Application of Hemoadsorption in Neonatal and Pediatric Hyperinflammatory States: A Case Series

Abstract

Objective: Extracorporeal blood purification therapies are increasingly applied in the field of intensive care medicine. Compared to filtration-based methods mainly used for renal replacement therapy, newest adsorptive approaches have shown to specifically target the inflammatory cascade by the effective removal of relevant mediators. In the neonatal and pediatric setting however, the application of these methods brings with it various challenges but also profound technical difficulties. Recently, a promising extracorporeal device for cytokine adsorption (CytoSorb) was introduced. However, data for its application in critically ill pediatric patients remains sparse. Design: Single center retrospective case study; Setting: Tertiary neonatal and pediatric general intensive care unit; Patients: The study comprised 10 critically ill pediatric patients; Interventions: We describe the use of CytoSorb in combination with standard therapy, continuous renal replacement therapy (CRRT) and plasmapheresis in ten severely ill pediatric patients with multiple organ failures of various etiologies; Measurements: The aim was to assess the effects on the inflammatory status, hemodynamics, and clinically relevant outcome parameters as well as the feasibility and safety of CytoSorb application in pediatrics; Main Results: We observed a marked decrease in inflammatory mediators, a reduction in catecholamine dosages and an improvement in organ functions, which was particularly pronounced in patients who survived. An early onset of treatment (at best within 24-48 hours after diagnosis of sepsis) seemed to be beneficial for eventual survival. Conclusions: The present case series is the first documentation of a set of pediatric/neonatal patients in which a combined therapeutic approach of hemoadsorption and renal replacement therapy showed promising results with regard to hemodynamic stabilization, control of the inflammatory response, improvement in organ functions as well as safety and feasibility. Further prospective randomized controlled studies in the pediatric field are necessary to elucidate the full potential of hemoadsorption in this set of patients.

The Potential Role of Extracorporeal Cytokine Removal in Hemodynamic Stabilization in Hyperinflammatory Shock

“…Out of the 163 clinical articles available in PubMed, 58 were identified that mentioned "catecholamines and/or vasopressors". In total, 25 papers were excluded; 12 because of non-comparability of the measurement scales [25][26][27][28][29][30][31][32][33][34][35][36]; 4 because the type and dose of vasopressors were not specified [37][38][39][40]; 1 that reported combined norepinephrine and epinephrine doses [41]; 1 that only reported on patients that had survived [42]; and 7 where there were no measurements pre-and post-adsorber use in the same patient [43][44][45][46][47][48][49]. The remaining 33 articles were summarized without considering different study designs or duration of treatment.…”

Our Four Years Experience of Hemoadsorption, Albumin and Heparin Treatment for Paediatric Sepsis: Let’s Give a Chance in Multifactorial Pathological Conditions

“…We observed a marked decrease in inflammatory mediators, a reduction in catecholamine dosages and an improvement in organ functions, which was particularly pronounced in patients who survived. An early onset of treatment (at best within 24-48 hours after diagnosis of sepsis) seemed to be beneficial for eventual survival [1]. These results were not "our first aim or intention" when we applied Cytosorb for the first time.…”

“…The use of CytoSorb allowed us to obtain a rapid improvement of the hemodynamic conditions, the upgrading of renal and pulmonary functions, the reduction of vasopressors and the resolutive reduction of "cytochine storm" in several dramatic condition [1][2].…”

“…We describe the use of Cytosorb in combination with standard therapy, continuous renal replacement therapy (CRRT) and plasmapheresis in 20 severely ill pediatric patients with multiple organ failure of various etiologies. This is a historical report of our clinical decisions pathway and of the changes we made in the applicative utilization of Cytosorb during a period of 4 years with particular attention to the story of patient cases that we consider as a turning point that supported our therapeutic strategy changes ( Figure 1) [1].…”

Exchange Transfusion in Neonatal Sepsis: A Narrative Literature Review of Pros and Cons

“…Several studies have reported that PE in neonates results in improvement of multiple organ failure caused by septicemia [ 65 ]. Recently, as the new technology of extracorporeal PE hemoabsorption devices for cytokine reduction (such as Toraymyxin (Toray, Tokyo, Japan) [ 66 ] and CytoSorb (CytoSorbents Europe, GmbH, Berlin, Germany) [ 67 , 68 ]) has been introduced, contributing to the achievement of rapid hemodynamic stabilization in neonatal and pediatric patients with refractory septic shock. However, using PE in neonates is considered a challenge due to the relatively large extracorporeal blood volume in relation to the apheresis machines, which are developed for adults.…”