TPE Education and Training, Therapeutic plasma exchange, Clinical Pathology - Full Vignette with Ext

Описание: A 56-year-old man undergoing urgent therapeutic plasma exchange for antibody-mediated neurologic symptoms develops circumoral tingling, metallic taste, and finger paresthesias within 20 minutes of the session, which progress to carpopedal spasm and hypotension. Telemetry reveals sinus rhythm with a transiently prolonged QTc. What clinical features and procedural factors should guide your immediate response to these acute symptoms during therapeutic plasma exchange, and how can you ensure patient safety while continuing the session?

VIDEO INFO
Category: TPE Education and Training, Therapeutic plasma exchange, Clinical Pathology
Difficulty: Moderate - Intermediate level - Requires solid foundational knowledge
Question Type: Complications
Case Type: Emergency - Emergency scenario requiring urgent decision-making

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QUESTION
A 56-year-old man in the ED starts urgent therapeutic plasma exchange for an antibody-mediated neurologic flare. He presented with palpitations from narrow-complex supraventricular tachycardia that converted to sinus rhythm (88 bpm) after a vagal maneuver by EMS. Pre-procedure vitals are pulse 88 bpm regular, respirations 16/min, blood pressure 128/74 mm Hg, and oxygen saturation 96% on room air. A temporary non-tunneled internal jugular catheter was placed aseptically....

OPTIONS
A. Pause the exchange; give calcium gluconate 2 g IV in 50-100 mL over about 10 minutes via a secure line; start a continuous calcium gluconate infusion at ~1.6 g/h with ionized calcium and ECG monitoring; then resume TPE at a lower citrate-to-blood ratio after symptoms abate.
B. Pause briefly; give calcium gluconate 1 g IV over 5 minutes; restart TPE at the same citrate rate using oral calcium only afterward; check ionized calcium every 30 minutes.
C. Administer 10 mL of 10% calcium chloride rapidly through a peripheral IV while continuing the exchange uninterrupted to avoid circuit clotting.
D. Treat as an anaphylactic reaction to albumin with intramuscular epinephrine, switch to plasma replacement immediately, and abort the session to arrange airway control.

CORRECT ANSWER
A. Pause the exchange; give calcium gluconate 2 g IV in 50-100 mL over about 10 minutes via a secure line; start a continuous calcium gluconate infusion at ~1.6 g/h with ionized calcium and ECG monitoring; then resume TPE at a lower citrate-to-blood ratio after symptoms abate.

EXPLANATION
This patient s circumoral tingling, metallic taste, carpopedal spasm, hypotension, QTc prolongation, and low ionized calcium during an ACD-A-anticoagulated exchange are classic for citrate toxicity. The immediate response is to pause the exchange, give an IV calcium gluconate bolus, initiate a continuous calcium infusion around 1.6 g/h with ionized-calcium and ECG monitoring, and then resume at a reduced citrate-to-blood ratio. This approach treats the complication, stabilizes physiology, and allows safe continuation of the session-aligning with operational practice and optimization data.

Brief pauses, small boluses without infusion, continuing the exchange during treatment, or mislabeling the event as anaphylaxis are unsafe. Rapid peripheral calcium chloride can extravasate and injure tissue; if calcium chloride is ever chosen for severe cases, central access and careful monitoring are required. Anaphylaxis would typically feature urticaria, wheeze, or airway compromise, which are not present....


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