This patient is a 48 year-old African-American female with a history of recurrent stroke in the setting of TTP. She was admitted for her third time ischemic stroke on 10/31/10. We are consulted by the neurology team for her management.

Past Medical History:

The patient is currently aphasic. Most of the history was obtained from her family members and/or chart review.

The patient experienced stroke in 2002 and 2004 during the plasmapheresis treatment of her underlying illness of TTP. No apheresis record regarding to her plasmapheresis has been found from our service.

Per hematology team, the patient might have had hypercoagulation and autoimmune disorder work-up done from the outside hospitals. However, no records can be obtained at this point.

She is suffering from an intensive ischemic stroke this time and received intra-arterial thrombectomy and thrombolysis on 11/1/10.

Past Surgical History:

Abortion.

Current Medications:

Docusate, Keppra, Dilantin, Pravastatin, Insulin sliding scale, and Tylenol.

Physical Exam:

Vital signs: T 98.3F P 66 BP 129/69 RR14

General: awake, slightly somnolent.

HEENT: Good eye movement, supple neck with no lymphadenopathy.

CV: Regular rate and rhythm; no murmurs, gallops or rubs.

Respiratory: Clear to auscultation bilaterally, no wheezes or rales.

Abdomen: soft, non-tender, moderately obese; no organomegaly present.

Extremities: No edema.

Neuro: Follow simple commends with severe dysarthria and expressive aphasia.

Laboratory Testing:

Na 142

K 3.8

Cl 110

BUN 6

Cr 0.8

LDH 238

WBC 11.6

Hgb 13.2 (10/31/10), 11.3 (11/2/10)

Hct 38.6 (10/31/10), 32 (11/2/10)

Plt 113 (10/31/10), 97 (11/2/10)

Retic: 1.6

PBS: No schistocytes are seen.

PT 15.6

INR 1.22

PTT 26.7

UA: Trace blood, WBC 0-2/HPF; RBC 0-2/HPF; Bacterial: occasional.

Imaging: Head CT: 1. Near-complete occlusion of the right middle cerebral artery at the origin of the M2 segment. Additional thrombus is present in a branch of right MCA along the posterior insular cortex. 2. Multiple areas of encephalomalacia, predominately within the distribution of the middle cerebral arteries.

Assessment and Plan:

1. The patient is a 48 year-old female with a history of recurrent stroke in the setting of TTP. She is admitted for her third time ischemic stroke. Although she has mild low Hgb/Hct, mild low platelet count, the absence of schistocytes, slightly elevated LDH and retics, as well as normal renal function, an early stage of TTP episode can’t be ruled out, esp. with a similar clinical presentation as to the previous TTPs. With the consideration of the high mortality rate in TTP untreated patient and no other etiology of intensive ischemic stroke can be identified in this young patient, the plasmapheresis (TPE) is indicated at this point.

The slight abnormal coag values are most likely related to her recent thrombectomy and thrombolysis procedure.

2. We will consent patient and/or her family member for the TPE.

3. Her peripheral access and her mental status are not optimal for multiple TPE procedures. A central access (Quinton catheter) is requested for the procedure.

4. Four Liters of FFP (1-1.5 plasma volume) will be used as the replacement fluid for the procedure each time.

5. We recommend daily TPE till platelet count stabilizes around 150 K, then TPE may be tapered upon her clinical response. TPE may be terminated earlier if other etiology of stroke can be identified.

6. ADAMTS 13 will be drawn prior the first TPE procedure. First TPE is scheduled for tonight immediately after the central line replacement is completed.

Transfusion Medicine Attending Note:

I personally discussed this patient with Dr. Ashley Gullett, MD, PGY-3 Pathology Resident and the hematology consultation team. I have personally interviewed the patient, performed the PE independently, reviewed patient’s history and laboratory data, wrote the consultation note and made arrangement for her treatment plan.

I have spent more than 70 minutes on the patient's evaluation and management for this case.

++++++++++

2.TPE for TTP/HUS, Consultation Note

Transfusion Medicine Consult Note

History of Present Illness:

25 year old white female, G2P1 with 15 weeks gestation who was transferred to Memorial Hermann Hospital from Clear Lake for evaluation and treatment of microangiopathic hemolytic anemia. Patient was admitted to Clear Lake hospital with symptoms of diarrhea and bloody stools. Patient received IV antibiotics (ciprofloxacin and flagyl). CT of the abdomen and sigmoidoscopy were consistent with colitis. During hospital course, patient became anuric and her Cr increased from 0.5 to 4.5; CBC and peripheral blood smear reportedly showed thrombocytopenia and many schistocytes; LDH in the 1500’s. Patient was then transferred to MHH-TMC. On admission to MHH-TMC, patient was intubated due to decreased respiratory function. Platelet count is 36k, LDH 2098, Cr 4.7, Hgb 7.5. Peripheral blood smear was reviewed which shows numerous schistocytes and large platelets. LFT showed moderate abnormalities. DIC panel showed PT 17.4, PTT 31, Fibrinogen 579, Thrombin Time 15.9, D-Dimer >20.

PAST MEDICAL HISTORY:

Unremarkable

FAMILY HISTORY:

Grandfather with colon cancer

Physical Exam:

Vital signs: T 98.69F P 110 BP 151/95 RR 13

HEENT: no jaundice, no lymphadenopathy

CARDIOVASCULAR: Regular rate and rhythm, no gallops or rubs

RESPIRATORY: Crackles at both bases.

