During a global pandemic such as with the SARS-CoV-2 virus, precautions must be taken to limit staff exposure as much as possible. Oftentimes, this involves measures such as reducing operating room capacities, deferring physical exams in known positive patients, or the modification of the same apheresis procedures that we perform every day. In the era of COVID-19 and social distancing, we successfully modified how to perform therapeutic plasma exchanges (TPEs) to allow the apheresis staff and device to stay outside of the patient's room for the vast majority of the procedure. A 77-year-old white male with a severe exacerbation of myasthenia gravis (MG) was discharged after five TPEs with clinical improvement. Only 5 days later, he presented again with worsening bulbar weakness and dysphonic speech, despite compliance with prednisone, azathioprine, and pyridostigmine. Due to potential COVID-19 exposure, he was transferred to the intensive care unit (ICU), the infection was confirmed with a PCR test, and we were consulted to restart TPE. The first procedure using the Spectra Optia apheresis system (Terumo BCT, Lakewood, CO) was performed as usual exchanging one plasma volume for 5% albumin. The nurse remained in the patient's room in full personal protective equipment (PPE) for approximately 2.5 hours. The patient tolerated TPE well and the machine was disinfected per the manufacturer's recommendation, which includes disinfection with a 70% isopropyl alcohol solution (customer letter to TerumoBCT, “TBCT Trima Accel and Spectra Optia exposure to COVID,” March 30, 2020), in line with CDC recommendations for the disinfection of medical devices. Prior to the second TPE, we learned from the dialysis service of their experience using two D-300 Level 1 normothermic IV fluid administration sets (Smiths Medical, Minneapolis, MN), which added an additional 6 feet of tubing to the access and return lines between the patient and the Spectra Optia. Combined with the original tubing, the total distance between the patient and the machine was approximately 12 feet, allowing the apheresis nurse and the machine to stay outside of the patient's room throughout the exchange (Figure 1). We estimated that the extracorporeal volume (ECV) using the extension set (which holds 90 mL each) totaled approximately 405 mL (8% of our patient's blood volume [BV]). At the end of priming the machine with saline and ACD-A, and before connecting the patient, we manually primed the extension tubing to ensure lack of residual air. We set the inlet speed at 100 mL/min and the AC ratio to 10:1 (we typically use an AC ratio of 13:1 in nonmodified procedures) to prevent clotting in the longer tubing. We also found that it was helpful to have one nurse at the

To The Editor: Many vascular access options, such as subcutaneous ports, are currently on the market for use in both medication infusion and for procedures, such as therapeutic plasma exchange (TPE), extracorporeal photopheresis (ECP), and red blood cell exchange (RBCx). Although most ports were not originally intended for such procedures, apheresis practitioners have used them for about 20 years. These devices yield flow rates of approximately 50 to 60 mL/min, which is enough for most apheresis applications. In general, subcutaneous ports are beneficial to patients requiring longterm repeated access for infusions or apheresis procedures. These ports minimize the psychosocial impact on patients by being less visible that central venous catheters (CVCs) or permcaths. CVCs also have a risk of being unintentionally pulled out by the patient during sleep or while exercising. The main downside to subcutaneous ports is the pain experienced during initial access of the port site (minimized with anesthetics or prophylactic injection of lidocaine). Like any other vascular access, ports may become clotted or infected, requiring removal and replacement. In April 2017, the FDA cleared the PowerFlow (Bard, Tempe, Arizona) for apheresis procedures and for other uses requiring repeat vascular access (eg, infusions, transfusions, and blood draws). This device has a unique design when compared to traditional ports. For example, the Vortex port (Angiodynamics, Latham, New York) sits parallel to the skin surface and requires perpendicular (90 ) access via a noncoring needle. In contrast, the PowerFlow is a cone-shaped titanium funnel that angles up from the subcutaneous tissue and is accessed much like an intravenous catheter at a 30 angle from the skin. This design reportedly allows for higher inlet flow rates (maximum 120-150 mL/min) and potentially less thrombus formation along the catheter surface. Figure 1B illustrates the access kit for the PowerFlow (left). Figure 1B demonstrates side-by-side placement of both ports in a patient undergoing TPE for Stiff Person Syndrome (Vortex left, PowerFlow right). Early reports on the usability of this port are encouraging. In February 2017 Transfusion Supplement, the Mayo Clinic (Scottsdale, Arizona) reported using the device to perform 70 ECP procedures, achieving flow rates of 30 to 50 mL/min for all patients with minimal pressure alarms. They also reported using the ports for plasma exchange at rates up to 100 mL/min. Our experience with the new ports is similar. We have 13 patients with PowerFlow ports. Three patients have only one PowerFlow, two patients have two PowerFlow ports, and eight patients have one PowerFlow and one Vortex. Seven patients have ports for ECP, three have ports for TPE, and three have ports for RBCx. A detailed analysis of our experience with two patients with at least 10 consecutive procedures with the Vortex port and 10 consecutive procedures with the PowerFlow port demonstrated statistically significant savings in terms of time to complete the procedures, as well as overall cost with the newer devices. Much of the cost savings came from the decreased need for thrombolytic agents prior to beginning a procedure and the time savings from faster inlet flow rates, fewer pressure alarms, and less time waiting for

Many vascular access options, such as subcutaneous ports, are currently on the market for use in both medication infusion and for procedures, such as therapeutic plasma exchange and extracorporeal photopheresis. We compared the cost and time necessary to complete apheresis procedures using either Angiodynamic's Vortex or Bard's PowerFlow subcutaneous ports by reviewing our experience on two patients undergoing long-term apheresis treatments with at least 10 procedures with each type of port. We analyzed the cost of needles and thrombolytic therapy, staff time, overall procedure length, and the total time the patient was in the apheresis unit. We also compared flow rates and alarm rates between the two ports. In this small pilot study, use of the PowerFlow port resulted in significant cost and time savings, with mixed results for flow rates. Our results need to be confirmed in a larger patient population prior to recommending wide implementation of Bard's PowerFlow port.

