Effects of therapeutic plasma exchange on anticoagulants in patients receiving therapeutic anticoagulation: a systematic review

Hodulik, Kimberly L.; Root, Adam G.; Ledbetter, Leila; Onwuemene, Oluwatoyosi A.

doi:10.1111/trf.15191

Cited by 13 publications

(17 citation statements)

References 27 publications

(85 reference statements)

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“…Nevertheless, the risk of clinically significant bleeding with plasma may not be high: A meta-analysis of anticoagulated patients who underwent TPE did not appear to show significant increase in bleeding or thrombotic risk. 79 …”

Section: Safety Suggestions and Considerations For Use Of Tpementioning

confidence: 99%

Therapeutic Plasma Exchange: A potential Management Strategy for Critically Ill COVID-19 Patients

Tabibi

Conic

et al. 2020

J Intensive Care Med

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In the 5 months since initial reports of COVID-19 came to light, the death toll due to SARS-CoV-2 has rapidly increased. The morbidity and mortality of the infection varies based upon patient age, comorbid conditions, viral load, and the availability of effective treatments. Findings from limited autopsies, clinical observations, and laboratory data suggest that high cytokine levels and a procoagulant state can precipitate acute respiratory distress syndrome and multi-organ dysfunction syndrome in critically ill patients. To complicate matters, comorbidities may affect the response to medical treatments currently in use, all of which are still in trial phase. Therapeutic plasma exchange (TPE) merits consideration in the treatment of critically ill COVID-19 patients and is an avenue for clinical trials to pursue. If efficacious, faster recovery of patients may lead to shorter intensive care unit stays and less time on mechanical ventilation. Herein, we briefly discuss some of the various approaches currently being investigated for the treatment of SARS-CoV-2 with a focus on potential benefits of TPE for selected critically ill patients.

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Section: Safety Suggestions and Considerations For Use Of Tpementioning

confidence: 99%

Therapeutic Plasma Exchange: A potential Management Strategy for Critically Ill COVID-19 Patients

Tabibi

Conic

et al. 2020

J Intensive Care Med

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“…Monitoring the patient's haemostasis parameters especially if FFP and/or CCP are not used as replacement fluids can mitigate additional haemorrhagic and thrombotic risks. Finally, TPE influences coagulation parameters in patients receiving therapeutic anticoagulation; thus, anti-Xa levels may decrease while partial thromboplastin and prothrombin times may increase, which might lead to mild risks of bleeding or thrombosis [53].…”

Section: Resultsmentioning

confidence: 99%

Understanding the role of therapeutic plasma exchange in COVID‐19: preliminary guidance and practices

et al. 2021

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Background and objectives Cytokine release syndrome in COVID‐19 is due to a pathological inflammatory response of raised cytokines. Removal of these cytokines by therapeutic plasma exchange (TPE) prior to end‐organ damage may improve clinical outcomes. This manuscript is intended to serve as a preliminary guidance document for application of TPE in patients with severe COVID‐19. Material and methods The available literature pertaining to the role of TPE for treatment of COVID‐19 patients was reviewed to guide optimal management. It included indication, contraindication, optimal timing of initiation and termination of TPE, vascular access and anticoagulants, numbers and mode of procedures, outcome measures and adverse events. Results Out of a total of 78 articles, only 65 were directly related to the topic. From these 65, only 32 were acceptable as primary source, while 33 were used as supporting references. TPE in critically ill COVID‐19 patients may be classified under ASFA category III grade 2B. The early initiation of TPE for 1–1·5 patient’s plasma volume with fresh frozen plasma, or 4–5% albumin or COVID‐19 convalescent plasma as replacement fluids before multiorgan failure, has better chances of recovery. The number of procedures can vary from three to nine depending on patient response. Conclusion TPE in COVID‐19 patients may help by removing toxic cytokines, viral particles and/or by correcting coagulopathy or restoring endothelial membrane. Severity score (SOFA & APACHE II) and cytokine levels (IL‐6, C‐reactive protein) can be used to execute TPE therapy and to monitor response in COVID‐19 patients.

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“…This possibility is suggested by our study finding that bleeding rates were highest in non‐TPE treated cases with a thrombotic complication, followed by TPE‐treated cases with a thrombotic complication, thus increasing the concern for bleeding due to therapeutic anticoagulation. Therapeutic anticoagulation is a known bleeding risk factor 30,31 . In a study of 85 patients undergoing 255 TPE procedures comparing procedural anticoagulation using systemic heparin, regional citrate, or no anticoagulation, 11 development of bleeding complications were reported in the heparin group alone (11.7% vs. 0% vs. 0%).…”

Section: Discussionmentioning

confidence: 99%

Bleeding outcomes of inpatients receiving therapeutic plasma exchange: A propensity‐matched analysis of the National Inpatient Sample

et al. 2021

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Background Although therapeutic plasma exchange (TPE) is associated with hemostatic abnormalities, its impact on bleeding outcomes is unknown. Therefore, the main study objective was to determine bleeding outcomes of inpatients treated with TPE. Study Design and Methods In a cross‐sectional analysis of the National Inpatient Sample (NIS), discharges were identified with 10 common TPE‐treated conditions. A 1:3 propensity‐matched analysis of TPE‐ to non‐TPE‐treated discharges was performed. The primary outcome was major bleeding and secondary outcomes were packed red blood cell (PRBC) transfusion, mortality, disposition, hospital length of stay (LOS), and charges. Multivariable regression analyses were used to examine the association between TPE and study outcomes. Results The study population was 15,964 discharges, of which 3991 were TPE‐ treated. The prevalence of major bleeding was low (5.4%). When compared to non‐TPE discharges, TPE had a significant and positive association with major bleeding (OR = 1.37, 95% CI: 1.16–1.63, p = .0003). TPE was also associated with PRBC transfusion (OR = 1.66, 95% CI: 1.42–1.94, p < .0001), in‐hospital mortality (OR = 1.45, 95% CI: 1.10–1.90, p = .0008), hospital length of stay (12.45 [95% CI: 11.95–12.97] vs. 7.38 [95% CI: 7.12–7.65] days, p < .0001) and total charges, ($125,123 [95% CI: $119,220–$131,317] vs. $61,953 [95% CI: $59,391–$64,625], p < .0001), and disposition to non‐self‐care (OR = 1.29, 95% CI: 1.19–1.39, p < .0001). Discussion The use of TPE in the inpatient setting is positively associated with bleeding; however, with low prevalence. Future studies should address risk factors that predispose patients to TPE‐associated bleeding.

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Effects of therapeutic plasma exchange on anticoagulants in patients receiving therapeutic anticoagulation: a systematic review

Cited by 13 publications

References 27 publications

Therapeutic Plasma Exchange: A potential Management Strategy for Critically Ill COVID-19 Patients

Therapeutic Plasma Exchange: A potential Management Strategy for Critically Ill COVID-19 Patients

Understanding the role of therapeutic plasma exchange in COVID‐19: preliminary guidance and practices

Bleeding outcomes of inpatients receiving therapeutic plasma exchange: A propensity‐matched analysis of the National Inpatient Sample

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