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What is Plasmapheresis (or plasma exchange)? Plasmapheresis involves using a machine to separate the plasma from the rest of the blood cells. When people donate their plasma, plasmapheresis is used to obtain their plasma. Plasmapheresis can also be performed to remove a patient's plasma and replace it with a replacement fluid. This procedure is technically called therapeutic plasma exchange (TPE) or plasma exchange. Healthcare providers often use the terms plasmapheresis, TPE, and plasma exchange interchangeably to refer to the process of removing and replacing a patient's plasma. What Diseases are Treated with Plasma Exchange? Plasma exchange treats a wide variety of autoimmune, neurologic, and blood conditions, including, but not limited to: Chronic Inflammatory Demyelinating polyneuropathy (CIDP) Guillain-Barre Syndrome Multiple Sclerosis Myasthenia Gravis Neuromyelitis Optica Thrombotic Thrombocytopenic Purpura (TTP) Transplant organ rejection In each of the above conditions, the body produces antibodies that cause harm to other cells in the body. Antibodies are typically made to attack foreign cells, but in medical conditions such as those above, the antibodies attack healthy cells and cause damage. Because antibodies are primarily contained in plasma, plasma exchange can remove these harmful antibodies and replace the patient's plasma with replacement fluid. Typically, the replacement fluid is fresh frozen plasma (FFP) or a protein-rich fluid called albumin. What Takes Place During a Plasma Exchange Treatment? A trained healthcare worker, usually a nurse, will set up the plasma exchange machine. A hemodialysis catheter is typically used for access in patients new to plasma exchange. Some long-term plasma exchange patients have arteriovenous fistulas, and the nurse will insert needles into the fistula for access. Once the treatment has started, it will typically last 1-3 hours. During treatment, the machine removes the patient's plasma while replacement fluid and the remainder of the patient's blood are returned to them. At the end of treatment, the patient's plasma is discarded. What are the Benefits Of Plasma Exchange? Plasma exchange is generally safe. Depending on the condition being treated, plasma exchange can provide symptom relief in a few days or weeks. Plasma exchange is used to improve symptoms, but it is not considered a cure for the underlying medical condition. What are the Potential Risks of Plasma Exchange? Low blood pressure is the most common side effect of plasma exchange, which can cause dizziness or headaches. The plasmapheresis nurse will monitor blood pressure closely and give fluid boluses if needed. Other potential risks include: Transfusion reaction If FFP is used as the replacement fluid, the patient will receive pre-transfusion medications such as acetaminophen, diphenhydramine, and hydrocortisone to prevent a transfusion reaction. However, transfusion reactions can occasionally occur, and the procedure may need to be paused or stopped. Low calcium The patient receives a sodium citrate infusion during the procedure to prevent blood clotting. Sodium citrate can reduce calcium levels, and a calcium infusion is given during the treatment to counteract this. The plasmapheresis nurse can give additional intravenous calcium if the patient experiences signs of hypocalcemia, such as muscle cramping or tingling. Infection Accessing the hemodialysis catheter or arteriovenous fistula inherently carries a risk of infection. What Should You Know if Your Patient is Scheduled for Plasma Exchange while in the Hospital? The plasmapheresis nurse may need your help with the following: Obtaining the prescribed medications from the pharmacy. If albumin is the prescribed replacement fluid, the plasmapheresis nurse will give the patient intravenous albumin, sodium citrate, and calcium gluconate infusions. If FFP is the replacement fluid, the plasmapheresis nurse will give pre-transfusion medications in addition to intravenous sodium citrate and calcium gluconate infusions. Dual blood verification for FFP. The plasmapheresis nurse will need your help performing the hospital's dual blood verification process for administering FFP. The volume of plasma exchanged is typically 4 L (or approximately 16 units of FFP), but it can be more than that depending on the patient's total blood volume. The plasmapheresis nurse will set up the plasma exchange machine and monitor the patient during the treatment. They will notify you if there are any critical changes in the patient's status. How Do Patients Feel after Plasma Exchange? Many patients report feeling tired after the treatment, and this is due to the fluid shifts that happen during treatment. Symptoms typically resolve within a few hours. How are Plasma Exchange and Hemodialysis Different? Plasma exchange and hemodialysis both filter substances from the blood. Plasma exchange removes antibodies from the blood, while hemodialysis removes harmful waste products, such as creatinine and urea, from the blood when the kidneys are not working correctly. References/Resources Plasmapheresis and Plasma Exchange: Cleveland Clinic Plasmapheresis: UC San Diego Health Plasmapheresis: What to Expect: Healthline
