University of Michigan Hospitals

Apheresis Service

Name:_____________________________________________________ Location: _______________________

CPI#:___________________________________ Age: __________________(M/F)___________________

House Officer (Name/pager): _________________________________________________________________

Attending (Name/pager) _____________________________________________________________________

Procedure Requested: ______________________________________________________________________

Reason/Recent PMH: _______________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Medical History: BP: _____________Pulse: _______________Height: _______________ Weight: ____________

Allergies: Hx_________________________________ Transfusion?/Rxn?:________________________________

Neuro: alert/cooperative _______________________________________________________________________

Cardiac: ___________________________________________________________________________________

Pulmonary: _________________________________________________________________________________

Renal: _____________________________________________________________________________________

Hematology: Bleeding risk with citrate/plt loss? ______________________________________________________

Venous Access (circle/see back): __________Peripheral __________Dialysis Catheter ________ A-V fistula (CRF)

Pertinent Laboratories:

ABO/Rh

CBC: Electrolytes: PT/PTT

Total Protein

Albumin

Ionized Ca++

Other (ex LDH): _________________________________________________________________________________

______________________________________________________________________________________________

Medications**: _________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

 

**STOPPED: ACE-Inhibitors (Lotensin/Benazepril, Capoten/Captopril, Vasotec/ Enalopril, Monopril/ Fosinopril, Zestril/Prinivil/Linsinopril, Accupril/Quinapril, Univasc/Moesipril, Altace/Ramipril, Movik/Trandolopril)

Diabetic, patient receiving insulin? eat prior to procedure? (risk for hypoglycemia)

Other: Hold next dose until after procedure, since these drugs may be removed with TPEX or may aggravate patient’s medical condition. For example, try holding antihypertensives since hypotension already risk of TPEX.

Protein-bound Drugs: Dilantin, Valproic Acid, Vincristine, Cisplatin, Digitoxin, Warfarin, Diuretics, Synthetic Penicillin, Oral hypoglycemics,

Immune-based Drugs: thymoglobulin, ATGAM, IVIgG, etc..

Pheresis Orders
Emergent (As Soon as Possible) Urgent (within 24 hours)
Acute TTP/HUS Recovering TTP/HUS
Symptomatic Hyperviscosity Acute Guillian-Barre Syndrome
Symptomatic Hyperleukocytosis (AML)

Asymptomatic Hyperviscosity

plasma viscosity >4 or IgM>3gm
   
   
   
   

 

Emergent (As Soon As Possible) Urgent (within 24 hours)

Acute TTP/HUS recovering TTP/HUS

Symptomatic Hyperviscosity Acute Guillain-Barre Syndrome

Symptomatic Hyperleukocytosis (AML) Asymptomatic Hyperviscosity

Thrombocytosis (>750K) with bleeding plasma viscosity>4 or IgM>3gm

Or thrombosis or platelets >1.5million Acute Vascular Rejection Kidney

Goodpastures with active pulmonary hemorrhage Bx + or PRA+ or crossmatch+

Acute Vascular Rejection Heart (biopsy +) FSGS post-kidney transplant

Venous Access

Peripheral Access: Central access Required

1. Patient alert, cooperative, adequate Poor venous access, intubated,

bilateral anticubital access (16 gauge needles) noncooperative, daily procedures

**placed by apheresis nurses NOT floor!! **Require: dialysis double lumen catheter

2. A-V fistula in chronic dialysis patient Sorenson or Quintan dialysis catheter

Therapeutic Apheresis/Cytopheresis

Indication: Replacement: Frequency Laboratories

TTP/HUS FFP/CPP q Day ABO type, pre-CBC, LDH,Bun/Cr

Acute rej. Liver 2 liters FFP q Day x 3 (Pre-HLA, ABO if indicated)*

Goodpastures with + albumin

Active hemorrhage 1 plasma vol q O Day Pre/post Fibr

TPEX + bleeding* Pre/post Fibr

Waldenstroms qODay x 3-6 Pre/Post Fibr,IgM,viscosity,TP,alb

FSGS 3 q wk x 9-10 Pre/Post Fibr

TPEX, elderly 100% albumin q O Day Pre/Post Fibr,TP,alb

TPEXw/¯ ¯ TP 1 plasma vol Pre/post Fibr, alb

(TPEX w/¯ ¯ Na+)* Pre/Post Fibr

MG,GBS,CIDP q O Day Pre/Post Fibr

Trnsplt Rejection qDx2,qoDx3 Pre/Post Fibr

Goodpastures saline/albumin q O Day (!) Pre/Post Fibr

Cryoglobulin 1 plasma vol 1-2x* Pre/Post Fibr, cryocrit

Multiple Myeloma q O D 1-2x Pre/Post Fibr, TP, alb, Quant. Ig

[G/A/M] & viscosity (if needed)

Sickle Cell* LP-RBC (Adsol)

Acute Chest 10-14 days old Current Type & Cross

Stroke Sickedex neg Once only Pre/Post CBC, ionized Ca++

Priapism Final Hct=30% Pre/Post Hgb electrophoresis

FCR=30% Post K+

Cytoreduction Pre/Post CBC (w diff-WBC)

AML/rare ALL* None Once Post WBC&diff –bag (WBC)

Thrombocytosis 2 blood vol Post Plt cnt-bag (Plt reduct)

Polycythemia

*call BB attending

 

Form HO2 Revision 1/2004