IntroductionAcute liver failure usually develops in multiple organ dysfunction syndrome and significantly increases the mortality risk in patients after cardiac surgery.AimTo assess the safety and efficacy of extracorporeal liver support in patients with acute liver failure after cardiac surgery.Material and methodsWe studied 39 adult patients with multiple organ dysfunction syndrome and acute liver failure as postoperative complication, treated with Prometheus therapy. Inclusion criteria comprised clinical and laboratory signs of acute liver failure. Criteria to start Prometheus therapies were: serum bilirubin above 180 µmol/l (reference values: 3–17 µmol/l), hepatocyte cytolysis syndrome (at least 2-fold increase in aspartate aminotranspherase and alanine aminotranspherase concentrations; reference values 10–40 U/l) and decrease in plasma cholinesterase (reference values 4490–13 320 U/l).ResultsExtracorporeal therapy provided stabilization of hemodynamics, decrease in serum total bilirubin and unconjugated bilirubin levels, decrease in cytolysis syndrome severity and positive effect on the synthetic function of the liver. The 28-day survival rate in the group treated with Prometheus therapy was 23%.ConclusionsPrometheus procedures could be recommended as a part of combined intensive care in patients with acute liver failure after cardiac and major vessel surgery. The efficiency of this method could be improved by a multi-factor evaluation of patient condition in order to determine indications for its use.

Sepsis remains the leading cause of morbidity and mortality in intensive care units. The extracorporeal therapy in the complex treatment of sepsis seems to be the most promising direction. The aim of this study was to assess the safety and effectiveness of selective endotoxin adsorption on the basis of the analysis of our own experience with the intensive therapy for sepsis in adult cardiac surgical patients. Our single-center study included 143 patients with sepsis. One hundred and three adult patients received lipopolysaccharide adsorption procedures using Toraymyxin-PMX-20R columns. The historical control group included 30 adult patients received only conservative therapy, and 10 children (6.2-14 kg) received hemoperfusion with Toraymyxin-PMX-0.5R. After the lipopolysaccharide-adsorption course, we noted improving of the hemodynamic and respiratory parameters. A favorable effect of hemoperfusion was a decrease procalcitonin and endotoxin activity assay, expressed by changes of leukocytosis, a normalization of body temperature. The 28-day survival was 53% in the study group and 30% in the control group (P = 0.037). The 28-day survival of children who received selective hemoperfusion was 90%. Our own experience with the use of selective hemoperfusion in a fairly large group of cardiovascular patients with sepsis showed the safety and efficacy of these procedures.

<b><i>Background:</i></b> To date, sepsis remains one of the main challenges of intensive care in pediatrics. Newborns with low birth weight and infants with chronic diseases and congenital disorders are particularly at risk. The incidence of infectious complications in pediatric cardiac surgery is known to be approximately 15–30%. The main etiological factor of sepsis is endotoxin. <b><i>Aim:</i></b> To evaluate the efficiency and safety of polymyxin (PMX) B-immobilized column-direct hemoperfusion in complex intensive therapy of sepsis in children after cardiac surgery with cardiopulmonary bypass. <b><i>Design:</i></b> Prospective cohort study. <b><i>Methods:</i></b> This study enrolled 15 children, aged 9–96 months, with congenital heart diseases and with body weights of 6.2–22.5 kg. The criteria for admission were body weight &#x3e;6 kg and clinical and laboratory signs of sepsis (microbiological analysis, procalcitonin [PCT] &#x3e;2 ng/mL, and endotoxin activity assay [ЕАА] &#x3e;0.6). Intensive care included inotropic and vasopressor support, mechanical ventilation, broad-spectrum antibiotic therapy, and PMX hemoperfusion procedures. Extracorporeal therapy was initiated within 24 h following the sepsis diagnosis. Every patient underwent 2 hemoperfusion sessions with the use of a PMX B-immobilized column; the session duration was 180 min. <b><i>Results:</i></b> We noted improvements in hemodynamic parameters, oxygenation index, and laboratory signs of sepsis, with decreases in the endotoxin concentration according to the EAA, PCT, and presepsin levels. The 28-day survival of the patients in this severely affected group was 80%. <b><i>Main Conclusion:</i></b> The inclusion of extracorporeal methods of blood purification, aimed at the selective elimination of circulating endotoxin, in the treatment of sepsis increases the survival rates of children after open heart surgery. <b><i>Second Conclusion:</i></b> The obtained results of sepsis therapy with PMX hemoperfusion in children after cardiac surgery enable us to suggest the sufficient safety and efficiency of the procedures in this category of severely affected patients.

