Intensive blood and plasma exchange for treatment of coagulopathy in meningococcemia

Abstract

Eight pediatric patients with fulminant meningococcemia, purpura, and disseminated intravascular cogulation who by multiple prognostic scoring systems were anticipated to have a poor outcome underwent intensive plasma exchange (IPE) or whole blood exchange (WBE) in addition to standard medical therapy. IPE/WBE was initiated shortly after admission with a mixture of both fresh frozen plasma and cryoprecipitate as the replacement solution. All IPE procedures were performed using a continuous flow system and a red cell prime. The mean fibrinogen level increased from 62 to 192 mg/dl, the prothrombin time (PT) decreased from a mean of 32.4 seconds to 15.1 seconds, and the mean activated partial thromboplastin time (APTT) decreased from 89.5 seconds to 40.1 seconds following completion of the initial IPE/WBE. There was a corresponding improvement in all coagulation factor levels but only slight improvement in antithrombin III (ATIII) and protein C levels. Seven of eight patients survived (87.5%) their initial presentation with the sole early death attributed to meningitis with cerebral edema. Mean fluid balance after the procedure was +10.8 +/- 5.87 cc/kg. There were no significant bleeding or cardiovascular complications during the procedure. There was no clinical or radiographic evidence of fluid overload after the procedure. This experience demonstrates that IPE/WBE may be conducted safely in critically ill, unstable pediatric patients and is effective in rapidly improving coagulopathy without fluid overload.

Fulminant Meningococcal Sepsis: Localized Outbreak of Three Patients Treated with Therapeutic Plasma Exchange by Membrane Filtration

“…All patients treated with adjunctive TPE survived to discharge. Our experience supports the data from Churchwell et al [11] and Van Deuren et al [12] that TPE improves mortality in meningococcal sepsis and is well tolerated. At our center all TPE procedures were performed using membrane filters and renal support equipment already available in the ICU by critical care personnel as opposed to the centrifugation technique of plasma exchange which requires specialized personnel and equipment.…”

“…Unfortunately, these trials were not conclusive of a benefit. There have been a number of small case series of fulminant meningococcemia treated with plasma or blood exchange [11,12,20] . In the absence of randomized controlled data supporting any one intervention, we used TPE in addition to conventional therapy to help support our patients with an otherwise devastating, rapidly fatal disease.…”

“…Churchwell et al [11] have shown rapid correction of coagulopathy and a mortality benefit with plasma exchange in a series of 10 patients with meningococcal sepsis. Van Deuren et al [12] have shown that plasma exchange was safe and improved mortality in a case series of 13 patients with meningococcal sepsis.…”

Plasma exchange therapy for thrombotic microangiopathies

“…22,28,29,31,32,[44][45][46][47][48][49][50][51] For example, Stegmayr et al reported in a large case series that adults with DIC and MOF who received plasma exchange had an 82% survival compared to <20% observed survival in historical controls. 31 Pene et al reported that plasma exchange in adults with TMA triggered by infections was independently associated with lower mortality, regardless of disease severity [Hazard Ratio = 0.234 (Confidence Interval 95%: 0.095-0.573), p = 0.001].…”

“…25 In DIC, plasma exchange is hypothesized to remove tissue factors, PAI-1 and replenish antithrombin III, protein C and S and tissue plasminogen activator inhibitor. [28][29][30][31][32] In essence, plasma exchange attempts to bring the patient's plasma from dysregulated prothrombotic and antifibrinolytic states back to its homeostatic milieu.…”