A 33-year-old woman came to the emergency department with asthenia, a history of unknown allergies, cutaneous lupus with malar erythema untreated for 8 years and under follow-up by rheumatology. Hashimoto's thyroiditis. Appendectomy. Ex-smoker for 7 years. Non-drinker. No toxic habits, except for quinine drinks (tonic). Episodes of anaemia after 2 births. Caesarean section and tubal ligation in the 3rd.
Current illness:
Consultation for intense asthenia and presyncope (of one week's evolution), making it difficult to ambulate, together with anorexia without weight loss. Menstruation very long-lasting (8 days) and abundant. No melenic stools, pale skin and mucous membranes. Epistaxis and gingivorrhagia.
Laboratory tests showed anaemia with 6.7 g/dl haemoglobin, thrombopenia with platelets of 6,000/mm3. LDH 1696 IU/l. Blood smear with presence of schistocytes. Other tests were normal.
Diagnosis: According to the clinical and laboratory data, the patient presented a compatible picture of TTP in the context of SLE.
On admission, a red blood cell concentrate and a platelet concentrate were transfused. One hour after transfusing the platelets, the patient began with a picture of global aphasia and deviation of the oral commissure to the left with no other neurological focality. Subsequently, she speaks with normal speech without obvious focality.
Given the added neurological symptom, the patient was admitted to haematology for further investigation.
As the patient presented thrombotic microangiopathy and seizures, the department requested plasmapheresis. Due to the clinical worsening of the patient, she was admitted to the ICU.
Plasmapheresis session plan:
The exchange volume should be between 1-1.5 times the plasma volume.
Treatment will be prolonged until 48 hours after response is achieved.
The patient weighs 75 kg, and according to the ratio tables, a total of 3,500 cc. of volume to be reinfused corresponds to her, so the following is programmed: 1,750 cc. of fresh plasma + 350 cc. of 20% human albumin + 1,400 cc. of Dianeal® 1.36% peritoneal dialysis solution.
Incidence of the sessions:
For the performance of the 1st plasmapheresis in ICU, an attempt was made to implant a catheter in the right jugular vein, but due to its difficulty and excessive bleeding, a double-lumen catheter was placed in the left femoral vein.
The monitor used for the technique was a PRISMA CRRT-TPE (Hospal®), with PTE-2000 filter.
The heparin dose was 15-5-5-5-5 mgr, the duration of the sessions was about 210 minutes, with an average infusion of 980 ml/h, blood flows between 120-140 ml/min and pressures of (BP. - 85 to -170 mmHg, and PV of 70 to 90 mmHg, maintaining a MTP between 25-55 mmHg).
The patient in the ICU presented a poor general condition (sedated), with the constants maintained. A total of 17 sessions were performed.
Incidence of the same:
She was very agitated during the 1st session.
In the 5th and 6th sessions she suffered hypotension and major convulsions, which subsided with diazepam and physiological saline, ending the treatment.
On the 16th there was an increase in TMP to 55 mm Hg with 50 minutes to go, ending the session.
In the 17th, there was a failure of the air test with 90 minutes to go, so the SET had to be changed.
The rest of the sessions were carried out without problems, being well tolerated by the patient.

