The nature and amount of replacement fluid is important. Although specific guidelines have not been developed, except for thrombotic thrombocytopenic purpura-hemolytic uremic syndrome in which fresh frozen plasma is the replacement fluid of choice, general guidelines are useful and can be modified to suit specific clinical situations. Colloid such as albumin must often be administered to maintain hemodynamic stability and to assure a steady colloid osmotic pressure.
Drawbacks of fresh frozen plasma include a small but significant risk of transmission of hepatitis B, hepatitis C, and HIV. Furthermore, administration of fresh frozen plasma may be replenishing the very factor(s) one is endeavoring to remove. A more economical approach is to replace the first third of the removed volume with crystalloid and the last two-thirds with albumin since most of the albumin initially infused will be exchanged. This replacement technique results in a postpheresis serum albumin concentration in the normal range, but can lead to a coagulopathy because albumin solution lacks coagulation factors. Pre-exchange monitoring of coagulation (international normalization ratio and partial thromboplastin time) is recommended, and infusion of fresh frozen plasma as part of the replacement solution may be necessary.
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