title: Continuous infusion of calcium gluconate in 5% albumin is safe and prevents most hypocalcemic reactions during therapeutic plasma exchange.
abstract: While therapeutic plasma exchanges (TPEs) performed with 5% albumin are considered safe, concerns regarding venous access and hypocalcemic toxicity remain. We reviewed the frequency of complications during TPEs performed with 5% albumin supplemented with calcium gluconate and potassium chloride for a 5 year period in our institution. Eighty-four adult patients (46 males and 38 females) underwent 581 plasma exchanges during the study period. The most common indications were myasthenia gravis (37%), acute inflammatory demyelinating polyradiculoneuropathy (31%), and chronic inflammatory demyelinating polyneuropathy (13%). All procedures used 2.2% ACD-A delivered at a calculated average rate of 0.26 mg/kg/min, which led to a mean dose of citrate per TPE of 2.18 +/- 0.48 g or 27.8 +/- 5.24 mg/kg of body weight. Venous access difficulties occurred in 85 procedures (14.6%), but most TPEs were completed successfully. Hypotension and citrate toxicity were seen in <5% of the TPEs and were mostly reversible. Only 17 exchanges (3%) had to be aborted because of the loss of venous access (n = 9), hypocalcemic toxicity (n = 3), hypotension (n = 2), panic attacks (n = 2), and one atypical reaction due to the interaction with an angiotensin converting enzyme inhibitor. Comparison between pre- and post-TPE potassium levels showed a statistically significant mean decrease of 7%, from 4.1 mequiv/l to 3.8 mequiv/l (P < 0.0001). We attribute the low rate of hypocalcemia to our practice of adding calcium and potassium to the replacement fluid and suggest that this method could become standard of care.
authors.affiliation: Department of Pathology, Division of Laboratory Medicine, University of Alabama at Birmingham, Birmingham, Alabama 35249, USA.
authors.forename: Suthida
authors.initials: S
authors.lastname: Kankirawatana
authors.forename: Shu T
authors.initials: ST
authors.lastname: Huang
authors.forename: Marisa B
authors.initials: MB
authors.lastname: Marques
mesh_terms: D000328:Adult; D000418:Albumins / Q000008:administration & dosage; D002125:Calcium Gluconate / Q000008:administration & dosage*; D002704:Chlorates / Q000008:administration & dosage; D005260:Female; D020275:Guillain-Barre Syndrome / Q000628:therapy; D006801:Humans; D006996:Hypocalcemia / Q000188:drug therapy / Q000209:etiology / Q000517:prevention & control*; D007262:Infusions, Intravenous; D008297:Male; D009157:Myasthenia Gravis / Q000628:therapy; D010951:Plasma Exchange / Q000009:adverse effects*; D020277:Polyradiculoneuropathy, Chronic Inflammatory Demyelinating / Q000628:therapy; D016896:Treatment Outcome
chemical_list: D000418:Albumins; D002704:Chlorates; D002125:Calcium Gluconate; C022842:chloric acid