ABDOMEN: Soft, nontender. Bowel sounds present.

EXTREMITIES: No edema, good range of motion

CENTRAL NERVOUS SYSTEM: Good reflexes throughout

Assessment and Plan:

25 y/o female, 15 week gestation with microangiopathic hemolysis. The clinical and laboratory findings are most consistent with thrombotic thrombocytopenic purpura/hemolytic uremic syndrome (TTP/HUS). We plan to perform the first therapeutic exchange (TPE) this afternoon to exchange 3.5 L of plasma with FFP. Due to her low Hgb prior to the procedure (7.5), we will prime the pheresis lines with 1 unit of PRBCs to enhance the efficiency of plasma exchange. We will continue TPE every day until improvement of LDH and platelet count. ADAMTS13 level was drawn for baseline prior to the procedure.

++++++++++++++++++++++++

3. RBC Exchange for Hgb SC, Consultation Note

History of Present Illness:

Ms. xxxx is 20-year-old African-American female with history of hemoglobin SC disease diagnosed at birth. She had her first pain crisis when she was 6 years old, and since the age of approximately 13 years old, she has had 2 pain crises per year. They have been treated with simple transfusion. She has had no previous red blood cell exchanges. She is gravida 2, para 1 at 32 weeks and 2 days and is currently admitted in the hospital with an episode of preeclampsia. She had high blood pressure at home and her urine protein is 866 mg/24 hours. Her hemoglobin electrophoresis from 1/13/2011 showed 48.6% Hb S and 45.8% Hb C. During this admission, she has developed pain in her back and extremities and now has shortness of breath with bilateral lower lobe infiltrates concerning for acute chest syndrome.

Review of Systems:

General: Complains of pain all over

HEENT: Denies any vision changes or rhinorrhea

Cardiovascular: Denies any lower extremity edema

Respiratory: Complains of dyspnea

GI: Denies any nausea, vomiting, diarrhea

GU: Denies dysuria

Neurologic: Denies dizziness and numbness

Musculoskeletal: Back and extremity pain

Past Surgical History:

C-section

Allergies:

NKDA

Family History:

Hypertension, DM

Current Medications:

Vancomycin 1gm IV qday

Cefepime 1gm IV qday

Magnesium hydroxide 30ml po q6

Hydromorphone 6mg IV

Folic acid 1mg po qday

Amoxicillin 500mg po BID

Naloxone 0.4mg IV

Docusate sodium 100mg po BID

Metronidazole 500mg po BID

Physical Exam:

Vital signs: T 99.9F P 144 BP 135/96 RR 18

HEENT: Nares clear, no lymphadenopathy

CARDIOVASCULAR: Regular rate and rhythm, no gallops or rubs

RESPIRATORY: Clear to auscultation bilaterally

ABDOMEN: Gravid, non-tender

EXTREMITIES: No edema, good range of motion

CENTRAL NERVOUS SYSTEM: Good reflexes throughout

Laboratory Testing:

Na 131 mEq/L

K 4.7 mEq/L

BUN 8 mg/dL

Cr 0.6 mg/dL

Ionized calcium 4.44 mg/dL

WBC 15.1 K/CMM

Hgb 10.5 g/dL

Hct 30.1 %

Plt 254 K/CMM

Imaging:

CT chest – bilateral lower lobe infiltrates with no evidence of pulmonary embolism

Assessment and Plan:

20yo gravid female with hemoglobin SC disease and pain crisis, now with possible acute chest syndrome. A red blood cell exchange is indicated and will be performed with 8 units PRBCs. A hemoglobin electrophoresis has been ordered for after the procedure.

Blood Bank Attending Note:

This is 20 y/o AA female with Hgb SC disease, pregnancy at 31 weeks, admitted with preeclampsia, pain in back and extremities. Her mental status is unchanged. Chest imaging showed bilateral infiltrates indicating acute chest syndrome. We were requested to evaluate this patient for red cell exchange to treat this episode of sickle cell crisis. Patient was explained of the benefits/risks and the rational for this procedure. Consent was obtained. We plan to perform red cell exchange to remove/replace 8 units of PRBCs. We will check the post-procedure hemoglobin electrophoresis to assess efficacy of the procedure.

I personally discussed this patient with Dr. xxxx, MD, PGY-2 Pathology Resident. I have personally interviewed the patient, performed the PE independently, reviewed patient’s history and laboratory data, wrote the consultation note and made arrangement for her treatment plan. I have spent more than 70 minutes on the patient's evaluation and management for this case.

++++++++++

4. TPE for Cryoglobulinemia, Consultation Note

Result type: Consultation

Result date: 12 November 2010 11:51

Result status: Auth (Verified)

Result title: Consult Report

Performed by: xxxx MD on 12 November 2010 12:34

Signed by: xxxx MD on 12 November 2010 18:42

Encounter info: xxxx, HH HERMANN, Inpatient, 11/12/2010 -

* Final Report *

THERAPEUTIC APHERESIS CONSULT REPORT

DATE OF CONSULT: 11/12/2010

REASON FOR CONSULTATION:

Ms. Xxxx has a history of chronic hepatitis C with prior treatment. She developed acute kidney injury. Therapeutic Apheresis service was consulted to evaluate her for treatment of hepatitis C related glomerulonephropathy.

