Plasma Exchange Service at NHNN

TPE is a common treatment that is known to be safe and well-tolerated. It is used to remove a patient’s plasma when it contains potentially harmful autoimmune antibodies.   

During the procedure, a small amount of your blood is drawn by the machine (Less than a cup at any one time), and it separates the plasma from the rest of the blood by spinning it through the centrifuge (see pictures). While the plasma is being removed it is simultaneously being replaced with a solution (Human albumin solution and/or Octaplas) made from donated human blood.

1. Plasma 
2. Packed red blood cells 
3. Buffy coat 
4. Platelet 
5. Lymphocyte 
6. Granulocyte 
7. Mononcyte

Plasma is the straw-coloured liquid part of the blood that carries red blood cells and white blood cells through the body. It contains minerals, proteins, clotting factors (agents which help the blood to clot) and antibodies. 

Some diseases, including several neurological conditions (diseases that affect the nervous system) can also cause the production of antibodies. These antibodies are produced by a fault in the body’s immune system and can cause damage to the nerves and muscles. Plasma exchange works by removing these damaging antibodies.

Some neurological conditions only improve after a course of plasma exchange; more than one treatment. Your neurologist will discuss this with you. 

Location: TPE is carried out in a dedicated room with specialist equipment. You will be collected by a hospital porter, from your ward or hotel each day of your treatment and return once the treatment is completed for the day.   

Team: Only nurses who have had training and are competent in plasma exchange will perform this procedure.

How does TPE take place – venous access?

There is an access line and a return line, this is the tubing that connects the patient to the Optia Plasma Exchange machine.   

TPE takes place through venous access, this may be with a...  

• Peripheral cannula - A small ‘tube’ that is placed in the vein. If you are having your TPE peripherally, the cannula will be inserted in your arm by a trained nurse or doctor daily and prior to treatment in the TPE room.  We require one cannula for access and one for return. The cannula (tube) is connected to a line, which in turn is connected to the TPE machine.   
• Port-a-cath - A line that we use for regular long-term patients; it is a more permanent line. The port is a small medical device inserted under the skin of the chest with a catheter, (a silicone tube) that is connected to a large vein in the neck. Having a port-a-cath avoids the need for frequent peripheral cannula or Vas-cath insertion. If you have a Port-a-cath this will be accessed daily by the TPE nurse and needles removed prior to return to ward or hotel. 
• Vas-Cath - is bigger than a cannula and is usually inserted into the large vein in the groin or neck; this remains for the duration of your treatment. If you require a Vas-Cath an anaesthetic doctor will consent you for this and insert the Vas-cath. The Vas-Cath will stay in for the length of your treatment and be removed after the last treatment. If you have a Vas-Cath, you are not permitted to leave the hospital without a nurse escort due to risk of dislodgement and bleeding. 

All treatments and procedures have risks and we will explain all the risks and benefits of plasma exchange to you. 

The most common risks include: 

Infection: There is a very small risk of infection from the intravenous line.  

Bleeding: There is a small risk of bleeding from a venous line after removal. If you have a Vas Cath, we will  ask you to stay resting in bed for several hours after the Vas Cath has been removed on the final day and to go home the day after  you have completed your course of TPE. Bleeding can be mild or more severe.  If severe you may require a blood transfusion. Severe bleeds requiring intervention are very rare. 

Damage to the blood vessel: In a very small number of cases, insertion of the line can cause damage to the blood vessel.  

Blood clots: There is a risk of blood clots. To reduce the risk of blood clots, we may give a preventative blood thinning injection when undergoing plasma exchange.

During plasma exchange some patients may experience the following side effects: 

• low blood pressure 
• feeling cold 
• nausea 
• tingling in the hands and feet
• electrolyte changes. 

These do not occur in every patient. Please tell us immediately if you experience any of these symptoms. We may prescribe calcium, magnesium and phosphate replacement tablets or infusions before, during and after the TPE, or we may need to slow down or stop the TPE.  

It is very common to feel tired during plasma exchange and for a few days after. We use a blood warmer to warm the replacement fluid prior to you receiving it.

There is no special preparation for undergoing TPE.  

TPE can be done as an inpatient, or as an outpatient. This will be depending on the type of access we need to use and why there has been a request for you to have TPE. 

Admission: You will receive a letter telling you which admission pathway you are on and a booklet about the hospital. If you do not receive a booklet, please contact the admissions officer.   

In-patient: If you are to receive your treatment as an in-patient you will be admitted to hospital the day before your first treatment and discharged from hospital either the day of or the day after your last treatment, again this will depend on what type of access line you have and how you have tolerated your TPE. You will be scheduled daily for your treatment and will be given the time in advance. You can expect to be in hospital for five to seven days.   
Outpatient: If you are having your treatment as an outpatient, you may be staying in a nearby hotel or coming from home. If you have a port-a-cath or are attending as an outpatient, you will be scheduled a specific time daily and will be given the time in advance. 

