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Statement 4
➤ Due to the severity and instability of their illness, TTP patients
experiencing an acute event are often managed in a setting with
critical / intensive care capabilities, including continuous monitoring
of neurologic status, cardiac status, and oxygen saturation. Initial
management in a critical / intensive care setting is considered
appropriate on the grounds that TTP patients may deteriorate quickly,
and have a high risk of severe organ dysfunction such as coma,
stroke, seizures, myocardial infarction, congestive heart failure,
arrhythmias, mesenteric ischemia, pancreatitis or acute kidney injury,
all of which require early detection, intensive monitoring, and rapid
treatment; furthermore, TPE is associated with rare adverse effects
that are best detected and managed in the critical / intensive care
setting.
Statement 5
➤ We did not systematically search and review the evidence on
different modalities of monitoring in TTP patients. In general, the
clinical evaluation of TTP patients at the time of hospital admission,
and regularly thereafter, emphasizes cardiac and neurological
assessment. Specifically, cardiac troponin levels are measured at
diagnosis, followed by serial troponin levels, electrocardiography,
and echocardiography as clinically indicated. Increased cardiac
troponin (>0.25 μg/L) appears to be associated with increased
cardiac and cerebral involvement, stroke, and mortality in TTP,
although most patients with an increased level of cardiac troponin are
asymptomatic.
Statement 6
➤ TTP patients often need a central venous access secured urgently.
Rapid placement of central venous access allows TPE to be started as
soon as possible. The type of central venous access depends on the
modality of TPE: centrifugal apheresis versus membrane filtration.
Centrifugal apheresis involves lower blood flow rates, and enables
the use of catheters with smaller diameters, and more flexible walls
(such as peripheral catheters or standard triple lumen central venous
catheters (CVCs). Conversely, membrane filtration involves higher
blood flow rates, which requires the use of larger diameter, stiffer
catheters (such as standard dialysis catheters or single lumen CVCs).
Clinicians should be aware of, or consult the appropriate service for
what modality of TPE is used at their center, so appropriate central
venous access can be secured before initiation of TPE.