HISTORY OF PRESENT ILLNESS:

Ms. xxxx is a 57-year-old American lady with a past medical history of hypertension, chronic hepatitis C, and congestive heart disease. She underwent resection of intracranial meningioma in 09/2010. Since that time she has progressively become more weak and tired with increased extremity swelling. She was treated for hepatitis C approximately 3 to 4 years ago and acheived end of treatment virologic response. She developed a relapse during follow up and she did not respond to antiviral treatment and had multiple side effects. She was hospitalized recently for acute kidney injury with fluid overload and significant proteinuria. At that time, she was found to have cryoglobulinemia, hepatitis C viral load>5,000,000, and membranoproliferative glomerulonephropathy by renal biopsy. She now presents for therapeutic apheresis for treatment of her likely Hepatitis C related glomerulonephropathy.

PAST MEDICAL HISTORY:

1. Congestive heart failure

2. Chronic kidney disease

3. Hypertension.

4. Rheumatoid arthritis

5. Depression

6. Chronic hepatitis C, status post treatment failure.

PAST SURGICAL HISTORY:

Craniotomy for meningoma resection, cholecystectomy and tubal ligation.

CURRENT MEDICATION:

Procardia XL, Norvasc, Coreg, Lasix and Nexium.

ALLERGIES:

CODEINE.

SOCIAL HISTORY:

She does not report any alcohol, tobacco or drug use. She has not had blood transfusions.

FAMILY HISTORY:

Lung cancer.

REVIEW OF SYSTEMS:

GENERAL: No fevers or chills. Some increased swelling of face, abdomen and all extremities. Weakness and fatigue since craniotomy. HEENT: Patient does not report any visual changes, hearing changes, no swallowing difficulty, no headaches or migraines.

CARDIOVASCULAR: No reports of palpitations, chest pain, lightheadedness or dizziness.

RESPIRATORY: The patient does not report any cough or hemoptysis.

GASTROINTESTINAL: No abdominal pain. No gastrointestinal bleeding. No dysphagia. Some swelling.

GENITOURINARY: The patient does not report any dysuria, polyuria, or hematuria.

HEMATOLOGIC: No easy bruising or bleeding.

SKIN: No skin changes.

PHYSICAL EXAMINATION:

VITAL SIGNS: Temperature 97.5, pulse 120, respiratory rate 20, pO2 of 95%, blood pressure 181/102.

GENERAL: No apparent distress, lying comfortably in bed, awake, alert, and oriented x3.

HEENT: Pupils equal, round, reactive to light and accommodation. Extraocular movements intact. No scleral icterus. Normal oropharynx.

RESPIRATORY: Clear to auscultation bilaterally.

CARDIAC: Regular rate and rhythm. No murmurs, rubs, or gallops. Normal S1, S2.

ABDOMEN: Obese, large previous cholecystectomy scar present. No hepatomegaly or splenomegaly. No abdominal bruits. No masses. Soft, nontender. Normal bowel sounds.

EXTREMITIES: Positive 2+ pitting edema but no cyanosis or clubbing.

NEUROLOGIC: Cranial nerves II-XII grossly intact, no asterixis.

SKIN: No rashes or skin changes.

IMAGING:

Ultrasound of the liver revealed mild hepatomegaly, possible cirrhosis and bilateral pleural effusions. Renal ultrasound revealed normal renal ultrasound. Echo revealed left ventricle is normal size with mild global systolic dysfunction, LVEF of 45%, right ventricle is normal. Left atrium is mildly dilated, right atrium normal, mild-to-moderate mitral regurgitation, minimal pericardial effusion.

LABORATORY DATA:

Sodium-148, Potassium-4.8, Chloride-110, CO2-20, BUN-48, Creatinine-3.8, Glucose-113, Total protein-6.2, Albumin-2.4, Calcium-8.4, WBC-6.8, Hemoglobin-10.5, Hematocrit-30.3, Platelet-368, Cryglobulin-(+), Cryocrit: 6.7%, HCV viral load-5,130,000.

SURGICAL PATHOLOGY:

11/5/2010:

Glomerulonephritis with a membranoproliferative pattern, advanced stage.

The biopsy shows evidence of an advanced glomerulonephritis with a membranoproliferative pattern. The glomeruli show marked luminal obliteration. Deposits by electron microscopy are sparse but immunofluorescence confirms the presence of immune complex deposition. The amount of cortical tissue is small to evaluate the degree of chronic tubulointerstitial changes. In a HepC positive patient these findings are consistent with hepatitis C related glomerulonephritis. However the possibility of this glomerulonephritis being related to other factors cannot be excluded.

ASSESSMENT:

Ms. xxxx is a 57-year-old African-American lady with multiple medical problems including hypertension, chronic kidney disease, congestive heart failure, and chronic hepatitis C. After review of laboraory data and surgical pathology results, we favor Hepatitis C related glomerulonephropathy with cryoglobulinemia likely caused by acute relapse of her Hepatitis C infection. Therapeutic apheresis is indicated in this patient (Category1).

RECOMMENDATIONS:

1. We will consent the patient for the therapeutic apheresis procedure with a goal of performing 5 total procedures beginning today (11/12/2010).