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X-rays, CTs, MRIs, and ultrasounds are all used to capture images of the internal structure of the body. As a nurse, it is common for patients to ask why they are receiving one type of imaging test over another. In order to educate patients, it is important to understand how these tests differ in terms of cost, time, level of detail, and risk. X-rays An X-ray is the quickest, least expensive, and most common type of imaging. X-rays send electromagnetic waves, or radiation, through the body. Dense areas, such as bones, block the radiation and appear white. X-rays are ideal for capturing problems with the bones, such as fractures, dislocations, or narrowed joint spaces (osteoarthritis). X-rays can also capture images of tissue consolidation, such as pneumonia. However, X-rays are ineffective at capturing images of soft tissues, such as tendons and ligaments. Even if a provider suspects a soft tissue injury, an X-ray might be ordered first to ensure that a fracture is not also present. The radiation from a single X-ray is not considered dangerous for adults, but X-rays are generally avoided in pregnant patients due to the risk to the fetus. CT Scans A CT scan, or Computed Tomography Scan, also uses radiation, similar to an X-ray. However, it produces much more sophisticated and detailed images with 360-degree views of internal structures. CT scans take longer than X-rays but are still very quick, often taking several minutes or less. In emergencies, this makes CTs preferable to MRIs because MRIs take more time. CTs can identify blood clots, organ injuries, and more subtle bone injuries. They are more expensive than X-rays and not always available at more rural hospitals. Because they use radiation, CT scans can still pose a risk to the fetus of pregnant patients. MRIs Magnetic Resonance Imaging, or MRI, does not use radiation. Instead, a powerful magnet sends radiofrequency pulses through the body. Highly detailed images of the body's soft tissues, brain, nerves, and blood vessels are produced. MRIs are generally used to diagnose musculoskeletal injuries such as herniated discs and torn ligaments or cartilage. When an MRI is performed, the patient lies on a table that slides into a cylinder-shaped MRI scanner. The machine produces a loud noise, and the total time needed is much longer than an X-ray or CT scan. For example, a knee or brain MRI can take 30-60 minutes. If contrast dye is used for more detailed images, even more time is typically needed. Because the MRI scanner uses large magnets, a patient cannot have an MRI if there are metal clips or metal implants in their body. They must undergo an extensive screening questionnaire to determine if they are eligible for an MRI. If they are not eligible for an MRI, they will typically have a CT instead. MRIs are more expensive than X-rays and CT scans and may also not be available at more rural hospitals. Ultrasounds Similar to MRIs, ultrasounds do not use radiation. They use high-frequency sound waves to produce images of structures in the body. Ultrasounds help evaluate real-time flow or movement in the body, such as blood flow through the heart or the movement of a fetus during pregnancy. They are not effective in examining areas with air or bone, such as the lungs or head. Depending on the part of the body that is being examined, an ultrasound may take 30-60 minutes. A trained technician, or sonographer, uses a small plastic device called a transducer and holds it to the skin near the area that is being examined. There are no known risks associated with ultrasounds, and price varies depending on body location, but is typically more than an X-ray and less or equal to a CT scan. Conclusion As a nurse, you have the opportunity to educate your patient on why a provider may have chosen to order one specific imaging test over another. Ultimately if you have questions, you can consult the ordering provider. They may have already consulted with the radiologist to determine the best imaging test for your patient's condition. References/Resources Health: 6 Key Medical Scans and What They Should Cost Healthline: How Long Does an MRI Take? Johns Hopkins Medicine: CT Scan Versus MRI Versus X-Ray: What Type of Imaging Do I Need? Mayo Clinic: Ultrasound North Central Surgical Center: What's the difference between an X-ray, CT scan and MRI?
