368 Successful Use of Plasmapheresis for Hyperbilirubinemia in a Premature Newborn While on Extracorporeal Membrane Oxygenation

Abstract

AJCP / Meeting AbstrActs oxyhemoglobin to methemoglobin. We present a case of severe methemoglobinemia that resolved rapidly with red blood cell exchange (RBCX). The patient is a 57-year-old African-American woman with stage IV rectal adenocarcinoma, hepatitis C, arthritis, and bipolar disorder who was admitted to the hospital with a partial small bowel obstruction, for which she was treated conservatively. On hospital day five, the patient developed acute confusion and diaphoresis, and her oxygen saturation was noted to be 73%-75%. ABG was drawn, the blood was noted to be chocolate brown, and the methemoglobin level was too high to be quantitated (on three separate co-oximeters). The patient admitted to going through almost two bottles of HurriCaine spray (benzocaine) that morning for her sore throat. Methylene blue was considered for treatment, but the patient was on three different selective serotonin reuptake inhibitors at the time and there was concern for the precipitation of serotonin syndrome. Ascorbic acid was also considered, but the hospital did not have sufficient quantities on hand. The decision was made to proceed with RBCX. Using the Spectra Optia Apheresis system (Terumo BCT, Lakewood, CO), a 2.0 RBC volume RCBX was completed, using nine units of leukocyte-reduced type A positive packed red blood cells. Rinseback was not done. After the 108-minute uncomplicated procedure, the patient's methemoglobin level was 5.8%, and she subjectively felt much better and no longer had signs of cyanosis. Her O 2 saturation was 97% on 2L nasal cannula, and the methemoglobin level was 1.7% 11.5 hours after the RBCX. Fewer than 10 cases of RBCX for methemoglobinemia have been published. Objectives: A premature baby girl with a complicated hospital course developed RSV pneumonitis at 2 months of age for which she was placed on extracorporeal membrane oxygenation (ECMO). In spite of earlier phototherapy, bilirubin was steadily increasing and reached 50.4 mg/dL with concern for bilirubin induced neurologic dysfunction. Exchange transfusion was not recommended due to patient instability and risk of significant deterioration while on ECMO. Plasma exchange (PLEX), although not a recognized as a category treatment option for hyperbilirubinemia by the American Society for Apheresis (ASFA), was suggested as an alternative management option. We present a case of successful management of hyperbilirubinemia by PLEX in a premature baby while on ECMO. Methods: PLEX was done via connection with the ECMO circuit. Parameters were appropriately adjusted for the small body weight and ECMO circuit. For the procedure we used all fresh frozen plasma with plasma volume exchange between 1.0 and 1.3. We also primed the apheresis machine with packed red blood cells to minimize volume loss in tubing systems. Results: A total of three procedures were done daily and resulted in rapid improvement and stabilizing of bilirubin level. The procedure was very effective and well tolerated. Despite stabilizing the bilirubin level, the patient ultimate...

Therapeutic Plasma Exchange (TPE) for Liver Transplant Associated-Thrombotic Microangiopathy (TA-TMA) in a 5 Month Old Infant

“…TPE in neonates can be challenging due to their low weight and less plasma volume. Belousova et al [5] reported a case in which TPE was performed for a 3.4 kg premature baby and concluded that use of TPE should be considered in babies for such cases who are not candidates for standard treatment options. Nishi et al [6] studied the effect of TPE in 18 such cases and concluded that survival of LDLT recipients with lateonset TMA treated with TPE was poor.…”