Combined Extracorporeal Therapy for Severe Sepsis in Patients after Cardiac Surgery

Abstract

Introduction: Sepsis still represents an obstacle in modern medicine. The aim of this study was to evaluate the effectiveness and safety of the combined use of lipopolysaccharide adsorption and haemodialysis (HD) with high cut-off haemofilters as part of the complex intensive care of patients with severe sepsis after cardiac surgery. Methods: The study group included 26 patients, 57 (48-62) years of age, with severe sepsis. The inclusion criteria were clinical signs of severe sepsis (systemic inflammatory response syndrome + infection site + failure of two or more organs) together with endotoxin activity assay (EAA) ≥0.6 and procalcitonin (PCT) levels ≥2 ng/ml. Antimicrobial therapy was initiated in the first hour after the diagnosis of severe sepsis and extracorporeal therapy was initiated within 24 h. All of the patients in the study group received standard therapy. Additionally, they received treatment consisting of two LPS adsorption procedures and HD procedures with high cut-off haemofilters in a single circuit. For the control group, 30 comparable patients, 57 (51-61) years of age, were selected and received only standard therapy. Results: After the last HD procedure within the extracorporeal therapy, we noted an increase in the mean arterial pressure from 76 to 90 mm Hg, p < 0.01, and oxygenation index (from 226 to 291, p < 0.02), in addition to decreases in the LPS concentration according to EAA (from 0.73 to 0.59, p < 0.01) and the Limulus amebocyte lysate test (from 1.44 to 0.36 IU/ml, p < 0.01); PCT falls from 8.19 to 2.44 ng/ml, p < 0.01, and sepsis-related organ failure assessment scores decreases from 13 to 10, p = 0.007. When we compared the data between the study group the day after the procedures and the control group 3 days after the start of intensive care, we discovered that there were statistically significant differences in mean arterial pressure (90 vs. 81 mm Hg, p = 0.0004), oxygenation index (291 vs. 229, p = 0.01), and EAA levels (0.59 vs. 0.67, p = 0.05). Differences in the PCT were not significant (2.44 vs. 3.41, p = 0.15). The 28-day survival rate in the study group was higher than that in the control group (65.4 vs. 33.3%, p = 0.03). Conclusion: The combined use of LPS adsorption and HD with high cut-off haemofilters in conjunction with standard therapy is a safe, effective method for treating patients who have severe sepsis.

Blood purification in intensive care patients with multiple organ dysfunction syndrome and sepsis after cardiac surgery

“…Bakulev NSPCCS in 2009-2016, showed the safety and efficacy of the combined therapies mentioned above. [53,54] We observed that the combination of LPS-adsorption and HDF filters with high cut-off EMiC2 membranes led to a 34% MAP increase [from 76 (65)(66)(67)(68)(69)(70)(71)(72)(73)(74)(75)(76)(77)(78)(79)(80)(81) to 90 (85-102) mmHg, P < 0.001] with reduced vasopressor and inotropic support. The increase in MAP during LPS-adsorption with CPFA was 12% with the significant decrease in vasopressor support [the dose of noradrenaline was halved from 0.2 (0.15-0.3) to 0.1 (0.05-0.15) µg/kg/min, P = 0.024].…”

“…[47,51,52] Modern methods of blood purification allow etiopathogenic therapy application for sepsis: to eliminate the etiotropic agent (endotoxin) by selective lipopolysaccharide (LPS)-adsorption and to remove the effector substances of systemic inflammation, replacing the functions of the affected organs and recovering the body's homeostasis by coupled plasmofiltration and adsorption (CPFA), convection and filtration techniques using ultrahigh permeable membranes. [53,54] Many authors have observed that LPS-adsorption with PMX cartridges leads to a significant decrease in endotoxin activity levels after two consecutive procedures. [55] Positive dynamics of the endotoxin concentration (lowering by 38%) in patients with abdominal sepsis and septic shock were demonstrated in the European multicenter study "EUPHAS".…”

“…[52,63] Our experience with combined application of various techniques in a single circuit (LPS-adsorption + CPFA and LPS-adsorption + HD/HDF using filters with high cut-off membranes) showed their safety and pathogenic efficiency. [53,54] The application of convection and filtration techniques (CPFA, HDF using filters with high cut-off membranes) allows the correction of water-electrolyte and metabolic disorders and azotemia, which often accompany sepsis-associated MODS. [64][65][66][67] LPS-adsorption using Toraymyxin-PMX-20R Polymyxin B immobilized fiber cartridges was found to be effective, simultaneously acting through sorption and apheresis on bacterial endotoxin, systemic inflammatory mediators and activated immune cells.…”

“…Both variants of combined blood purification contributed to decreases in C-reactive protein (CRP) and pro-inflammatory cytokine levels, thus confirming the decrease in the intensity of the systemic inflammation response. [53,54] Including combined blood purification methods into the complex therapy for sepsis allowed the results of treatment to be optimized. The 28-day survival was 65% in the LPS-adsorption + HDF with EMiC2 group and 75% in the LPS-adsorption + CPFA group.…”

Is Procalcitonin Reduction Indicative of Immunomodulation in Septic Patients Treated with Hemodialysis with High Cutoff Membrane?

“…I read with great interest the article published in your journal by Yaroustovsky et al [1] regarding the beneficial effects of combining hemodialysis with high cutoff membranes (continuous venovenous hemodiafiltration with high cutoff membranes, HCO-CVVHD) and lipopolysaccharide adsorption in cardiac surgery patients with severe sepsis. The authors reported that the benefits of using extracorporeal therapies were demonstrated by several changes in the parameters analyzed, including the reduction of procalcitonin (PCT) during treatment.…”