2. We will use 3.5 liters of 5% albumin as a replacement fluid.

3. We will administer 4 g of calcium gluconate during the procedure to prevent citrate-induced hypocalcemia.

4. We will order an ionized calcium panel prior to the procedure to evaluate calcium levels.

Thank you for the consultation. We will follow the patient with you. The patient has been seen, discussed, evaluated and examined with Dr. xxxx.

Blood Bank Attending Note:

This is a 57 y/o female with history of chronic HCV, now presented with high HCV viral load, cryoglobulinemia and progression of renal failure. Her clinical manifestations are consistent with cryoglobulinemia with renal damage that is considered as a Category I indication for plasmapheresis. Consent for the procedure has been made and questions regarding to the procedure has been answered. Since she also has significant medical history of HTN, CHF and chronic renal renal dysfunction, plus pitting edema, we will use "ISOVOLUMIC" setting for the procedures to avoid volume overload and shall monitor her vitals closely during the procedures. Her renal functions, esp. the protein level in the urine need to be monitored to determine the response. The instruction for the line care will be given to her and her family members.

I have personally interviewed the patient, performed the physical exam independently, reviewed her history, diagnostic testing data. I have discussed the case with Dr. Ashley Gullett, MD, PGY-3 Pathology Resident and the nephrology team. I agree with Dr. Gullett's note and treatment plan.

I have spent 50 minutes on the patient's evaluation and management for this case.

Thanks for the consultation.

++++

5.TPE for Catastrophic Antiphospholipid Syndrome, Consultation Note

Result type: Consultation

Result date: 27 June 2011 14:48

Result status: Auth (Verified)

Result title: Transfusion medicine consultation

Performed by: xxxx MD on 27 June 2011 14:49

Signed by: xxxx MD on 27 June 2011 17:33

Encounter info: 397757231168, HH HERMANN, Inpatient, 6/17/2011 -

* Final Report *

Transfusion Medicine Consult Note

Reason for consultation: Therapeutic plasma exchange

History of Present Illness:

The patient is a 30-year-old Hispanic woman with a history of recurrent venous thromboses. She had a left lower lobe pulmonary embolism and a right popliteal DVT March 2011, so she was placed on Coumadin. After 3 weeks, she had another pulmonary embolism with extension of the right lower extremity DVT. She had an IVC filter placed. Her platelets dropped, and the HIT antibody panel assay was weakly positive. On 05/13/2011, she was found to have extensive DVTs of the bilateral lower extremities. On 06/07/11, she presented again for worsening shortness of breath, leg pain and swelling. She had a massive PE of the left pulmonary artery with a thrombus at the level of the IVC and extending above to the renal veins. An anti-Xa factor level was checked and it was therapeutic at 1.18. She was transferred to MHH for a higher level of care. She has no history of clots. She has had four pregnancies with no history of miscarriage. She denies any family history of clots. She is a nonsmoker and was on oral birth control pills until November of 2010. The initial hypercoagulable workup was negative and consisted of the following: Factor V Leiden, protein C, and antithrombin III. Anticardiolipin was done and repeated and was negative. Her lupus anticoagulant was positive but may have been related to the anticoagulant medication. Hematology and the CVICU have consulted our team for therapeutic plasmapheresis (TPE) with FFP.

PAST MEDICAL HISTORY:

None

PAST SURGICAL HISTORY:

Inferior vena cava filter

Thrombectomy

MEDICATIONS:

1. Xanax 0.25 mg p.o. b.i.d.

2. Lexapro 10 mg p.o. daily.

3. Atrovent 0.5 mg nebs q.6 hours.

4. Protonix 40 mg p.o. q. evening.

5. Argatroban drip.

FAMILY HISTORY:

-No history of DVTs

-Father: CVA in his late 60s

-Mother: Breast cancer and is currently age 58

SOCIAL HISTORY:

No tobacco or alcohol use. Married with four children.

ALLERGIES:

Heparin

REVIEW OF SYSTEMS:

CONSTITUTIONAL: Negative for fevers, chills, appetite change.

CARDIOVASCULAR: Negative for chest pain, palpitations, dyspnea on exertion and orthopnea.

RESPIRATORY: Shortness of breath.

GASTROINTESTINAL: Negative for nausea, vomiting, constipation, diarrhea. GENITOURINARY: Negative for dysuria, hematuria.

MUSCULOSKELETAL: Mild lower extremity swelling.

NEUROLOGIC: Negative for seizures, trauma, headache, paresthesias.

PHYSICAL EXAM:

Vital signs: T 96.7 P 54 BP 138/88 RR 29

Gen: Alert and oriented, in acute distress.

HEENT: Normocephalic, atraumatic. No lymphadenopathy, nares clear. Nasal canula and nebulizer in place.

CV: Regular rate and rhythm, no murmurs, gallops or rubs.

Pulm: CTA bilaterally.

Abd: Soft, non-tender.

Ext: Mild lower extremity edema below knees.

Neuro: Good strength throughout.

LABS:

Na 136 mEq/L

K 4.3 mEq/L

BUN 16 mg/dL

Cr 0.6 mg/dL

Ionized calcium level 4.68 mg/dL

WBC 15.4 K/cm²

Hgb 9.6 g/dL

Hct 28.6 %

Plt 136 K/Cm²

^{PT 22.3
seconds}

^{PTT 50
seconds}

^{INR 1.93}

^{Fibrinogen 102}^mg/dL

ASSESSMENT AND PLAN:

The patient is a 30-year-old Hispanic woman with a history of recurrent venous thromboses and what appears to be an antibody mediated hypercoagulability. She is currently being treated with an Argatroban drip. She has been consented for TPE with FFP. The CVICU team is placing a quinton catheter. 5 TPE procedures are planned.

