Therapeutic Plasma Exchange Procedure Note

Procedure Date and Time: [Date] [Start time] - [Stop time / Run time] (If stop time unknown at drafting, enter [PENDING] and complete before signing.)

Location: [Inpatient unit / ICU / Apheresis clinic / Other]

Session Number: [#X of planned Y] (Cumulative sessions to date: [number])

Responsible Physician: [Name, credentials]

Operator(s): [Names and roles of RN, apheresis technician, APP, or other team members]

Indication and Treatment Context

[Primary diagnosis/indication prompting TPE] ([ASFA category if used locally]). Clinical urgency: [routine / urgent / emergent]. Treatment intent: [bridge to definitive therapy / rescue therapy / relapse treatment / other]. Planned course: [frequency], [anticipated total exchanges], [endpoint or stopping criteria if known]. (If indication is uncertain or evolving, document both the ordering team's stated indication and the apheresis service's assessment.)

Consent and Pre-Procedure Verification

Consent: [Obtained / Reconfirmed on file / Waived due to emergency] from [patient / surrogate with relationship] on [date/time]. (If waived, document basis and who authorized.)

Time-out: Pre-procedure verification completed confirming two patient identifiers, correct procedure (TPE), planned vascular access, replacement fluid plan, and anticoagulation plan. Discrepancies: [none / describe and resolution].

Interval History Since Last TPE: [Bleeding / allergic symptoms / hemodynamic issues / access problems / new anticoagulants / recent transfusions / infections / none / not applicable - first session].

Focused Exam: [Vascular access site condition], [cardiopulmonary status], [other relevant findings].

Baseline Vitals: BP [value], HR [value], SpO2 [value] on [room air / supplemental O2], Temp [value].

Pre-Procedure Labs

CBC: Hb [value], Hct [value], Platelets [value] ([timestamp]). Electrolytes: Na [value], K [value], Ca total [value] / ionized [value] ([timestamp]). Coagulation: PT/INR [value], aPTT [value] ([timestamp]) (if applicable). Fibrinogen [value] ([timestamp]) (if applicable). Disease-specific markers: [name and value] ([timestamp]). (If a safety-relevant lab was not obtained, document the reason and mitigation.)

TPE Prescription

Patient Parameters: Height [value], Weight [value] ([measured / stated], [timestamp]), Hematocrit for calculation [value]. Special considerations: [pregnancy / pediatric / small body size / none].

Target Exchange: Plasma volume estimation method: [Nadler / Kaplan / device-estimated / other]. Target exchange: [PV multiple] ≈ [volume in liters].

Replacement Fluid: [5% albumin 100% / albumin X% + NS Y% / plasma-only / other]. (If plasma: ABO compatibility approach [ABO-identical / ABO-compatible / group AB].) Adjunct replacement: Calcium [prophylactic infusion / bolus PRN / none] via [route] with [titration triggers]; [K/Mg supplementation if used]; [cryoprecipitate or fibrinogen plan if applicable].

Anticoagulation: [Citrate (ACD-A) / Heparin / Other] at [dosing parameters]. Ionized calcium monitoring: [frequency or per protocol]. Calcium replacement: [continuous infusion / intermittent bolus / PRN] with triggers [ionized Ca threshold / symptoms]. Contraindications or mitigations: [bleeding risk / citrate metabolism concerns / none].

Vascular Access: [Peripheral IV: gauge and site(s) / Central venous catheter: type, site, lumen details]. Anticipated access limitations: [none / describe].

Premedications: [Antihistamine / Steroid / Acetaminophen / Electrolyte boluses / Vasopressor / Fluids / Medications held / None].

Procedure Summary and Tolerance

Run Details: Actual start [time], stop [time] (run time [duration]). Device: [platform]. Access used: [as prescribed / changed to: describe].

Delivered Volumes: Exchange volume [actual] L (planned [target] L). Replacement infused: Albumin [volume], Plasma [volume], NS/other [volume]. Anticoagulant volume [value] (if tracked). Net fluid balance [value] (if tracked). Calcium administered: [dose and route].

Monitoring and Events: Vitals: Pre [BP/HR/SpO2], Post [BP/HR/SpO2] (intra-procedure values if events occurred). Patient symptoms: [none / perioral tingling / paresthesias / nausea / chills / dyspnea / chest pain / other]. Objective events: [none / hypotension with intervention / allergic signs with treatment / access complications / other].

Tolerance Statement: [Tolerated well without complications / Tolerated with the following events: [describe] / Procedure stopped early due to [reason]; patient [stable / unstable]; [team] notified].

Complications

[No complications] (If complications occurred, document each below:)

Type: [Citrate toxicity / Hemodynamic instability / Allergic or anaphylactoid reaction / Bleeding or access site issue / Circuit clotting / Suspected transfusion reaction / Other]

Severity: [Mild / Moderate / Severe]

Description: [Narrative of event]

Treatment: [Medications, fluids, adjustments, interventions]

Outcome: [Resolved / Improving / Ongoing]. Notifications: [Primary team / ICU / Transfusion medicine / Rapid response / None required]. (If plasma used and transfusion reaction suspected, note whether transfusion reaction protocol initiated.) (If evaluation pending, note where follow-up documented.)

Post-Procedure Status

Post-Procedure Vitals: BP [value], HR [value], SpO2 [value], Temp [value]. Overall status: [stable / symptomatic: describe].

Vascular Access: [Site condition], [dressing / flush / heparin lock / capped / removed as applicable].

Post-Procedure Labs: [Obtained: list with timestamps / Ordered: list with timing].

Disposition: [Remained on inpatient unit / Returned to ICU / Discharged from apheresis clinic]. Instructions: [bleeding precautions / catheter care / hydration / return precautions / none].

Assessment and Plan

Response to Date: [Clinical response relevant to indication: symptom changes, lab trends, antibody titers].

Next TPE Session: [Planned timing] (contingent on [labs / clinical status] if applicable). Changes planned: [none / dose adjustment / replacement fluid change]. Pre-session labs: [list].

Criteria to Modify or Stop: [Triggers or thresholds if established].

Communication: [Primary service / Consulting specialty / ICU team] updated via [method].