Erythematodes (SLE)
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thrombocytopenia, hemolytic anemie, neurologic symptoms. Substitution of FFP is
therapeutic desired.
High blood viscosity i.g. in plasmocytoma, M. Waldenström. Neurologic and hematologic
disturbances, organ damage.
Immunglobulin complexis which precipitate in coldness. Skin bleeding closed to fingers
and toes, articulation pain, glomerulonephritis.
Rapid progressive glomerulonephritis and lungs bleeding. Prognostic important early
indication to plasmapheresis in combination with Immunsuppressive therapy.
IgG-Autoantibodies against Acetylcholin rezeptors of skeletal muscles. Neuro-muscular
symptoms. Myasthenic crises with respiratory paralysis.
Acute inflammatory attack of myelin sheat in peripheral nerves and spinal ganglions
through IgG-Antibodies and immuno-complexes. Ascending paralysis of extremities and
trunk up to respiratory paralysis.
Autoimmuno desease of skin and vessels with deposition of immuno-complexes composed
by DNA and DNA-Antibodies.
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Remind
1. Plasmapheresis is often a symptomatic
therapy
2. Plasmapheresis can cause a „ReboundEffect“ by resynthesis and
redistribution of pathogens
3. Therefore plasmapheresis is regulary
accompanied by an immunosuppressive or cytostatic therapy
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Cascade Filtration
Heater
PV
PPL
BLD
Heparin
V
V
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Cascade Filter
SAC
Plasma Filter
SAD
PA
Advantages
Disadvantages
not too expensive
bride spectrum of
indication
semi-selective
complex
mechanism
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Cascade Filtration (Dead–End-Procedure)
Heater
PV
PPL
BLD
Heparin
V
V
Cascade Filter
SAC
Plasma Filter
SAD
PA
Retinate Pump
Retinate Bag
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Cascade Filtration (Recirculation-Procedure)
Heater
PV
PPL
BLD
Heparin
V
V
Cascade Filter
SAC
Plasma Filter
SAD
PA
Recirculation Pump
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Thermofiltration
PV
PPL
BLD
SAC
V
Cascade Filter
Heparin
V
Plasma Filter
SAD
Heater
PA
Retinate Pump
Retinate Bag
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PAP – Plasmaadsorption „single column“
Heater
PV
PPL
BLD
Heparin
V
V
PA
Particle Filter
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Advantages
Disadvantages
selective
chronic
application
expensive
complex
mechanism
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Plasma Adsorber
SAC
Plasma Filter
SAD
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PAP – Plasmaadsorption „double column“
Heater
PV
PPL
Regeneration
Solution
BLD
SAC
Heparin
V
V
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Plasma Filter
SAD
PA
Plasma
Adsorber
Advantages
Disadvantages
selective
chronic
application
expensive
complex
mechanism
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Particle Filter
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