CPT: 99223-GC

Blood Bank Attending Note:

This is a 30 y/o Hispanic female with 4-month history of recurrent DVT and PE (unprovoked). Patient’s clinical course has worsened despite treatment with IVC filter, Coumadin, and LMWH.

Patient had no significant prior clinical history, also no family history of thrombophilia. She is not a smoker. She was on OCP prior to 11/2010. Thrombophilia workup revealed negative results for the following: F V Leiden, F II mutation, PC deficiency, PS deficiency, AT deficiency, ACA, homocysteinemia, beta-2 glycoprotein I. Patient was started on Argatroban after admission to MHH-TMC. Previous testing for lupus anticoagulant (3/2/11) was negative. Lupus anticoagulant was positive on 6/17/11, however a false-positive result due to argatroban cannot be ruled out. Fibrinogen level has also been decreased in level. Dysfibrinogenemia cannot be ruled out.

Her clinical manifestations may be due to dysfibrinogenemia or catastrophic antiphospholipid syndrome which may be benefitted from plasmapheresis. Consent for the procedure has been made and questions regarding to the procedure have been answered. A Quinton catheter has been successfully placed prior to the procedure.

I have personally interviewed the patient, performed the physical exam independently, and reviewed her history, and diagnostic testing data. I have discussed the case with Dr. Nadja Burns, MD, PGY-3 Pathology Resident. I agree with Dr. xxxx’s' note and treatment plan.

I have spent 50 minutes on the patient's evaluation and management for this case.

Thanks for the consultation.

++++++

10.TPE for TTP with CVA, Procedure Note

Result type: Procedure Note

Result date: 04 November 2010 12:49

Result status: Auth (Verified)

Result title: Therapeutic PLasma Exchange

Performed by: xxxx MD on 04 November 2010 12:57

Cosigned by: xxxx MD on 04 November 2010 20:00

Signed by: xxxx MD on 04 November 2010 20:00

Encounter info: xxxx, HH HERMANN, Inpatient, 10/31/2010 -

* Final Report *

THERAPEUTIC APHERESIS – PROCEDURE NOTE

Diagnosis: TTP

Type of Procedure: Therapeutic Plasma Exchange

Procedure Number: #3

Assessment: 48 year old female with a history of TTP now with recurrent stroke. Therapeutic plasma exchange #3 was performed using 4 Liters of fresh frozen plasma without complications. The patient was premedicated with Benadryl prior to the procedure. 4 g of calcium gluconate was also given during the procedure.

Preprocedure vital signs: BP 137/78 T 98.9 P 78 R 16

Post procedure vital signs: BP 116/67 T 100.6 P 78 R 17

Pertinent Labs:

Hgb: 9.3 g/dL

Hct: 27.1 %

Plts: 89 /uL

K+ : 3.8 mEq/L

nCa++ : 4.4 mg/dL

LDH: 162 U/L

Retic: 1.7 %

Fliud Balance:

Total Infused: 4569 ml

Total Removed: 4047 ml

Balance: (+)522 ml

Replacement Fluid Used: Fresh frozen plasma

The patient was seen during the apheresis procedure. Good access and return flow was obtained via the Quinton catheter and the catheter site was without evidence of inflammation or infection. 10% calcium-gluconate was given PRN throughout the procedure. No complications were noted at the time the patient was seen. The slight elevation in temperature is most likely secondary to blood warming during the procedure, but will watch for signs of other causes. Next apheresis procedure is scheduled for Friday, 11/5/2010.

Blood Bank Attending Note:

This is 48 y/o female with recurrent storke most likely associated TTP. Per patient's husband, she felt tired. No bleeding from any access lines. Her mental status is unchanged. Both her RBC and platelet count decreased, with slight increase of Retic. Still no schistocytes are seen on PBS. LDH is in normal range. We will follow-up the ADAMTS 13 activity assay. Per hematology, steroid is to be added. We will continue the daily TPE at this time. However, other etiologies may need to be ruled out. We will discussed the case with the teams.

I have seen the patient and supervised the procedure. I agree with the resident's note and further treatment plan.

++++

11. RBC Exchange for Hgb SC, Procedure Note

RED BLOOD CELL EXCHANGE PROCEDURE NOTE

DIAGNOSIS: Hemoglobin SC disease, pain crisis / acute chest syndrome

ASSESSMENT: Ms xxxx is 20-year-old African-American female with history of hemoglobin SC disease diagnosed at birth. She had her first pain crisis when she was 6 years old, and since the age of approximately 13 years old, she has had 2 pain crises per year. They have been treated with simple transfusion. She has had no previous red blood cell exchanges. She is gravida 2, para 1 at 32 weeks and 2 days and is currently admitted in the hospital with an episode of preeclampsia. She had high blood pressure at home and her urine protein is 866 mg/24 hours. Her hemoglobin electrophoresis from 1/13/2011 showed 48.6% Hb S and 45.8% Hb C. During this admission, she has developed pain in her back and arms and now has shortness of breath with bilateral lower lobe infiltrates concerning for acute chest syndrome. A red blood cell exchange was performed with 8 units PRBCs and 3 amps calcium gluconate via peripheral access. The patient had no complaints during the procedure, however the baby became bradycardic towards the end of the procedure. The primary team was aware and was assessing and treating the patient for this issue.