Development of extracorporeal blood purification acquires greater significance in the intensive care of multiple organ failures (MOF) with all the pathophysiological aspects of its constituent parts. MOF are the main cause of mortality among critically ill patients and treatment of these patients require significant investment. The purpose of the implementation of extracorporeal blood correction techniques today is multiple organ support therapy (MOST). Early extracorporeal therapy is used only in the treatment of renal failure. Today extracorporeal techniques are increasingly being used to replace the functions of various organs and systems. MOST includes diffusion, convection, filtration, sorption, apheresis methodic. They affect the molecular and electrolyte composition of blood, allow to correct, repair, replace, and maintain homeostasis in severe multiorgan dysfunction. Extracorporeal new molecular technologies have been successfully applied in the intensive care of severe heart and respiratory failure, acute kidney injury and acute hepatic dysfunction, in the treatment of severe sepsis, metabolic disorders, the correction of immune imbalance.

Molecular techniques in transfusion medicine have become popular in the clinical practice of pediatric intensive care units when the patient needs blood purification, more recently, in children in critical condition. Considering the anatomical and physiological characteristics of the child’s body, pronounced severity, and rapid progression of multiple organ disorders, the key problems defining the treatment results are instrument reading, choice and timely initiation of extracorporeal therapy. Today, along with the methods of renal replacement therapy in children albumin dialysis therapy and high-volume plasmapheresis are successfully applied in the treatment of acute liver dysfunction; extracorporeal membrane oxygenation — in the treatment of biventricular cardiac and/or respiratory failure. Selective endotoxin sorption methods (LPS-adsorption) are implemented in the treatment of severe gram-negative sepsis.

How to cite this article: Yaroustovsky M, Abramyan M, Komardina E, Nazarova H. Blood purification in intensive care patients with multiple organ dysfunction syndrome and sepsis after cardiac surgery. Vessel Plus 2017;1:49-60.Extracorporeal blood purification is becoming increasingly important in intensive therapy for multiple organ dysfunction syndrome (MODS) and sepsis, considering all of their pathophysiological aspects. The results of treatment, particularly in children, considering their anatomical and physiological features, are related to the severity and progression of organ failure, the indications that are found, the choice of method, and the timely initiation of blood purification. Multiple organ support therapy is the aim of introducing and applying blood purification today. Various extracorporeal blood purification techniques directly affect the molecular and electrolyte composition of blood and influence all structures of the human body, which can allow us to correct, recover, replace and maintain homeostasis in MODS. The potential of new extracorporeal molecular technologies allows their successful use in severe cardiac and respiratory failure, acute kidney injury and hepatic dysfunction and in complex therapy for severe infections and sepsis and extreme metabolic violations. Adult and pediatric patients after cardiac surgery with cardiopulmonary bypass form a special cohort that often requires the application of various intra-and extracorporeal techniques due to the development of MODS, infections and sepsis in the postoperative period. Key words:Extracorporeal blood purification, acute kidney injury, acute liver failure, extracorporeal membrane oxygenation, sepsis, selective lipopolysaccharideadsorption, critical condition, cardiovascular surgery ABSTRACT Article history:

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Aim: To assess the safety and efficiency of H.E.L.P.-apheresis and cascade lipid-filtration in the treatment of severe lipid disorders in high-risk patients. Methods: From 2016 to 2018 we observed 6 patients hyperLDLemia and high Lp(a)emia (> 60 mg/dL). The first group with H.E.L.P.-apheresis (n = 74 sessions) included 3 patients who underwent revascularization (coronary, femoral arteries). In the second group with cascade lipid-filtration (n = 92 sessions)-one patients underwent revascularization, two patients received drug therapy. Despite the lipid-lowering conventional therapy, no targeted low density lipoprotein (LDL) was obtained. Results: The patients of the 1st group had threefold decrease of LDL, in patients of the 2nd group LDL decreased by 68%. At the same time, in both groups, we noted a decrease in Lp(a) after the procedure by 65%-68%. Despite a decrease in high density lipoprotein (by 22%-29%) after lipid apheresis procedures, there was a positive trend in apoB100/apoA index (a decrease of 33% after HELP-apheresis procedures and 60% after cascade lipid-filtration) and a decrease in atherogenic index (38% and 53%, respectively). The changes in hematological and haemostatic parameters remained within physiological intervals. Conclusion: We noticed the successful application of lipid apheresis in patients with multifocal atherosclerosis and its complications.