Therapeutic Plasma Exchange in Tandem With Other Types of Extracorporeal Circuits: The Experience of a Pediatric Center and a Review of Other Pediatric Center Reports

Therapeutic plasma exchange (TPE) concurrently performed in critically ill pediatric patients with other extracorporeal circuits is a complex process. We sought to characterize tandem procedures, including patient demographics, primary diagnosis, American Society for Apheresis (ASFA) category indications, survival at 24 h and 30 days after completion, blood product utilization, and complications. A retrospective analysis of medical records was performed. Data were collected from July 2014 to January 2021 with institutional review board approval. Patients' demographics, blood product utilization, and adverse events data were collected. In addition, we performed a literature review to identify studies in the pediatric population that were similar in design to our study. Fifty patients underwent 262 procedures. The median age was 9 years, and median weight was 21 kg (42% of patients weighed less than 10 kg). The most frequent indications for plasma exchange included sepsis with multiorgan failure (11 patients) and multiorgan failure (9 patients). ASFA indication category III was the most common (42 patients), followed by uncategorized indications (6 patients). The most common adverse events were hypocalcemia, occurring in 120 (45%) procedures, hypotension in 25 (9.5%) procedures, and circuit clotting in 12 (4.5%) procedures. Citrate, heparin, and bivalirudin were used as anticoagulants. Thirty-nine (78%) patients survived 24 h, and 26 (52%) patients were alive 30 days after completion of tandem procedures. Despite the high level of complexity, tandem procedures can be performed efficiently and safely in critically ill children.