Preprocedure vital signs: BP 150/97 T 99.3F P 130 R 14

Postprocedure vital signs: BP 142/77 T 98.4F P 145 R 26

Pertinent Labs:

Hgb: 11.8 g/dL

Hct: 35.2 %

Plts: 187 K/CMM

K+: 4.7 mEq/L

iCa++: 4.44 mg/dL

Fluid Balance:

Total infused: 2813 mL

Total removed: 2529 mL

Balance: + 284 mL

Replacement fluid used: 8 units PRBCs

A hemoglobin electrophoresis has been ordered for after the procedure.

Blood Bank Attending Note:

This is 20 y/o AA female with Hgb SC disease, pregnancy at 31 weeks, admitted with preeclampsia, pain in back and extremities. Chest imaging showed bilateral infiltrates indicating acute chest syndrome. Her mental status is unchanged. We performed red cell exchange to remove/replace 8 units of PRBCs. We will check the post-procedure hemoglobin electrophoresis to assess efficacy of the procedure.

I have seen the patient and supervised the procedure. I agree with the resident's note and assessment.

++++++

12.TPE for Renal Transplant Rejection, Procedure Note

Result type: Procedure Note

Result date: 25 December 2010 9:20

Result status: Auth (Verified)

Result title: Plasmapheresis

Performed by: xxxx MD on 25 December 2010 9:24

Cosigned by: xxxx MD on 25 December 2010 11:32

Signed by: xxxx MD on 25 December 2010 11:32

Encounter info: xxxx, HH HERMANN, Inpatient, 12/16/2010 -

* Final Report *

THERAPEUTIC APHERESIS – PROCEDURE NOTE

Diagnosis: Pre Renal Transplant with Donor Specific Antibodies

Type of Procedure: Therapeutic Plasma Exchange (TPE)

Procedure Number: 4 of 5

Assessment: Mr. xxxx is a 40 year old male with ESRD requiring cadaveric transplant on 9/18/2009 which was subsequently complicated by acute humoral rejection. He was originally scheduled for living donor transplant on 12/22/10 after 5 rounds of TPE but his donor specific antibodies, while decreased in both Class I and Class II, were still prohibitively high and a second round of 5 daily TPEs was initiated.

Mr. xxxx underwent TPE #4 of 5 of his second round of TPEs today. The patient was seen by both myself and Dr. xxxx during the procedure. Good access and flow was obtained from the right subclavian catheter. 4 liters of 5% serum albumin were used, and the patient received 5 grams of 10% calcium gluconate throughout the procedure. The patient tolerated the procedure without complications.

Pre Procedure Vital Signs: BP: 122/75 T: 97.4 P: 78 R: 14

Post Procedure Vital Signs: BP: 114/66 T: 97 P: 78 R: 16

Pertinent Labs:

WBC: 6.8 K/CMM

Hgb: 7.9 g/dL

Hct: 23.6 %

Plts: 247 /uL

Na+: 141 mEq/L

K+ : 4.6 mEq/L

IonCa++ : 4.48 mg/dL

Fluid Infused: 4313 mL

Fluid Removed: 4047 mL

Fluid Balance: + 266 mL

Replacement Fluid Used: 4 Liters of 5% albumin

Plasmapheresis number 5 of 5 is scheduled for 12/26/2010 exchanging 4L of 5% albumin.

Blood Bank Attending Note:

The #4/5 plasmapheresis procedure was performed today without complications. The exam of his access remained unchanged without signs of infection. His vitals and WBCs are stable. The blood culture for the access remains negative. We will continue the current treatment plan. I also have discussed the options of the replacement fluid for tomorrow's procedure with the renal fellow with the concern of the possible surgical procedure within 48 hours of the last plasmapheresis. Albumin is desired from the primary team. I have recommended to closely monitor the patient's coagulation status prior to his surgical procedure.

I have seen the patient and supervised the procedure. I agree with Dr. xxxx's note and management plan.

+++++

13.TPE with Hypotension, Procedure Note

Result type: Procedure Note

Result date: 06 November 2010 7:58

Result status: Auth (Verified)

Result title: Apheresis/Clinical Pathology Service

Performed by: xxxx on 06 November 2010 8:06

Signed by: xxxx on 06 November 2010 17:08

Encounter info: xxxx, HH HERMANN, Inpatient, 10/27/2010 -

* Final Report *

PLASMAPHERSIS PROCEDURE NOTE

This is a 29 year old female with neuromyelitis optica scheduled for plasmapheresis #4 this morning. About 2 minutes into the procedure she became hypotensive from a BP of 108/57 to 70/30. We stopped plasmapheresis immediately. She was asymptomatic and denied dizziness, chest pain, or nausea. Nurse Patricia Anna was informed who subsequently contacted the primary team. In the interim we gave a 200 mL bolus of saline. We checked the blood pressure again 5 minutes later, but she remained hypotensive at (78/36). After consulting with Neurology, we decided to try the procedure later in the day. The Neurology team gave a 500 mL bolus of saline and placed her on a saline drip as well. Her blood pressure had increased to 100/57 by the afternoon. We resumed plasmapheresis and exchanged 3.5 L of 5% albumin and 4 grams of calcium gluconate. The patients tolerated the procedure well without complications. Her blood pressure remained stable throughout the procedure. Dr. xxxx supervised the procedure.

