We describe a 6-year-old boy who presented with massive
hemolysis,
shock, disseminated intravascular coagulopathy, and
acute renal failure after loxosceles envenomation. In this patient,
plasma exchange therapy (PEX) successfully cleared the plasma from an initial hemolytic index of 2000 (equivalent to 2 g/dL
hemoglobin, where optimetric laboratory evaluation is impossible) to an index of <50 (no detectable
hemolysis). This allowed the PICU team to correct his coagulopathy, assess his degree of organ dysfunction, and provide routine laboratory assessments during
continuous venovenous hemodiafiltration. After 9 single volume PEX sessions, his
hemolysis and coagulopathy had resolved and his plasma had cleared sufficiently to permit routine laboratory assessments without difficulty. Multiorgan system support with an aggressive transfusion strategy,
mechanical ventilation, inotropes, and
continuous venovenous hemodiafiltration resulted in complete recovery. We conclude that in the presence of overwhelming
hemolysis, plasma can become so icteric that optimetric laboratory evaluation is impossible. In this setting, PEX can be used to clear the plasma, restoring the ability to perform routine laboratory assessments.