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Role of therapeutic apheresis and phlebotomy techniques in anaesthesia and critical care.

ABSTRACT: Therapeutic transfusion techniques such as apheresis and phlebotomy are frequently used in intensive care units. Use of the apheresis technique for the treatment of various diseases in critically ill patients is growing day by day. There are increasing evidences for using apheresis as a primary therapy or as an adjunct to other therapies for various diseases such as thrombotic thrombocytopenic purpura, haemolytic uremic syndrome, drug toxicities, autoimmune disease, sepsis and fulminant hepatic failure. Apheresis is an invasive procedure. It has significant physiologic consequences, so the care of these patients requires continuous supervision. Phlebotomy is performed as an intervention for some disease management. Its use is nowadays restricted to conditions such as polycythaemia, haemochromatosis and porphyria cutanea tarda. In this review, we have looked at various indications, procedure and complications of apheresis and phlebotomy in critical care unit.

SUBMITTER: Bose N

PROVIDER: S-EPMC4260318 | biostudies-other | 2014 Sep

REPOSITORIES: biostudies-other

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Role of therapeutic apheresis and phlebotomy techniques in anaesthesia and critical care.

Bose Neeta N Kanzariya Hitendra H

Indian journal of anaesthesia 20140901 5

Therapeutic transfusion techniques such as apheresis and phlebotomy are frequently used in intensive care units. Use of the apheresis technique for the treatment of various diseases in critically ill patients is growing day by day. There are increasing evidences for using apheresis as a primary therapy or as an adjunct to other therapies for various diseases such as thrombotic thrombocytopenic purpura, haemolytic uremic syndrome, drug toxicities, autoimmune disease, sepsis and fulminant hepatic ...[more]

PMID: 25535434

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Project description:BackgroundTherapeutic plasma exchange (TPE) is a well-known apheresis technology since many years and is available worldwide. Myasthenia gravis is one of the first neurological diseases successfully treated with TPE. TPE is also frequently applied in acute inflammatory demyelinating polyradiculoneuropathy (Guillain-Barré syndrome). Both neurological disorders are immunologically mediated and might cause life-threatening symptoms in patients.SummaryThere is a large body of evidence from many randomized controlled trials (RCTs) that the application of TPE in myasthenia gravis crisis or in acute Guillain-Barré syndrome is effective and safe. Thus, TPE is recommended as first-line therapy with a grade 1A recommendation during the critical course of these neurological diseases. Even chronic inflammatory demyelinating polyneuropathies characterized by complement-fixing autoantibodies to myelin are successfully treated with TPE. The plasma exchange reduces inflammatory cytokines, complements activating antibodies, and leads to an improvement of neurological symptoms. TPE is no standalone treatment but often combined with immunosuppressive therapy. Recent studies (clinical trials, retrospective analysis, meta-analysis, and systematic reviews) evaluate special apheresis technology (i.e., immunoadsorption [IA], small volume plasma exchange), compare different treatments of these neuropathies, or report on the therapy of rare immune-mediated neuropathies in case reports.Key messagesTA is a well-established treatment and is safe in acute progressive neuropathies (myasthenia gravis, Guillain-Barré syndrome) with an immune etiology. TPE has been applied for decades and thus has the best evidence so far. The indication for IA depends on the availability of that technology and the evidence by RCTs in special neurological diseases. The treatment with TA should improve the clinical outcome of patients, reducing acute or chronic (chronic inflammatory demyelinating polyneuropathies) neurological symptoms. The informed consent of the patient should carefully weight risks and benefits of the apheresis treatment and consider alternative therapies.

Project description:BackgroundPoint-of-care ultrasound (POCUS) has become an essential tool for anaesthesia and critical care physicians and dedicated training is mandatory. This survey describes the current state of Italian residency training programs through the comparison of residents' and directors' perspective.MethodsObservational prospective cross-sectional study: 12-question national e-survey sent to Italian directors of anaesthesia and critical care residency programs (N = 40) and residents (N = 3000). Questions focused on POCUS teaching (vascular access, transthoracic echocardiography, focused assessment for trauma, transcranial Doppler, regional anaesthesia, lung and diaphragm ultrasound), organization (dedicated hours, teaching tools, mentors), perceived adequacy/importance of the training and limiting factors.ResultsFive hundred seventy-one residents and 22 directors completed the survey. Bedside teaching (59.4-93.2%) and classroom lessons (29.7-54.4%) were the most frequent teaching tools. Directors reported higher participation in research projects (p < 0.05 for all techniques but focused assessment for trauma) and simulation (p < 0.05 for all techniques but transthoracic echocardiography). Use of online teaching was limited (< 10%); however, 87.4% of residents used additional web-based tools. Consultants were the most frequent mentors, with different perspectives between residents (72.0%) and directors (95.5%; p = 0.013). Residents reported self-training more frequently (48.5 vs. 9.1%; p < 0.001). Evaluation was mainly performed at the bedside; a certification was not available in most cases (< 10%). Most residents perceived POCUS techniques as extremely important. Residents underestimated the relevance given by directors to ultrasound skills in their evaluation and the minimal number of exams required to achieve basic competency. Overall, the training was considered adequate for vascular access only (62.2%). Directors mainly agreed on the need of ultrasound teaching improvement in all fields. Main limitations were the absence of a standardized curriculum for residents and limited mentors' time/expertise for directors.ConclusionPOCUS education is present in Italian anaesthesia and critical care residency programs, although with potential for improvement. Significant discrepancies between residents' and directors' perspectives were identified.

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Role of therapeutic apheresis and phlebotomy techniques in anaesthesia and critical care.

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Role of therapeutic apheresis and phlebotomy techniques in anaesthesia and critical care.

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