In this video:
Marlene Healy, RN and Ashley Hallice demonstrate therapeutic plasma exchange (TPE) for TTP on the Spectra Optia, from setup and priming with saline and citrate to entering patient data and staging approximately 3,600 mL of plasma.
Marlene Healy is an RN at Beth Israel Deaconess Medical Center in Boston, who works in Apheresis Services. She serves as the Clinical Resource for the Apheresis unit. She provides direct care to all patients requiring therapeutic apheresis including plasma exchanges, cell collections, cell exchanges.
Ashley Hallice is a senior nursing major at Fairfield University in Connecticut, where she will graduate in May of 2026. She is from Arlington, Massachusetts, and graduated high school at Buckingham Browne and Nichols in 2022. This summer, she had the role of Student Research Intern at BIDMC where she was part of the therapeutic apheresis and stem cell collection research team.
Audio Transcript:
ASHLEY: Hi, my name’s Ashley and today Marlene is going to be teaching us about therapeutic plasma exchange for TTP. So, Marlene, could you walk us through how the procedure is done using the Spectra Optia machine?
MARLENE: Sure. So this is the Spectra Optia here. I have turned it on and I’ve loaded the software. When we turn on the machine, it does a whole bunch of different procedures, but I’ve loaded plasma exchange, and I’ve primed the machine. So turning it on, loading the software, priming, it takes about 15 or 20 minutes to really get ready. So I’ve done that so far. It is primed with saline and citrate. Citrate is an anticoagulant to keep the blood flowing, keep things from clotting. And at this point I’ve come to the screen where I need to put my patient information in. So I just chose one of our last TTP patients and put the information in. So it was a female who was 5’4”, 205 pounds. Her hematocrit was 20 on this day. And so it tells me her total blood volume is 4,789 mL and then it asks me what kind of fluid I’m going to use. I’m going to use plasma 100% and then I’m gonna go to my run screen and it’s gonna tell me I need 3,600 mL of plasma from the blood bank. So I would have ordered that before this moment and they would have it set up in coolers for me to go pick up. So at this point, I’ve done all the pieces that I need to. I would wheel my machine to the patient’s bedside and get ready to start. I’d also have my coolers of plasma that come on ice from the blood bank in the room ready to go. So I’d be ready to get started next.
MARLENE: Do you wanna hop in bed and be my patient? And I’ll talk you through how we actually hook up and get started.
ASHLEY: Sure.
MARLENE: All right. Get comfortable. I’ll get you a nice warm blanket. So, I would have a warmer on here. The plasma comes cold from the blood bank, so we heat it up but people do tend to get cold during this procedure. At this point I would put a blood pressure cuff on you, do a full set of vital signs, check your temperature. Because you are alert oriented, you can tell me how you’re feeling. I will monitor your calcium just by talking to you today. So you would have a central line for this procedure. So when the doctors say that we’re worried about TTP, we need to start plasma exchange, they put a central line in and it’s typically in the right side of your neck. So at this point in the procedure, I would hook up to your line, I put some gloves on. I would pull out the heparin in your line and then I would hook up. So your line would have, it’s one line with two pigtails. This is the draw line. I would draw your blood out with this one and this is the return line. So I’d hook up both of them to your line, secure it. Get ready to turn the calcium on. I would do a quick time out with you. You would tell me your name and your birthday, I’d look at your bracelet, make sure I have the right person. We’re doing the right procedure. And then we spike the bags of plasma, which you can’t see here, but they would be right here, the two bags of plasma. And we’d be ready to start. So at this point I would hit start, run and the machine would start. So it would take your blood out of here. Right here where this orange line is where the citrate, the anticoagulant gets added to your blood. It comes in here. There’s a centrifuge here. Actually can show you since it’s not running. So this is a centrifuge. It spins your blood and it separates, it skims out the plasma. The plasma will go up here in the discard bag. So at the end this bag will be full, like three or four liters of plasma. And it gives everything else back to you. So it takes the blood, sends it in here, spins it, siphons off the plasma and gives everything else back to you in the return line. And this is where we also add the calcium. So on this line we’re adding the citrate, lowering your calcium. And in this line, right before it’s given back to you is where I add the calcium. And then throughout the procedure I’ll ask you how you’re feeling. Are you having any numbness or tingling in your lips or your fingertips? I’ll notice if you’re shivering, that could be from two things. It could be because the warmer needs to be making it warmer or because your calcium level’s dropping a little bit. I’ll be monitoring your vital signs and if you notice any changes, you tell me and I will either increase your calcium or slow the machine down, whatever we need to do. Also monitoring you for any response to the plasma. So anytime we give plasma from other patients, like from the blood bank, there’s a chance that you could have a reaction to it. You could get hives. That’s the most common thing, anywhere from hives to a full blown reaction. I would be monitoring you continuously for that. If that were to happen, we would pause the machine, we’d treat it with rescue meds, wait till it resolves and then let the doctors know and then continue on when you resolve those symptoms.
ASHLEY: Great. Awesome. What would you need in terms of venous access to treat a patient with suspected TTP for plasma exchange?
