Eficacia de la terapia hemoadsortiva combinada con hemofiltración de alto volumen en el manejo del shock séptico refractario

Abstract

IntroductionSeptic shock continues to be one of the main causes of mortality in intensive care units. Recently, hemoadsorption therapies have emerged as an additional tool to address this pathology, contributing to reestablishing the patient's immune homeostasis. However, there are still doubts about the effectiveness of these interventions and it is necessary to improve knowledge about their application in clinical practice. ObjectiveAssess the impact of combined hemoadsorptive therapy and high-volume hemofiltration in the treatment of refractory septic shock in a non-concurrent patient cohort, analyzing clinical and laboratory parameters. MethodsA non-concurrent review of patients admitted to the intensive care unit with refractory septic shock who received hemoadsorptive associated with high-volume hemofiltration therapy over a period of five years (2016-2020) was conducted. Clinical variables, including age and gender, APACHE II and SOFA scores, vasopressor requirements, laboratory parameters, as well as in-hospital mortality and mortality at 30 and 90 days, were analyzed. Descriptive statistics were calculated, and pre- and post-therapy variables were compared using the Mann-Whitney test. ResultsThe mean age of the cohort was 54.57 years and consisted of 14 patients. Hemoadsorptive therapy was associated with a reduction in vasopressor requirements, with a median initial requirement of noradrenaline of 0.7μg/kg/min (IQR 0.45-0.8875) that decreased to 0.12μg/kg/min (IQR 0-0.225) after therapy. The total normalized vasopressor requirement to noradrenaline at the start of therapy was 0.8125μg/kg/min (IQR 0.56-1.08), and after therapy, it was 0.175μg/kg/min (IQR 0.01-0.29). All patients received norepinephrine as the primary vasopressor agent. 71.4% had additional treatment with adrenaline, 28.6% with vasopressin, and only 7.1% were supplemented with dobutamine.The median APACHE II scores pre- and post-therapy were 30.5 and 20.5, respectively, while the SOFA scores were 13.5 and 11.5. Mean lactate levels decreased by 60%, from 7.47mmol/l pre-therapy to 2.97 mmol/l post-therapy. Inflammatory parameters, such as C-reactive protein, mean procalcitonin levels decreased from 206mg/dl to 180mg/dl, mean level of procalcitonin decreased from 58 to 8.91ng/ml. Hospital mortality was 57%, increasing to 64% at 90-day follow-up. ConclusionIn our non-concurrent cohort of 14 patients, hemoadsorptive therapy combined with high-volume hemofiltration demonstrated encouraging results in the treatment of refractory septic shock, significantly improving intermediate outcomes such as vasopressor requirements, lactate levels, and inflammatory parameters. However, our results in hard outcomes, such as mortality, were similar to those reported in cases of refractory septic shock without the use of this therapy, which allows us to consider them as a historical control group. These results are promising and justify the need for larger cohort studies to evaluate the impact of hemoadsorptive therapy on long-term mortality and explore its potential role as a standard treatment option for refractory septic shock.