(P-TA-17) Successful Therapeutic Plasma Exchange in a Less Than 4-Kilogram Neonate on Concurrent ECMO and CRRT Support

Background/Case Studies: Therapeutic plasma exchange (TPE) in neonates is rarely performed due to technical limitations and physiologic fragility. This complexity is magnified in critically ill neonates requiring extracorporeal life support. We report a successful TPE in a less than 4kg, few day old neonate supported simultaneously with venoarterial extracorporeal membrane oxygenation (VA-ECMO) and continuous renal replacement therapy (CRRT), demonstrating feasibility and safety in one of the smallest and most medically complex patients reported to date.

A term male neonate (gestational age 41 weeks) was admitted to the neonatal intensive care unit (NICU) two days post-discharge after presenting with pallor, jaundice, hyperbilirubinuria, and respiratory distress. The patient decompensated rapidly, requiring mechanical ventilation, VA-ECMO initiation, and CRRT within 24 hours for fluid and metabolic management. Seizures and suspected septic shock prompted further evaluation. Given the severity of clinical status and multi-organ involvement, the NICU team requested a TPE consult to manage suspected immune-mediated or toxin-related pathology.

Study

Design/Methods: TPE was conducted via integration with the VA-ECMO and CRRT circuits. The total blood volume (TBV) was calculated to include the patient's native TBV plus the volume of the extracorporeal circuits. A Spectra Optia Apheresis System was primed with a unit of irradiated packed red blood cells. Thawed Plasma was used for replacement, and normal saline replaced ACD-A as anticoagulant due to systemic anticoagulation through ECMO and CRRT. Coordination among the ECMO, CRRT, and transfusion medicine teams was critical for timing and safety.

Results/Findings: Three TPE procedures were performed without complication. The patient maintained hemodynamic stability throughout all procedures. No adverse transfusion reactions, line-related issues, or electrolyte derangements occurred. Each procedure was completed without interruption or need for protocol deviation.

Conclusions: This case demonstrates that TPE can be safely and effectively performed in neonates weighing less than 4 kg who are concurrently on VA-ECMO and CRRT. With precise circuit calculations, interdepartmental collaboration, and protocol optimization, TPE is a viable adjunctive therapy in critically ill neonates with suspected immune-mediated pathology or toxin accumulation.