Abstract
A 13-month-old boy presented with bradycardia and hypotension during centrifugal plasma exchange therapy for Kawasaki disease. A significant decrease in ionized calcium levels was observed, and its correction resulted in rapid hemodynamic stabilization. Compared to membrane plasma exchange, centrifugal plasma exchange has higher plasma removal efficiency and can be performed with lower blood flow, allowing treatment through peripheral vascular access without the need for central venous catheterization. However, citrate, an anticoagulant used in the procedure, accumulates when its metabolic clearance is exceeded. This accumulation can lead to reduced ionized calcium levels, elevated anion-gap metabolic acidosis, and potentially life-threatening circulatory instability. Citrate accumulation is a rare but serious complication requiring meticulous attention. In pediatric patients, the risk factors for citrate accumulation remain inadequately understood; however, clinical markers, such as an increased total calcium-to-ionized calcium ratio and a rising anion gap, may serve as useful indicators. To minimize the risk of complications, rigorous monitoring of vital signs, namely total and ionized calcium levels and anion gap fluctuations, is essential during centrifugal plasma exchange. Monitoring should be conducted in an intensive care setting to ensure timely detection and intervention, thereby preventing severe outcomes.
