Predictability and efficacy of therapeutic plasma exchange for hypertriglyceridemia induced acute pancreatitis.

BACKGROUND: Hypertriglyceridemia induced acute pancreatitis is associated with more severe clinical course than acute pancreatitis caused by other etiologies. Therapeutic plasma exchange (TPE) is a potential treatment for patients with severe hypertriglyceridemia induced acute pancreatitis due to its rapid effect in lowering triglycerides (TG) levels and reducing inflammatory cytokines. However, clinical data regarding the effectiveness and safety of TPE is limited. METHODS: We retrospectively reviewed eight cases of hypertriglyceridemia induced acute pancreatitis and treated with TPE. Patients' demographic data, personal history, clinical course, laboratory results, apheresis data and clinical outcome were collected and analyzed. RESULTS: At initial presentation, the average TG levels for the eight patients was 3381.6 mg/dl (SD: 1491.6 mg/dl). Twelve procedures were performed on the eight patients in the study, and TG levels decreased by an average of 2673.2 mg/dl (SD: 2306.3 mg/dl) with a corresponding average reduction rate of 60.3 % (SD:21.1 %), ranging from 14.6%-84.9%. A 60 % or greater reduction was achieved in 66.7 % of all the procedures; however, the degree of reduction for each procedure was not predictable, even among repeat procedures on the same patient. CONCLUSIONS: Our study indicates that TPE is an effective and safe treatment option for patients with hypertriglyceridemia induced acute pancreatitis. However, due to the unpredictability of TG removal, repeat procedures may be necessary for some patients.

Solving the calcium gluconate shortage in real-time: Mistakes made and lessons learned.

PURPOSE: During a national shortage of calcium gluconate, we switched to calcium chloride for routine supplementation for peripheral blood stem cell (PBSC) collections. Subsequently, we analyzed the postprocedure ionized calcium level, as we aimed for an equivalent result compared to before the shortage. METHODS: Pharmacy representatives helped us to find an "equivalent" substitute for calcium gluconate at 46.5 mEq in 500 mL normal saline, infused at 100 mL/hour. After instituting a presumably comparable protocol using calcium chloride (40.8 mEq in 250 mL normal saline at a rate of 100 mL/hour), we reviewed ionized calcium results post-PBSC procedures to compare with those obtained with calcium gluconate. Having noticed a difference in the mean values, we adjusted the rate of calcium chloride to reach our desired outcome. RESULTS: Twenty-seven procedures were analyzed on 15 unique patients. We used the Spectra OPTIA with a whole blood: anticoagulant ratio of 13:1. Ionized calcium levels post-PBSC collection with the first calcium chloride protocol were significantly higher (P = 0.003) in nine patients treated. Subsequently, we decreased the calcium chloride infusion rate to 75 mL/hour and achieved similar mean levels to calcium gluconate (P = 0.382). CONCLUSION: Changes in replacement fluids for apheresis procedures can be complex, particularly when dealing with electrolytes that could be clinically significant at critically high or low levels. Once we recognized the need to take into account the amount of elemental calcium infused, we achieved the desired postprocedure ionized calcium results. This study can serve as a lesson for future shortages of infusions used during apheresis procedures.