VS:

Preprocedure vital signs: BP (108/57) T (98.1 F) P (85) R (16)

Post procedure vital signs: BP (123/73) T (98.1 F) P (69) R (14)

Volume exchange, in mL:

Fluid in- 3786

Fluid out- 2920

Balance- (+) 866

Pre-procedure Labs:

Na 141 mEq/L

K 4.3 mEq/L

Cl 101 mEq/L

CO2 34 mEq/L

BUN 5 mg/dL

Cr 0.3 mg/dL

Ionized Ca 4.56 mg/dL

WBC 12.6 k/cmm

Hgb 10.2 g/dL

Hct 30.6%

Plt 157 k/cmm

Assessment and Plan:

29 year old female with neuromyelitis optica undergoing plasmapheresis procedures. We completed the 4th procedure today. The last plasmapheresis procedure (the 5th) is schedule for Monday, Novermber 8, 2010.

++++

14.TPE with Infected Catheter, Procedure Note

Result type: Procedure Note

Result date: 07 November 2010 10:51

Result status: Auth (Verified)

Performed by: xxxx MD on 07 November 2010 11:00

Cosigned by: xxxx on 07 November 2010 14:01

Signed by: xxxx on 07 November 2010 14:01

Encounter info:xxxxx, HH HERMANN, Inpatient, 10/31/2010 -

* Final Report *

THERAPEUTIC APHERESIS PROCEDURE NOTE

DIAGNOSIS: TTP

TYPE OF PROCEDURE: Therapeutic Plasma Exchange

PROCEDURE NUMBER: 6

ASSESSMENT: 48 year old female with a history of TTP now with recurrent stroke. Patient's platelet count has been progressively improved with the previous 5 aphereres. The platelet count this morning is 143k. We attempted to perform therapeutic plasma exchange #6 using 4 liters of fresh frozen plasma. The Quinton line had poor access and poor return flow at the beginning of the procedure. The insertion site was found to be indurated, suggestive of line infection. The Hematology fellow on call was consulted and the consensus was to discontinue the procedure for today. The line is to be removed by Dr. Reddy (Hematology resident) today. We will reevaluate the patient tomorrow 11/8/2010 for further management.

Preprocedure vital signs: BP 117/74 T 97.8 P 92 R 18

Postprocedure vital signs: BP 130/77 T 99 P 92 R 16

Pertinent Labs:

Hgb: 7.8 g/dL

Hct: 23.1 %

Plts: 143 /uL

K+: 3.6 mEq/L

iCa++: 4.44 mg/dL

LDH: 167 U/L

Fluid Balance:

Total infused: 414 mL

Total removed: 198 mL

Balance: (+) 216 mL

++++++++++++++++++++

15. TPE for GBS, Consultation Note

Transfusion Medicine Consult Note

History of Present Illness:

18 y/o white female with history of GBS who presented with weakness of upper and lower extremities, also with numbness. She was last admitted to MHH-TMC in Aug 2011 with weakness and respiratory distress that required intubation. Her symptoms were alleviated with 5 sessions of therapeutic plasma exchanges (TPEs). Prior to admission to MHH-TMC in Aug 2011, patient was reportedly treated with IV IG without success.

PAST MEDICAL HISTORY:

GBS diagnosed in Aug 2011

FAMILY HISTORY:

A maternal aunt with history of seizure

MEDS: Gabapentin 300 mg TID

REVIEW OF SYSTEMS:

GENERAL: Weakness in extremities and decreased sensation, no fevers or chills.

HEENT: Patient does not report any hearing changes, no swallowing difficulty, no headaches or migraines.

CARDIOVASCULAR: No reports of palpitations, chest pain, lightheadedness or dizziness.

RESPIRATORY: The patient does not report any cough or hemoptysis.

GASTROINTESTINAL: No abdominal pain. No gastrointestinal bleeding. No dysphagia. GENITOURINARY: The patient does not report any dysuria, polyuria, or hematuria.

HEMATOLOGIC: No easy bruising or bleeding.

SKIN: No skin changes.

Physical Exam:

Vital signs: T 99.5 BP 125/86 RR 18

HEENT: no jaundice, no lymphadenopathy

CARDIOVASCULAR: Regular rate and rhythm, no gallops or rubs

RESPIRATORY: Clear to auscultation bilaterally

ABDOMEN: Soft, nontender. Bowel sounds present.

EXTREMITIES: No edema, good range of motion, weakness in upper and lower extremities

Assessment and Plan:

18 y/o female with exacerbation of GBS, currently having stable respiratory status. Given her prior episode of GBS with respiratory distress requiring intubation, we plan to perform the first therapeutic plasma exchange (TPE) as soon as possible to exchange 2.5 L of plasma with 5% serum albumin. The TPE procedure benefits and risks were explained to patient. Consent form was obtained. We will continue TPE every other day with daily assessment of patient’s clinical status.