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Hemodialysis treatments clean the blood and remove extra fluid from the body when the kidneys are not functioning well. As an ICU nurse, you will likely care for patients who are new to hemodialysis or have been receiving it already prior to this hospital admission. On the day that dialysis is scheduled, "dialysis day", the acute dialysis nurse will arrive and provide the hemodialysis treatment to your shared patient. Treatments typically last 3-4 hours. The treatment is delivered either through a hemodialysis catheter or by inserting needles into an arteriovenous fistula or graft. Here are several tips for how to provide the best care for your patient before, during, and after the hemodialysis treatment. Before Dialysis Scheduling: Are any other procedures scheduled today? If your patient is scheduled for any other procedures or imaging in addition to dialysis, it is helpful to call the on-call acute dialysis nurse to help coordinate the timing of their treatment. It is especially important to keep in mind the type of procedure or imaging that is scheduled. For example, if a patient is scheduled for a CT scan with contrast, they will typically need to have dialysis after the CT scan in order to clean the contrast from their blood because the kidneys are unable to clean the blood. If you are uncertain whether dialysis should be scheduled before or after a procedure, you can call the on-call dialysis nurse to discuss this. If they have questions, they will call the nephrologist. Medications Are there scheduled antibiotics or blood pressure medications? It is important to review a patient's medications before they receive dialysis. Because dialysis cleans the blood, it can also clean out, or "dialyze out,” any medications that the patient takes before or during the treatment. There are many medications that are dialyzed, but there are generally two main medications to consider holding before dialysis: antibiotics and antihypertensive medications. Antibiotics: Most antibiotics are dialyzed out of the blood and are not recommended to be given right before or during treatment. Antihypertensive medications: Most blood pressure medications are also dialyzed out of the blood. The second reason why antihypertensives are often held before and during dialysis is that the patient's blood pressure must be high enough to tolerate fluid being removed from the blood. *If you are considering holding a scheduled medication before or during dialysis, you will need to receive an order from the prescribing provider in order to hold the medication. During Dialysis Monitor blood pressure Hemodialysis treatments can cause hypotension due to fluid removal. If the patient's blood pressure is low, the acute dialysis nurse can adjust how much fluid is being removed. Sometimes fluid removal is such a priority that the nephrologist and ICU doctors prefer to start a pressor medication in order to increase the patient's blood pressure and enable fluid to be removed. If a pressor is started, you will be responsible for titrating the medication and will be working closely with the dialysis nurse as they perform the dialysis treatment. Assist with patient comfort The hemodialysis treatment itself does not usually cause pain, but it can be uncomfortable for the patient to lay in bed for 3-4 hours. As the ICU nurse, you can help by repositioning the patient and by giving scheduled or as-needed pain medications if indicated. After Dialysis Care for the patient's access If the patient has an arteriovenous fistula or graft for dialysis, a bandage will be placed on the sites where the needles were removed. This bandage should be removed after 4-6 hours to prevent infection. If the patient has a hemodialysis catheter, the dialysis nurse will instill either heparin or citrate into the catheter to prevent clots from forming inside and place caps on the end of the catheter. The dressing on the catheter site will typically be changed by the dialysis nurses, but you can notify them if it looks like the dressing is soiled and needs to be changed. Receive report When dialysis is completed, the acute dialysis nurse will report to you how much fluid was removed during the treatment and the final blood pressure reading. Anticipate patient fatigue Hemodialysis is a necessary, life-saving treatment for patients with kidney failure, but it can cause extreme fatigue. Many patients report feeling tired after dialysis day. Your patients need several hours of rest before they have enough energy to participate in other activities, such as physical therapy. References/Resources Be Aware – Medications NOT to Take Before Dialysis Guidelines for Managing Hospitalized Hemodialysis Patients