Duration: TPE is usually undertaken every day up to  five days, this will depend on your individualised treatment plan. The treatment takes approximately three hours each day, this will depend on the volume of plasma that is replaced and how well you tolerate the treatment. 

Diet: You will be able to eat and drink normally during treatment. Please make sure you have breakfast daily prior to starting your TPE. 

Hydration: We ask that you stay well hydrated, let us know if you need assistance with this.

Telephone clinic: The senior nurse for TPE will be in touch with you via telephone to answer any questions and provide additional information prior to your admission.   

Mobilisation:  You can mobilise as usual during your treatment unless otherwise instructed, eg. if you have a Vas-Cath, on day of removal you will be required to stay flat for a short period, if no bleeding, you can mobilise with caution, you will be given instructions on the day. 

Coagulation: If you are on coagulation therapy (blood thinners), please let us know, we will then discuss with haematology.  

Medications: Some medication may be affected by TPE; ask your doctor about any impact to medication you are taking.

On arrival to the ‘PLEX Suite’ the nurse performing the TPE will connect you to a heart monitor, they will take your blood pressure & temperature. The TPE nurse will take a sample of blood daily pre-TPE for monitoring purposes.  

The nurse will then connect the access line and return line from the plasma exchange machine to the venous access device (cannula, vas-cath, port-a-cath). During the procedure the nurse will monitor you closely and take regular blood pressure recordings. 

You will be able to eat and drink normally. You will need to remain in bed/on the chair whilst the plasma exchange is in progress. Please go to the toilet prior to coming for your TPE.   

Due to limited space we ask that you do not have any visitors during your treatment. We will be able to let you know in advance if your treatment will be in the morning or afternoon so that  you can let family and friends know when you will be available.

We want to involve you in all decisions about your care and treatment. If you decide to go ahead with this procedure, by law we must ask for your consent. Your neurology doctor will talk through the process of plasma exchange with you. The process of consent confirms that you agree to have the procedure or treatment and understand what it involves. 

Staff will explain all the risks, benefits, and alternatives before they ask you to sign a consent form where required. If you are unsure about any aspect of your proposed treatment, please don’t hesitate to speak to a senior member of staff again. 

If you require a Vas Cath the anaesthetic doctor who puts in the vas-cath will discuss this procedure with you and consent this separately.

You will receive written information in the form of a discharge summary at the completion of your treatment, explaining the nature of the TPE completed and the vascular access used. A copy of this will be sent to your GP.

It is important you can recognise and report any complications to your medical team / nurses / GP or A&E such as:  

• Signs of exit site infection (warmth, inflammation, redness, swelling, exudate, pus, spots, cellulitis).  
• Dressing reaction – redness, itching or swelling. 
• Blood clot – pain, swelling, heat of the shoulder, neck, leg or arm, chest pain or shortness of breath. 

If you have had a peripheral line and it has now been removed the instructions are as follows:

• If you notice any redness, pain at the wound site, bleeding, or oozing contact your GP as you may have a local site infection. 
• Any bleeding or oozing, apply pressure and new dressing, if this does not resolve contact your GP or local A&E. 

If you have a Vortex Port-a-cath: 

• A clean dry waterproof dressing is applied over the needle sites after each day TPE, do not remove this dressing. On discharge the dressing can be removed after 24 hours. Do not wash vigorously over site. 
• You will need to have four weekly flushes of the port arranged, arranged through your GP. 
• If signs of redness, pain, or swelling contact your GP or attend your local A&E. 

If you had a Vas-Cath inserted for your treatment and it has now been removed the instructions are as follows: 

• Dressing to stay intact and undisturbed for at least 24 hours. If removed earlier do not be concerned, unless oozing, bleeding, or swelling. See you pharmacist if additional dressings needed. 
• Monitor the site for minimum of five days. 
• You should not take baths in the first 48 hours after removal however showering is permitted. 
• Any signs of bleeding from the site, apply pressure and call for help, this can be a medical emergency. 
• Any swelling, soreness, redness, oozing at the site, please seek urgent medical attention from your GP or local A&E. 
• If you have any leg swelling, leg pain or shortness of breath, this can be a medical emergency, call 111, 999, or attend your local A&E.

The Plasma Exchange service in this hospital is supervised by a Neurology Consultant and senior Nurse. If you have any questions about plasma exchange prior to admission, please speak with your Neurology team. The specialist nurse trained in Plasma Exchange can provide further information when they meet you on your admission. If you have a question about the date for your admission to hospital, please contact the Admissions Office via switchboard on 0845 155 5000 or 020 3456 7890.