Journal of Clinical ApheresisVolume 33, Issue 1 p. 121-123 LETTER TO THE EDITOR Blood prime for patients with single-needle access requiring extracorporeal photopheresis: How to do and why it may be useful Michael N. Boshell, Michael N. Boshell Infusion and Apheresis Service, University of Alabama at Birmingham Hospital, Birmingham, AlabamaSearch for more papers by this authorDaniel B. Peavey, Daniel B. Peavey Hospital Laboratories, University of Alabama at Birmingham Hospital, Birmingham, AlabamaSearch for more papers by this authorSierra C. Simmons, Sierra C. Simmons orcid.org/0000-0001-5980-1089 Department of Pathology, University of Alabama at Birmingham, Birmingham, AlabamaSearch for more papers by this authorLance A. Williams III, Lance A. Williams III Department of Pathology, University of Alabama at Birmingham, Birmingham, AlabamaSearch for more papers by this authorHuy P. Pham, Corresponding Author Huy P. Pham huyppham@uab.edu orcid.org/0000-0003-4168-3859 Department of Pathology, University of Alabama at Birmingham, Birmingham, AlabamaCorrespondence Huy P. Pham, MD, MPH, Division of Laboratory Medicine, Department of Pathology, The University of Alabama at Birmingham, 619 19th Street S, WP-P230, Birmingham, AL 35249, USA. Email: huyppham@uab.eduSearch for more papers by this author Michael N. Boshell, Michael N. Boshell Infusion and Apheresis Service, University of Alabama at Birmingham Hospital, Birmingham, AlabamaSearch for more papers by this authorDaniel B. Peavey, Daniel B. Peavey Hospital Laboratories, University of Alabama at Birmingham Hospital, Birmingham, AlabamaSearch for more papers by this authorSierra C. Simmons, Sierra C. Simmons orcid.org/0000-0001-5980-1089 Department of Pathology, University of Alabama at Birmingham, Birmingham, AlabamaSearch for more papers by this authorLance A. Williams III, Lance A. Williams III Department of Pathology, University of Alabama at Birmingham, Birmingham, AlabamaSearch for more papers by this authorHuy P. Pham, Corresponding Author Huy P. Pham huyppham@uab.edu orcid.org/0000-0003-4168-3859 Department of Pathology, University of Alabama at Birmingham, Birmingham, AlabamaCorrespondence Huy P. Pham, MD, MPH, Division of Laboratory Medicine, Department of Pathology, The University of Alabama at Birmingham, 619 19th Street S, WP-P230, Birmingham, AL 35249, USA. Email: huyppham@uab.eduSearch for more papers by this author First published: 02 June 2017 https://doi.org/10.1002/jca.21559Citations: 2Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume33, Issue1February 2018Pages 121-123 RelatedInformation

Introduction: Red blood cell exchange (RBCX) is an acceptable alternative to simple transfusion for patients with sickle cell disease (SCD) as a means of secondary stroke prevention. Unfortunately, RBCX is more expensive and requires increased exposure to red blood cell (RBC) units. Isovolemic hemodilution red blood cell exchange (IHD-RBCX) is a recently described, modified RBCX procedure that reduces the number of RBC units required. In November 2015, we implemented IHD-RBCX for selected patients. The aim of this study was to determine how implementation of the modified procedure affected the cost, RBC unit exposure, and the number of adverse reactions at our facility. Methods: A retrospective study was performed identifying patients receiving IHD-RBCX from November 2015 to April 2016. Collected variables included pre-exchange hematocrit (Hct) and hemoglobin S (HbS), goal Hct and HbS, RBC units used during IHD-RBCX, and volume of albumin used. These values were used to calculate number of RBC units estimated for conventional RBCX and, thus, the cost savings from IHD-RBCX. Results: During the 5-month period, 8 patients received a total of 27 IHD-RBCXs (median: 3, range: 1-8 procedures). In total, 57 RBCs units were saved (median: 2, range 1-4/procedure) and 12.25 L albumin was used instead (median: 500mL, range: 250-500mL/procedure). Factoring in cost savings for RBC units, including special requirements such as partial phenotypically matched units for each patient, as well as added cost for albumin, approximately $17,849 was saved ($661/procedure, $3570/month). Two adverse events were noted (port malfunction and seizure) though both were chronic issues unrelated to IHD-RBCX. Conclusions: The findings at our institution indicate that IHD-RBCX is a safe and potentially cost-saving therapy for secondary prevention of stroke in stable SCD outpatients. Longer term study is needed to determine the effect of procedures in other SCD parameters, such as iron status. AJCP / MEETING ABSTRACTS