Belousova Tatiana, Tong Yi, Bai Yu, Klein Kimberly, Tint Hlaing, Castillo Brian
Department of Pathology and Laboratory Medicine, UTHealth, The University of Texas in Houston, McGovern Medical School, Houston, Texas.
J Clin Apher. 2019 Oct;34(5):615-622. doi: 10.1002/jca.21708. Epub 2019 May 6.
We report a case of a premature newborn girl with a hospital course complicated by suspected respiratory syncytial virus pneumonitis for which she was placed on veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Despite phototherapy, her total bilirubin steadily increased to a peak of 50.4 mg/dL with concern for bilirubin-induced neurologic dysfunction, kernicterus.
Therapeutic plasma exchange (TPE) was achieved via connection with the VA-ECMO circuit. Our institution's standard apheresis procedural parameters were adjusted to account for the small body weight and thus the low blood volume of the neonate while on ECMO. These included calculating the total blood volume to include the patient as well as the ECMO circuit, priming of the apheresis instrument with packed red blood cells to limit the extracorporeal volume, using a lower inlet flow rate, the connection setup of the inlet and return line, and monitoring of ionized calcium and anticoagulation throughout the procedure.
A total of three TPE procedures were performed over three consecutive days. This resulted in improvement and stabilization of the patient's bilirubin.
This case emphasizes that TPE is feasible on a neonate with a suboptimal body weight and thus a low blood volume due to the increased blood volume provided while on ECMO. In the absence of ECMO, whole blood manual exchange transfusion is recommended as TPE would be unsafe due to significant extracorporeal volume that would occur during TPE in a pediatric patient with low body weight.
我们报告了一例早产女婴的病例，其住院过程因疑似呼吸道合胞病毒肺炎而复杂化，为此她接受了静脉-动脉体外膜肺氧合（VA-ECMO）治疗。尽管进行了光疗，但她的总胆红素仍稳步上升至50.4mg/dL的峰值，令人担心胆红素诱导的神经功能障碍，即核黄疸。
通过与VA-ECMO回路连接实现治疗性血浆置换（TPE）。我们机构调整了标准的血液分离程序参数，以考虑到新生儿体重小以及在接受ECMO治疗时血容量低的情况。这些参数包括计算总血容量，将患者以及ECMO回路纳入其中；用浓缩红细胞预充血液分离仪器以限制体外循环血量；使用较低的进血流速；进液管和回液管的连接设置；以及在整个过程中监测离子钙和抗凝情况。
连续三天共进行了三次TPE程序。这使患者的胆红素得到改善并稳定下来。
该病例强调，对于体重不理想且因接受ECMO治疗时血容量增加而血容量低的新生儿，TPE是可行的。在没有ECMO的情况下，建议进行全血手工换血，因为对于体重低的儿科患者，TPE期间会出现大量体外循环血量，TPE不安全。
