American Society for Apheresis

Five Things Physicians and Patients Should Question

April 25, 2018

  1. 1

    Do not place a central venous catheter if peripheral vein access is a safe and effective option.

    For most adult patients and donors, peripheral venous access is the safest, quickest and most easily achievable route for performing a limited number of apheresis procedures. Avoiding a central venous catheter reduces the risk of harm.

  2. 2

    Do not routinely use plasma as replacement fluid for therapeutic plasma exchange unless there is a clear indication to replete a plasma component.

    Plasma is a limited resource with added concern for potential transmission of infectious agents and transfusion reactions. Albumin is an effective replacement fluid for therapeutic plasma exchange and is a safe alternative to plasma when a pathogenic protein or solute is removed without the need to replete any plasma component.

  3. 3

    Do not continue simple transfusions in patients with stroke from sickle cell disease who have iron overload, if red blood cell exchange is available.

    Stroke is a common cause of serious morbidity in children and mortality in adults with sickle cell disease. Exchange transfusion is a more effective method than simple transfusions to prevent both recurrent strokes and the complications of iron overload.

  4. 4

    Do not routinely monitor coagulation tests during a course of therapeutic plasma exchange, unless the procedure is performed daily.

    For most indications, therapeutic plasma exchange can be performed on an intermittent schedule using clotting factor deficient replacement fluid without the need for routine monitoring of the patient’s hemostasis status. Daily treatments significantly reduce clotting factors; therefore, coagulation testing may be appropriate.

  5. 5

    Do not routinely continue a series of apheresis procedures without a predefined objective goal, and stop the series if it is apparent that the goal cannot be reached or adverse effects outweigh potential benefits.

    Apheresis procedures are performed sequentially until a predefined objective goal is reached. When the goal is either achieved or is determined to be unreachable the burden and potential adverse effects of performing additional procedures outweighs the potential benefits.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physicians.

The American Society for Apheresis (ASFA) is the premier organization of physicians, scientists, and allied health professionals whose mission is to advance apheresis medicine for patients, donors, and practitioners through education, evidence-based practice, research, and advocacy. ASFA creates guidelines for the appropriate use of apheresis techniques, provides education for apheresis practitioners, and promotes research in apheresis medicine, as well as provides information for patients regarding apheresis procedures. For more information about ASFA, please visit www.apheresis.org.

How This List Was Created

Recommendations were drafted by the ASFA Choosing Wisely Working Group, which consisted of nine society members from the major committees of ASFA. Guiding principles included a focus on frequent practices that should be questioned, are supported by evidence, free from harm, truly necessary and not duplicative of other procedures or tests. Nine draft statements were reviewed, rated and ranked, using a nominal group scoring approach, by 41 physician and allied health members representing a diverse cross-section of apheresis medicine practitioners and content experts. The top five draft recommendations, chosen by cumulative rating and ranking scores, were further refined before submission to the Board of Directors and the ABIM Foundation for external review. Recommendations were incorporated by the ASFA Choosing Wisely Working Group into the final list, which was ultimately approved by the Board of Directors for publication and distribution.

ASFA Choosing Wisely Working Group – (Committee representation)

Michael Linenberger, MD (Chair) – University of Washington/Fred Hutchinson Cancer Research Center
Joseph Schwartz, MD, MPH (Research Committee) – Columbia University Irving Medical Center
Sarita Joshi, MD (Communications Committee) – Cleveland Clinic Foundation
Meghan Delaney, DO, MPH (Clinical Applications Committee) – Children’s National Health System
Christine Fernandez, RN, MSN/Ed, OCN (Allied Health Committee) – Consultant
Laura Connelly-Smith, MBBCh, DM (JCA Special Issue Committee) – University of Washington/Fred Hutchinson Cancer Research Center
Vishesh Chhibber, MD (Education Committee) – Northwell Health
Yvette Tanhehco, MD, PhD, MS (Apheresis Physicians Committee) – Columbia University Irving Medical Center
Quentin Eichbaum, MD, PhD, MPH (International Affairs Committee) – Vanderbilt University

Sources

  1. Putensen D, Leverett D, Patel B, Rivera J. Is peripheral access for apheresis procedures underutilized in clinical practice? – A single centre experience. J Clin Apher. 2017;32(6):553-59.

    O’Leary MF, Dunbar NM, Kim HC, Draper NL, Linenberger M, Schwartz J, Miller Y, Murtaugh A, West FB, Fernando LP, Park YA. Venous access for hematopoietic progenitor cell collection: An international survey by the ASFA HPC donor subcommittee. J Clin Apher. 2016;31(6):529-34.

    Foundation for the Accreditation of Cellular Therapy. FACT-JACIE International Standards for Hematopoietic Cellular Therapy Product Collection, Processing, and Administration, 6th edition. University of Nebraska Medical Center: FACT;2015.

  2. Schwartz J, Padmanabhan A, Aqui N, Balogun RA, Connelly-Smith L, Delaney M, Dunbar NM, Witt V, Wu Y, Shaz BH. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice-Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Seventh Special Issue. J Clin Apher. 2016;31(3):149-338.

    Yang L, Stanworth S, Hopewell S, et al. Is fresh-frozen plasma clinically effective? An update of a systematic review of randomized controlled trials. Transfusion. 2012;52(8):1673-86.

    Roback JD, Caldwell S, Carson J et al. Evidence-based practice guidelines for plasma transfusion. Transfusion. 2010;50(6):1227-39.

  3. Sarode R, Ballas SK, Garcia A, Kim HC, King K, Sachais B, Williams LA. Red blood cell exchange: 2015 American Society for Apheresis consensus conference on the management of patients with sickle cell disease. J Clin Apher. 2017;32(5):342-67.

    Howard J. Sickle cell disease: when and how to transfuse. Hematology Am Soc Hematol Educ Program. 2016;2016(1):625-31.

    National Heart, Lung, and Blood Institute. Evidence-Based Management of Sickle Cell Disease. Expert Panel Report, 2014.

  4. Weinstein R. Basic Principles of Therapeutic Blood Exchange. In: McLeod BC, Szczepiorkowski ZM, Weinstein R, Winters JL, eds. Apheresis: Principles and Practice, 3rd edition. Bethesda, MD: AABB Press, 2010:269-93.

    Tek I, Arslan, O, Arat M, Ozcan M, Akdag B, Ilhan O. Effects of replacement fluids on coagulation system used for therapeutic plasma exchange. Transfus Apher Sci. 2003;28(1):3-7.

    Zantek ND, Morgan S, Zantek PF, Mair DC, Bowman RJ, Aysola A. Effect of therapeutic plasma exchange on coagulation parameters in patients on warfarin. J Clin Apher. 2014;29(2):75-82.

  5. Schwartz J, Padmanabhan A, Aqui N, Balogun RA, Connelly-Smith L, Delaney M, Dunbar NM, Witt V, Wu Y, Shaz BH. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice-Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Seventh Special Issue. J Clin Apher. 2016;31(3):149-338.