Abstract
BackgroundSeveral case series and small randomized controlled trials suggest that therapeutic plasma exchange (TPE) improves coagulation, hemodynamics and possibly survival in severe sepsis. However, the exact role of TPE in modern sepsis therapy remains unclear.MethodsWe performed a retrospective observational single-centre study on the use of TPE as rescue therapy in 23 consecutive patients with severe sepsis or septic shock from 2005 to 2012. Main surrogate markers of multiple organ failure (MOF) before, during and after TPE as well as survival rates are reported.ResultsAt baseline, mean SOFA score was 13 (standard deviation [SD] 4) and median number of failed organ-systems was 5 (interquartile range [IQR] 4–5). TPEs were performed 3 days (IQR 2–10) after symptom onset and 1 day (IQR 0–8) after ICU admission. The median total exchange volume was 3750 ml (IQR 2500–6000), which corresponded to a mean of 1.5 times (SD 0.9) the individual plasma volume. Fresh frozen plasma was used in all but one treatments as replacement fluid. Net fluid balance decreased significantly within 12 hrs following the first TPE procedure by a median of 720 mL (p = 0.002), irrespective of outcome. Reductions of norepinephrine dose and improvement in cardiac index were observed in individual survivors, but this was not significant for the overall cohort (p = 0.574). Platelet counts decreased irrespective of outcome between days 0 and 2 (p < 0.003), and increased thereafter in many survivors. There was a non-significant trend towards younger age and higher procalcitonin levels among survivors. Nine out of 23 TPE treated patients (39%) survived until ICU discharge (among them 3 patients with baseline SOFA scores of 15, 17, and 20).ConclusionsOur data suggest that some patients with severe sepsis and septic shock may experience hemodynamic stabilisation by early TPE therapy.
Highlights
Several case series and small randomized controlled trials suggest that therapeutic plasma exchange (TPE) improves coagulation, hemodynamics and possibly survival in severe sepsis
We report our single-centre experience with TPE as rescue therapy in 23 consecutive patients admitted for severe sepsis or septic shock between 2005 and 2012
The Ethics Committee of the Hannover Medical School waived the need for ethical approval and informed patient consent, as i) data acquisition was retrospective observational within our clinic, ii) data were de-identified, and iii) the study relied on measurements and rescue therapies applied as part of routine care
Summary
Several case series and small randomized controlled trials suggest that therapeutic plasma exchange (TPE) improves coagulation, hemodynamics and possibly survival in severe sepsis. The rationale for the use of therapeutic plasma exchange (TPE), a non-selective intervention, is to remove multiple toxic mediators including endotoxins, proinflammatory cytokines and procoagulant factors. Depleted plasma factors involved in the homeostasis of microcirculation are replenished by TPE [8]. One such factor could be a disintegrin-like and metalloprotease with thrombospondin type 1 repeats (ADAMTS) that regulates primary hemostasis by proteolyzing von Willebrand factor and is possibly involved in disseminated intravascular coagulation due to severe sepsis [9]
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