Plasma Chasers and the Quiet Rituals of Apheresis

Two different patients. Two plasma exchange treatments. Two nurses asking me, gently and matter-of-factly, the same question: “Do you want to chase with some plasma?”

Before becoming an attending, I had never heard the phrase. It wasn’t part of residency, fellowship, ASFA courses, or any protocol I’d ever followed. It certainly isn’t in textbooks. The first time someone asked me, I wondered whether this was a regional term or a long-standing tradition I’d somehow missed.

What I’ve realized is that “plasma chasers” aren’t a formal practice at all—they’re a local solution to a real physiologic concern, passed down through experience rather than evidence.

And once I understood that, the whole thing made much more sense.

Two Encounters, Two Decisions

The first patient had an endomyocardial biopsy two days before their TPE. That felt like a clear “yes.” Even a small pericardial bleed can turn into tamponade quickly, and albumin-only exchanges temporarily lower fibrinogen in exactly the wrong moment.

The second patient had a chest-tube exchange two days prior. Compressible, external, and not associated with catastrophic rebleeding after 48 hours. That one was a comfortable “no.”

Both decisions felt reasonable. But afterward, I found myself thinking about why the question exists in the first place — and why different centers use different rituals to manage uncertainty.

Ambiguity Breeds Ritual

During my PhD years, I saw how easily small rituals form in the lab.

The postdoc who said you had to swirl counter-clockwise for best DNA yields.

The technician who swore PCR only worked if she spun down tubes twice.

The graduate student who insisted cells behaved better if passaged on Tuesdays.

None of these traditions were harmful. They were simply the human response to complex systems with hidden variables. When outcomes are unpredictable and stakes feel high, it’s natural to reach for anything that offers a sense of control.

Clinical medicine is no different.

Apheresis has many moving parts, physiology we can’t always observe directly, and very little high-quality evidence for the fine details of practice. It’s not surprising that different institutions develop their own habits — some sound, some questionable, some simply inherited.

“Plasma chasers” live right in that space.

What the Survey Data Actually Tell Us

Before I wrote this, I went looking for anything peer-reviewed about plasma chasers specifically. There isn’t anything — not a single survey or guideline entry.

But there is a published ASFA-linked survey (Zantek et al., J Clin Apher 2018) about hemostasis management and replacement fluid decisions. And the results were eye-opening:

• When a patient had major surgery just one day earlier, 8.9% of respondents still used albumin-only replacement, a much higher percentage than I expected.

• For minor procedures one day prior, 49.5% used albumin-only, and 50.5% included some or all plasma. That’s about a 50/50 split.

• For a patient scenario with no bleeding risk, 94.7% used albumin-only. Which is still short of 100% like I expected.

  
  

To me, that’s fascinating. It shows how inconsistent — and how intuitive — these decisions really are.

Clinicians are already making judgment calls about post-procedure bleeding risk every day, even without formal algorithms. Plasma chasers are simply a more granular version of that same instinct: Does this patient need some factors right now? Could a small bleed matter?

The Framework That Actually Makes Sense

When I strip away the inherited rituals, peer pressure, institutional memory, and “this is how we do it here,” the physiologic picture becomes surprisingly straightforward.

Use a plasma chaser when:

• The patient had an endomyocardial biopsy < 72 hours.

• The patient had a renal biopsy < 72 hours.

• There is a fresh injury in a space where even a small bleed can be dangerous before it becomes obvious.

  
  

These are the scenarios where a little post-exchange factor support truly makes sense.

Consider partial FFP replacement when:

• A patient has severe allergic reactions to plasma but still needs some factor replacement.

• A patient is highly citrate-sensitive, and full FFP carries risks.

  
  

Use full FFP replacement when:

• The indication is TTP.

• There is active or recent major bleeding.

• There is a high-risk coagulopathy.

  
  

Use albumin-only when:

• A small bleed won’t be catastrophic, such as with chest tubes, lumbar punctures, and GI biopsies.

• There’s no compelling reason for factor support.

  
  

This framework isn’t mystical. It isn’t ritualistic. It’s just physiology, risk, and common sense.

Why I’m Writing About This

I’m not criticizing the practice of plasma chasers. In many ways, I admire the quiet wisdom embedded in these unofficial patterns of care. They represent clinicians trying to do the safest thing for their patients in a landscape where evidence is incomplete.

But I also believe there’s value in naming the uncertainty, reflecting on it, and disentangling ritual from reasoning.

I don’t think we talk enough about the gray zones in our specialty — the places where we make decisions based on physiology, pattern recognition, and a little bit of fear of the worst-case scenario.

And I think there’s a kind of comfort in acknowledging that these instincts come from somewhere real.

Because in the end, apheresis is full of places where the science is incomplete, and the art of medicine steps in — not as hoodoo, but as thoughtful, experience-guided care.