A 33-year-old woman presented to the emergency department with asthenia, a history of unknown allergies, cutaneous lupus with malar erythema without treatment for 8 years and under rheumatology follow-up.
Very common:
Cholecystectomy.
Ex-smoker for 7 years.
Don't drink.
Non-toxic habits, except for drinks with quinine (tonic).
Anaemia episodes after 2 births
Cesarean section and ligation of dyes in the third.
Current illness:
She consulted due to intense asthenia and presyncopes one week later, which made it difficult to walk, along with anorexia without weight loss.
Very long lasting menstruation (8 days) and abundant.
Not melanic stools, cutaneous dryness and mucosa
Epistaxis and gingivorragia
The analytical highlights anemia with 6.7 gr / dl hemoglobin, thrombopenia with platelets of 6,000 / mm3.
LDH 1696 IU/l.
Blood smear with presence of schistoocytes
Normal test results.
Diagnosis: According to clinical and laboratory data, the patient presents a compatible picture of TTP in the context of SLE.
Upon admission, a concentrate of platelets is transfused.
One hour after the platelet count passed, the patient began with a picture of global aphasia and deviation of the oral commissure to the left without any other neurological focus.
Later he speaks with normal language without evident focus.
Due to the added neurological symptom, the patient was admitted to hospital for study.
When presenting the patient with thrombotic microangiopathy and seizures, plasmapheresis is requested from this service.
Due to the clinical worsening of the patient, she was admitted to the ICU.
Plasmapheresis session plan:
The replacement volume should be 1-1.5 times the plasma volume.
Treatment should be continued for up to 48 h after the response has been obtained.
The patient weighs 75 kgr., and according to relationship tables, it corresponds to a total of 3,500 cc. of volume to be reinfused, for which dialysis is programmed: 1,400 cc. peritoneal dialysis 20%.
Impact of meetings:
To perform the first plasmapheresis in the ICU, an attempt is made to implant a right jugular catheter, but due to its difficulty and excessive bleeding, a double-lumen catheter is placed in the left femoral artery.
The monitor used for the technique was a PRISMA CRRT-TPE (Hospal®), with PTE-2000 filter.
The dose of heparin was 15-5-5 mgr, with the duration of the sessions of approximately 210 minutes, with an average infusion of 980 ml/h, blood flows between 120-140 ml/min and 85 mmHg PPV-155.y
The patient in the ICU has a poor general condition (sedated), with maintained constants.
A total of 17 sessions were carried out.
Impact of the measures
The first session was very agitated.
In the 5th and 6th she suffers hypotension and major convulsions, with diazepam and physiological saline, finishing the treatment.
In the 16th there is an increase in MPT up to 55 mm Hg, missing 50 minutes, ending the session.
In the 17th, there was a failure of the air test when 90 minutes were missing, so the ETT had to be changed.
The rest of the sessions were carried out without problems, being well received by the patient.
