Hemapheresis services for neonates

A colleague in Connecticut reports that their newborn specialty team in conjunction with their liver team has asked the hospital to provide various hemapheresis procedures for neonates. The inquiring colleague would like know if any other institutions provide hemapheresis services for neonates, either in-house or contracted, and if so, would those who are be willing to share their experiences, esp. regarding to the indications for neonatal hemapheresis and any special issues (medical and technical) relating to neonatal apheresis.

The following replies were submitted in response to the above:

ADDENDA March 19, 2009

1. The medical director of a contract hemapheresis service reports that they have not had a request for any hemapheresis procedure for a neonate from any of the hospitals that they cover. They assume that if a hemapheresis procedure is being performed for a neonate at one of their contracted hospitals, that either a manual exchange is being performed or the neonate is being transferred to a hospital specializing in neonatal hemapheresis. Currently, their experience/expertise is with children that weigh >18 kg and adults. However, they are looking for pediatric apheresis nurses that have experience with neonates and children <18 kg so that they can provide hemapheresis services for this select group of patients.
   
   
2. The medical director of a busy therapeutic apheresis unit in the northern portion of the US reports that in neonates, because of their small blood volume, difficulty in obtaining vascular access, and the large extracorporeal volume of the apheresis instrument, his service has not performed red cell exchanges or plasma exchanges using automated methods, though they have been requested. Instead, they have had the clinical service perform manual exchanges. It is the respondent's opinion that automated procedures in such small patients, given the need for intensive electrolyte monitoring of the patients (especially ionized calcium, potassium, and magnesium), difficulties with access, and the blood priming of the instrument, do not offer any benefit over manual exchanges. Having said the aforementioned, they have performed therapeutic leukocytapheresis on two occasions (one congenital leukemia and one patient with Downs syndrome and transient myeloproliferative disorder), one hematopoietic progenitor cell collection for an allogeneic transplant, and a handful of hematopoietic progenitor cell collections for autologous transplants. All of these procedures were well tolerated. Procedures were done in the pediatric intensive care unit. All required that the instruments be primed with red blood cells to compensate for the large extracorporeal volume of the instruments. All patients had temporary central venous catheters placed (usually femoral) for vascular access. All of the patients had their electrolytes monitored throughout (usually bedside POC instrument) and all received calcium supplementation. While he has not been involved in this personally, there are reports of the use plasma exchange in neonates receiving ABO incompatible cardiac transplants. Again, essentially a manual exchange is performed at the time the patient is placed on cardiac bypass. This indication was categorized as a category II indication for plasma exchange by the American Society for Apheresis (Szczepiorkowski ZM, Bandarenko N, Kim HC, et. al. Guidelines on the use of therapeutic apheresis in clinical practice - Evidence-based approach from the Clinical Applications Committee of the American Society for Apheresis. J Clin Apheresis 2007;22:106-175.) The reference for the article describing the use of plasma exchange in cardiac transplantation in neonates is West LJ, Pollock-Barziv SM, Dipchand AI, et. al. ABO-incompatible heart transplantation in infants. N Engl J Med 2001;344:793-800. Finally, the responding physician concludes saying that he cannot imagine a circumstance where other procedures such as therapeutic plateletapheresis, LDL apheresis, photopheresis, or immunoadsorption would be necessary in neonates. Therapeutic plateletapheresis could be performed if needed using precautions used for leukocytapheresis mentioned above. For the other mentioned procedures, the extracorporeal volumes of the available instruments would be too large and diseases requiring these treatments would not be seen in a neonate.

3. An assistant medical director at a community blood collection center/centralized transfusion service located on the Pacific Coast reports that they operate a mobile apheresis service that serves a Children's hospital. They very rarely get requests for neonatal apheresis because the patients are too small for the volume of distribution required by the instrumentation, and it is technically difficult to insert central venous access lines that are sufficiently large to withstand the necessary flow pressures of a hemapheresis procedure. Neonates in need of red cell exchanges usually have them done manually. Before attempting automated hemapheresis, neonates must meet the following requirements: a minumum of 7Fr catheter in place and a patient weight of >/=8 Kg. They have done procedures for a few children smaller than what is called for in the aforementioned guideline, but these patients were on ECMO and the hemapheresis procedures were piggybacked with the ECMO circuit (usually heart transplant recipients). The ECMO circuit makes the blood volume greater (essentially doubles it for a ~6 kg patient). By plugging into the ECMO circuit that already has very high flow rates, it also removes the small diameter catheter issue. When a small child undergoes therapeutic hemapheresis through ECMO, they can experience issues with calcium homeostasis and may need multiple calcium boluses in addition to a calcium drip. All patients <20kg require a blood prime as well.

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