Numerous types of cell separator machines are now available, but all operate on either a continuous or intermittent flow principle, allowing for the rapid return of anticoagulated blood (Figure 21.8). These systems consist of a device that will carry out whole‐blood separation, normally using a sterile, functionally closed‐system, single‐use disposable apheresis kit (Howell et al. [52]) with a citrate or heparin anticoagulant solution. All equipment must conform to relevant safety requirements. Regular servicing should be undertaken according to manufacturers’ guidelines with service records kept (Howell et al. [52]). It is recommended that a service contract exists to ensure that an engineer can be contacted to repair the machine within a stipulated timeframe. Cell separator machines must be regularly cleaned with a suitable decontaminating agent and a standard procedure for dealing with blood spillage must be used (Howell et al. [52]). It is recommended that cell separator facilities undertake a risk assessment and prepare a business continuity plan to manage untoward incidents (FACT‐JACIE [40]).

High blood flow rates are required for apheresis, so particular care must be taken over the peripheral venous assessment and vein selection of patients and donors. A rigid 16/17 G needle, cannula or equivalent is placed in the antecubital fossa for access (Figure 21.9) and a 20 G cannula or equivalent is sited in a peripheral vein for return. Peripheral access and return are usually sited in opposing arms. Side‐effects from needle insertion may include pain, bleeding and haematoma. In addition, patients and donors may suffer from needle phobia, resulting in anxiety and vasovagal reactions (Association of Anaesthetists of Great Britain and Ireland [4], Dougherty and Lister [36]).

When there is poor venous access, a central venous catheter needs to be placed to undertake the procedure (NHS Blood and Transplant [83]). This has been identified as the greatest risk that patients and donors face (Stroncek et al. [107]). Standard alternatives to peripheral access include rigid percutaneous polyurethane or tunnelled silicone catheters (Pertine et al. [94]). An estimated 1% of central catheter placements are associated with haemorrhage, pneumothorax or infection (Stroncek et al. [107]). These risks are reduced by experienced personnel inserting the catheters with the assistance of ultrasound. In addition, placing the catheters in the femoral vein eliminates the risk of pneumothorax and these types of catheters are well tolerated for a short time (Stroncek et al. [107]). Further information about the general management of venous access devices can be found in Chapter c17: Vascular access devices: insertion and management.

It is standard practice to make use of a pre‐prepared apheresis worksheet, and this should form part of a wider quality management and document control system. Information detailed usually contains at least the information included in Box 21.3.

It is good practice to apply a local anaesthetic cream to peripheral venous access sites to minimize pain and discomfort during cannulation. Apprehensive patients may be given an oral sedative to relieve anxiety.

Anticoagulants used to prevent blood clotting in the extracorporeal circuit are usually citrate based; however, heparin is used for some procedures. If a citrate‐based anticoagulant is used, it is important that nurses are aware that electrolyte supplements may be needed during the procedure if the patient/donor experiences any signs of citrate toxicity. One example is tetany related to hypocalcaemia. An algorithm of drug management for citrate toxicity should be used to guide staff.

Replacement fluids that may be used during exchange procedures include sodium chloride 0.9%, human albumin solutions, fresh frozen plasma (FFP), cryo‐poor FFP, solvent/detergent plasma and human red cell concentrates.

Predosage of donors with corticosteroids and G‐CSF to enhance the yield of granulocyte collections is sometimes undertaken. Records of cumulative doses for each donor must be kept (Howell et al. [52]).

G‐CSF is routinely used for patients and donors to stimulate haematopoietic stem cell release and improve collection efficiency during stem cell collections by means of apheresis. Plerixafor is a more recent drug intervention that can be utilized to enhance the mobilization of stem cells for collection and subsequent autologous transplantation in patients with lymphoma and multiple myeloma who have failed to mobilize adequately with first‐line mobilization therapy, that is, chemotherapy with G‐CSF or G‐CSF alone (Chen et al. [21]). Plerixafor is an antagonist that blocks stromal cell‐derived factor (SDF)‐1‐alpha to the cellular receptor CXCR4, resulting in stem cell release from bone marrow (National Cancer Institute [82]). An additional application of plerixafor to a standard G‐CSF mobilization regimen may lead to a significant increase in stem cell release (Chen et al. [21]). Both G‐CSF and plerixafor should be used in accordance with the manufacturer's recommendations and local guidelines.

Nurses working in cell separator facilities with responsibility for patient/donor care must have knowledge of the side‐effects of any fluids and drugs used and also any drugs patients may already be taking that may affect the apheresis procedure, for example angiotensin‐converting enzyme (ACE) inhibitors (Howell et al. [52]).

An apprehensive patient will experience a sympathetic nervous system response and consequently vasoconstriction. This will diminish blood flow to the cell separator and result in a less efficient procedure. All measures should be taken to reassure and calm patients and provide them with support.