Extracorporeal cytokine elimination as rescue therapy in refractory septic shock: a prospective single-center study

Abstract

Sepsis is the most common cause of death in medical intensive care units (ICU). If sepsis progresses to refractory septic shock, mortality may reach 90-100% despite optimum current therapy. Extracorporeal cytokine adsorption in addition to regular therapy was studied prospectively in refractory septic shock patients on a medical ICU. Refractory shock was defined as increasing vasopressor dose required to maintain mean arterial blood pressure above 65 mmHg or increasing lactate levels despite protocol-guided shock therapy for 6 h. We analysed noradrenaline requirements after 6 and 12 h (primary endpoint), lactate clearance after 6 and 12 h, SOFA-scores in the first days and achievement of shock reversal (i.e., normalization of lactate concentrations and sustained discontinuation of vasopressors; secondary endpoints). Twenty consecutive patients with refractory septic shock were included; CytoSorb treatment was started after 7.8 ± 3.7 h of shock therapy. Following the initiation of adsorption therapy, noradrenaline dose could be significantly reduced after 6 (-0.4 µg/kg/min; p = 0.03) and 12 h (-0.6 µg/kg/min; p = 0.001). Lactate clearance improved significantly. SOFA-scores on day 0, 1 and 2 remained unchanged. Shock reversal was achieved in 13 (65%) patients; 28-day survival was 45%. In severe septic shock unresponsive to standard treatment, haemodynamic stabilization was achieved using cytokine adsorption therapy, resulting in shock reversal in two-thirds of these patients. The study was registered in the German Register for Clinical Trials (DRKS) No. 00005149.

Clinical Utility of Extracorporeal Cytokine Hemoadsorption Therapy: A Literature Review

“…The findings of improved serum lactate levels and decreased vasopressor requirements were replicated in a single-center prospective cohort of 20 patients with refractory septic shock, although this study's conclusions were limited by the lack of a control group with which to compare clinical outcomes [104]. None of these cases series reported any device-associated adverse effects [83,104,105]. Table 1 presents a summary of peer-reviewed articles examining the benefits of CytoSorb therapy.…”

“…Numerous case reports and case series have suggested improved clinical outcomes with hemoadsorption devices such as the CYT-860-DHP membrane [102,103], AN69ST [49,78], modified AN69ST [80], PMMA [77], and CytoSorb [83,104]. The conclusions of many of these reports, however, are hindered by small sample sizes and, at best, they advocate for larger, RCTs to evaluate any potential benefits in septic patients.…”

“…They posited that use of this therapy within 24 h of diagnosis could lead to decreased mortality in both medical and post-surgical patients [83]. The findings of improved serum lactate levels and decreased vasopressor requirements were replicated in a single-center prospective cohort of 20 patients with refractory septic shock, although this study's conclusions were limited by the lack of a control group with which to compare clinical outcomes [104]. None of these cases series reported any device-associated adverse effects [83,104,105].…”

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

“…Hemodynamic stabilization with a concomitant reduction of catecholamine dosages but also milrinone is another prominent finding associated with the application of CytoSorb hemoadsorption. A recently published prospective single-center study by Friesecke and coworkers in twenty patients with septic shock refractory to standard treatment that were treated with CytoSorb showed a significant reduction in norepinephrine dosages and shock reversal in two thirds of the patients [19]. Likewise, patients undergoing cardiopulmonary bypass-assisted cardiac surgery (including those with endocarditis) who developed post-operative hyperinflammation, showed a marked benefit from hemoadsorption treatment in terms of hemodynamic stabilization and reduction in catecholamine dosages [2,20].…”

Emelt szintű szervtámogató és életfenntartó kezelések kritikus állapotú COVID–19-fertőzött betegeken

“…Egy 2017-ben végzett vizsgálatban a noradrenalin dózisát az ilyen kezelés indítása után szignifikánsan redukálni lehetett, és a sokkfolyamat a vizsgált betegek 66%-ában visszafordítható volt. Ez a kedvező hatás a leginkább azokon a betegeken jelentkezett, akiknél a terápiát a diagnózis felállítása után 24 órán belül megkezdték [3,4]. A citokinszint redukciója klinikai tanulmányok alapján ARDS-ben is javította az oxigenizációt, a mechanikus tüdőfunkciós paramétereket, valamint mérsékelte a 'capillary leak' szindróma káros következményeit [5,6].…”