++++++++++++++++++++++++

16. TPE for GBS, Procedure Note

Diagnosis: Guillain-Barre Syndrome

Type of Procedure: Therapeutic Plasma Exchange (TPE)

Procedure Number: 1 of 5

Assessment:

18 y/o white female with history of GBS who presents with relapse without respiratory distress. She has a reported history of failed treatment with IVIG. She uneventfully underwent her first therapeutic plasma exchange #1 today using 2.5 liters of 5% albumin. The patient was seen during the apheresis procedure. Good access and return flow was obtained via the Quinton catheter and the catheter site was without evidence of inflammation or infection. 3 amps of 10% calcium gluconate were administered during the procedure. The patient tolerated the procedure without complications.

Vital Signs:

Pre Procedure at 0110: BP: 127/73 mmHg T: 96.9 F P: 102 bpm R: 12

Post Procedure at 0215: BP: 120/72 mmHg T: 96.6 F P: 111 bpm R: 18

Pertinent Labs:

Na 141 mEq/L

K 4.2 mEq/L

BUN 14 mg/dL

Cr 0.7 mg/dL

WBC 7.1 K/cm³

Hgb 12.5 g/dL

Hct 36 %

Plt 216 K/Cm³

ionized calcium 4.72 mg/dL

Fluid Infused: 2856 mL

Fluid Removed: 2594 mL

Fluid Balance: + 262 mL

Replacement Fluid Used: 2.5 Liters of 5% albumin

She will receive TPE every other day for a total of 5 TPE procedures. Her next TPE procedure (2^nd out of 5) is scheduled for Wednesday (09/14/2011).

Blood Bank Attending Note:

Patient completed her first TPE today without complications. A plasma volume of 2.5L was exchanged with 5% albumin. I have seen the patient and supervised the procedure. I agree with the resident's note and further treatment plan.

++++

17. E-ORDERS (EXAMPLES)

-New order: Orders-> Add

-To revise previous orders: Orders-> look for order under Lab, medication, etc -> ® click ->

Options: modify, cancel & reorder, cancel & DC

-To save order as Favorites: before signing order-> save to

Order for TPE next day with FFP for TTP

1. MD to Nurse Order, Misc: 4/10/11 7:00:00, Plasmapheresis #3 to be performed by pheresis nurse on 4/10/2011

Steps: MD to Nurse Order, Misc: scheduled date/time; Plasmapheresis #3 to be performed by pheresis nurse on 4/10/2011

2. heparin: 1,000 unit, Route: IV, Drug form: INJ, ONCALL, routine, Dosing Weight 98.5, kg, Start date: 4/10/11 7:00:00 . Please have 1,000 U/ml in 1 mL by bedside to pack Quinton catheter for pheresis on 4/10/11

Steps: Heparin-> heparin->[none]-> details (1,000 unit, IV, INJ, freq:ONCALL, routine), comments (Please have 1,000 U/ml in 1 mL by bedside to pack Quinton catheter for pheresis on 4/10/11)

3. calcium gluconate: 5,000 mg, Route: IV, Drug form: INJ, ONCALL, routine,Dosing Weight 98.5, kg, Start date: 4/10/11 7:00:00. Please have 5 gm of 10% calcium gluconate (50 mL) by bedside for pheresis on 4/10/11 at 7 am.

Steps: Calcium gluconate->[none]-> details (5,000 mg, IV, INJ, freq:ONCALL, routine), comments (Please have 5 gm of 10% calcium gluconate (50 mL) by bedside for pheresis on 4/10/11 at 7 am).

4.CBC w/ Diff and Platelet: 4/10/11 3:00:00, Routine, Early AM, 3, day

(scheduled to be done on 4/10/11, for 3 days)

5. Ionized Calcium Level: 4/10/11 3:00:00, Routine, Early AM, 3, day

6. BMP: 4/10/11 3:00:00, Routine, Early AM, 3, day

7. FFP product order: 4/9/11 12:49:00, Routine, ONCE, # Units 5 L, To give, 4/10/11. FFP to be used for plasmapheresis on 4/10/11

Steps: FFP-> [FFP,routine, ONCE]-> details (schedule on: date/time, 5 L, freq:ONCE, routine, reason:to give, schedule for: date/time), comments (FFP to be used for plasmapheresis on 4/10/11)

8. For 1^st TPE, order ADAMTS13

Steps: MD to Nurse Order, Misc type “ADAMTS13”, also type instructions in Order Comment (collect in one blue top tube, send to lab with downtime test request, specify “ADAMTS13”)

Order for TPE next day with Albumin for CIDP, etc.

Same as above except that FFP->5% albumin as ordered below

Steps: albumin-> albumin 5% IV-> [none] -> details (5,000 mL, IV, freq:ONCE); Comments (Please have 5 L of 5% albumin by bedside for plasmapheresis on 9/10/11 at 8 AM)

Order for RBC Exchange (today)

Same as above except that FFP-> __units of RBCs

Steps: RBC->RBC product order-> ( ,STAT, ONCE)

Also:

Pre-exchange Hgb electrophoresis (Stat)

Post-exchange Hgb electrophoresis (Order comments: sample to be collected at or after xx:xx on 9/10/11)

Excluding tests already done today

For same day TPE-> STAT; excluding tests that were already done

Benadryl for Allergic reaction

Benadryl 50 mg, IV, INJ, ONCE,…

Steps: Benadryl -> [none] -> details (50 mg,….),Comments (50 mg Benadryl in 1 mL)