MARLENE: So if you wanted me to do it peripherally, I would need to, one, come take a look at your veins. So I would put a tourniquet on your arm, both arms. I would look at both of them. In order to do it peripherally, I need really big veins on both arms. Most of these people that come in with TTP, their platelets are in the single digits or low double digits. So whenever you’re gonna poke somebody’s arms, you want to be really, really confident that you’re gonna be successful. And veins don’t like this. So what we would normally use if we were going to do it peripherally would be a fistula needle. So this is what a fistula needle looks like. So this is a very large bore IV that has a hole on the top and the bottom. And that would go in one of your veins to be the draw line. And then I would, so that would be this line, and then I would return your blood into another large IV on the other arm. So in order for me to do it peripherally, you need to have multiple large veins on both arms. So if I said I would do it peripherally and then your vein didn’t like it, I might have to switch. I might have to put another IV here and another draw line there. And somebody with TTP is gonna bleed for a long time after every stick. So it is unlikely we would be successful. It’s unlikely that you would have enough veins to tolerate this. Now remember these patients are all anemic when they come in. So their blood count’s already low and they typically don’t have big juicy veins. So it would be very difficult to be successful with a peripheral plasma exchange.
ASHLEY: Okay, great. These patients usually present to the emergency room. What critical piece of information do you need from the emergency room doctor or nurse?
MARLENE: So before I come in I’m going to try to find out the patient’s height and weight and their hematocrit so that I can order their proper amount of plasma from the blood bank. It takes a while to get everything ready. So if a patient comes to the emergency room that’s never been here before, we don’t know their type, their blood type, the blood bank demands that we draw two type and screens separately, type and screen them. It takes 45 minutes just for that. And then I need to order the plasma. It takes another hour for the plasma. So I’m gonna try to get as much information before I even leave my home or leave my unit to go to the patient, height and weight so I know how much, and hematocrit, so I know how much plasma to order. Have they had their type and screen drawn? Have they had a second one drawn? And as well as how stable is the patient, how alert are they, are they confused? Like if I need to prepare to do calcium levels instead of someone who can talk to me, that type of stuff.
ASHLEY: Great. How long does it usually take to thaw a sufficient volume of FFP?
MARLENE: About an hour. If the blood bank’s not busy. So if they’re in an emergency or it’s a busy day, it’s gonna take longer.
ASHLEY: Great. Good to know. And during the procedure, what kind of support do you need from your apheresis doctor or ED or ICU nurse?
MARLENE: So things that could happen are reaction to the plasma is number one. So if you were to develop hives or some type of reaction, I would stop the machine and treat you and let my attending know, my apheresis doctor as well as the ICU doctor know that you were having a reaction, because some of them are mild, but it could continue. Some people drop their blood pressure and they need blood pressure support from the ICU team. So I can give a bolus of fluid but you might also need some blood pressure support to tolerate this.
ASHLEY: Great. And you mentioned hypocalcemia before, but how do you monitor for hypocalcemia during this procedure and how is it a different approach for a patient who’s awake and alert versus obtunded?
MARLENE: So someone who’s awake and alert can tell me how they’re feeling. If you start to notice any numbness or tingling in your lips or your fingers, that’s the first symptom. If you have some shivering or if I notice, you know, if you’re starting to feel nauseous then I need to give you more calcium. And so we would dial up the calcium and see after about 15 or 20 minutes if that feels better. So there’s not only citrate in the bag on the machine, but there’s also citrate in the plasma. So it’s not uncommon for people to feel that and we give them a little extra calcium and that resolves it. If you were not, if you were confused or intubated or not able to communicate with me, I would draw your blood mid procedure and get an objective data point from the lab how your calcium is. And if it’s normal, great, we continue as is. If it’s low, we increase the rate.
ASHLEY: Great. And what other monitoring is routine during plasma exchange for TTP?
MARLENE: So because we’re giving blood product the entire time, we’re doing full sets of vital signs about every six to ten minutes. We’re continuously monitoring your heart rate, your temperature, your blood pressure. I’m watching you to see if you’re having any hives. Typically you see them before you feel them. But yeah, so hemodynamically we’re monitoring you the entire time.
ASHLEY: Great. And what does priming the machine mean?
MARLENE: So sometimes people’s hematocrit is really, really low and maybe they’re tachycardic or they’re a little hypotensive and we’re concerned that pulling 200 cc out to send into the machine will be too much for the patient to tolerate. So what that means is that after we prime it with the liquid, with the saline and the citrate, we then get a bag of red blood cells from the blood bank and then backprime the blood into the machine so that when I hook up the return line, instead of giving you saline right away, it will give you blood from the blood bank. So that’s the prime so that when we start taking out, we’re also giving back blood so that however your hemodynamic status is at that point, it should not be adversely affected.
ASHLEY: Great. Thank you so much. That’s all the questions I have for you today.
MARLENE: Okay.
ASHLEY: Thank you for watching and if you want to learn more, you can find more information on thebloodproject.com.