Hemoperfusion Research Articles

Extracorporeal Removal Techniques for the Poisoned Patient: A Review for the Intensivist

The kidney is able to rapidly eliminate many water-soluble xenobiotics (exogenous chemicals). However, in the face of extraordinary serum concentrations of these xenobiotics or renal dysfunction, alternative elimination techniques often become necessary. Extracorporeal removal (ECR) techniques are used to increase the clearance of xenobiotics. These techniques include hemodialysis (HD), charcoal hemoperfusion (HP), and modalities grouped under the heading of continuous renal replacement therapy (CRRT): continuous venovenous hemofiltration (CVVH) and continuous venovenous hemodiafiltration (CVVHDF). Extracorporeal removal is limited to patients with significant or potentially significant clinical poisoning because the resources required to perform ECR are great. Therefore, most patients who are treated with these techniques are being cared for in intensive care units (ICUs). Our goal in this review is to discuss the properties that make xenobiotics amenable to removal by ECR and the advantages and disadvantages of the individual techniques. We discuss xenobiotics that constitute clear indications for ECR, including the toxic alcohols, salicylates, and lithium. We review the use of CRRT, a modality for which clear indications for treatment of poisonings are currently lacking.

130: Hemoperfusion (HP) vs Hemodialysis (HD) In a Case of Combined Overdose (OD) With Acetaminophen and Valproic Acid (VPA): Implications of Our Findings

130: Hemoperfusion (HP) vs Hemodialysis (HD) In a Case of Combined Overdose (OD) With Acetaminophen and Valproic Acid (VPA): Implications of Our Findings

Effect of hemoperfusion on clearance of organophosphorus in rabbits poisoned by methamidophos.

Objective To evaluate the clearance efficacy of resin hemoperfusion(HP) on the removal of organophosphorus in the rabbits poisoned by methamidophos(MAP) and its effects on organ injury. Method Six-teen healthy Japanese white rabbits were randomly divided into HP group and non-HP group. MAP was given through gastric tube in a dosage of 20 mg/kg to rabbits of both groups. Rabbits of liP group received resin hemop-ersion plus conventional treatment including early gastric lavage, atropine and pralidoxime. Rabbits of non-HP group received only conventional treatment. The plasma concentration of MAP was determined by using gas chro-matography before and after rabbits were poisoned at different intervals. Serum choline esterase (ChE),lactic de-hydrogenase (LDH), alanine aminotransferase (ALT), aspartate aminotransferase (AST), creatine kinase (CK) and creatine kinase isoenzyme (CK-MB) of rabbits of both groups were assayed 6 hours after rabbits poisoned. Pathological changes in lung, liver, kidney and muscle were investigated simutaneously. SPSS 10.0 software was used for statistical analysis. The comparison between groups was carried out by using t -test. Results ① The typical symptoms of organophospborus poisoning were occurred in rabbits within 5 - 10 minutes after ingestion of MAP. In HP group, the plasma levels of rabbits before,and 30 min,60 min,90 min and 120 min after hemoperfu-sion were (11.43±1.56),(7.82±1.54),(4.97±1.58),(5.66±1.75) ,(5.49±1.68) μg/mL, respectively (P <0.01). After hemoperfusion, the plasma MAP levels of rabbits in HP group were lower than those in non-HP groups (P < 0.01). The improveme, nt of clinical presentation of rabbits was observed shortly after HP. ② The blood choline esterase activity of rabbits were depressed in hoth groups without significant difference. In contrast, the blood levels of ALT, AST,LDH,CK and CK-MB of rabbits in non-HP group elevated significantly than in HP group (P < 0.01). ③ The more severe injury of muscle, liver, kidnet and lung of rabbits can could be seen in non-HP group. Conclusions ① HP can effectively eliminate the plasma MAP and has the potential to improve the clinical presentation of intoxication in rabbits. ② Early intervention of Hp exerts a protection from organ dam-age of organophosphorus pesticide. Key words: Hemoperfusion; Poisoning; Methamidophos; Clearance; Organ injury

Polymyxin B Hemoperfusion Improves Outcomes in Abdominal Septic Shock

Gram-negative bacteria, alone or in combination with other organisms, are frequent causes of severe sepsis and septic shock from abdominal infections.

Effect of hemodialysis with hemo-perfusion on microinflammatory and vascular endothelial function of chronic hemodialysis patients

Objective To investigate the effect of hemodialysis with hemo-perfusion on microinflammatory and vascular endothelial function of chronic hemodialysis patients. Methods Twenty hemodialysis patients were divided into two groups, 10 patients received hemodialysis therapy for four times (as control group), and 15 patients received hemodialysis with hemoperfusion(HD+HP) therapy for four times. The level of TNF-α and sVCAM-1 were detected before therapy and after therapy for four times. Results The level of TNF-α and sVCAM-1 in chronic hemodialysis patients were higher than that of control group; The level of TNF-α were positive correlated with the level of sVCAM-1 (r=0.674, P 0.05). Conclusions Microinflammatory possibly lead to vascular endothelial function damage in chronic hemodialysis patients.Hemodialysis with hemo-perfusion could effectively reduce microinflammation and alleviate vascular endothelial function damage in chronic hemodialysis patients. Key words: Hemodialysis; Hemo-perfusion; Microinflammation; Endothelia cell

Clinical efficacy and nursing of hemoperfusion (HP) in the treatment of patients with severe organic phosphorus pesticide poisoning

Objective To discuss the clinical efficacy and nursing methods of hemoperfusion (HP) in the treatment of severe organic phosphorus pesticide poisoning (AOPP). Methods 48 cases of severe organic phosphorus pesfcide poisoning were randomly divided into the conventional therapy group (22 cases) and the blood perfasion group (26 cases). The conventional therapy group received stomach lavage, liquid supplement, diuresis, catharsis, and drug therapies of atropine and pralidoxime. The bemoperfusion group received the treatment of blood perfusion for 1 ～ 3 times on the basis of the conventional treatments and the corresponding observation and nursing. Results The time of coma to sober and the hospitalization time were shorter, the total amount of atropine was less and the cure rate was higher in the hemoperfusion group compared to those in the conventional therapy group (P < 0.05). Conclusions The hemoperfusion in combination with conventional medical treatments is the most effective way to rescue severe organic phosphorus pesticide poisoning. The corresponding nursing should be given to the patients during the therapy. Key words: Hemoperfusion; Organic phosphorus pesticide; Poisoning; Emergency nursing

Assessment of liver fibrosis in different degree: preliminary study on multi-slice CT perfusion imaging

Objective To evaluate the role of multi-slice CT (MSCT) perfusion in early diagnosis of liver fibrosis. Methods Thirty-three subjects underwent CT perfusion of the liver. Among whom, 11 subjects were volunteers without hepatic disease and the other 22 subjects were pathologically confirmed with liver fibrosis who were further divided into slight (n= 10) and severe (n=12)liver fibrosis according to the lshak system. Parameters of CT perfusion were measured and compared among three groups. Results The mean hepatic arterial fraction in controls, light and severe fibrosis tended to increase with the severity of liver fibrosis[(18. 49 ± 9. 69) %, (19. 92 ± 6.01) % and (21.31±7.47)% ,respectively], and the mean mean transit time tended to decrease with the severity of liver fibrosis [(13.80 ± 2. 60) s, (12.35 ± 1.31) s and (12.19 ± 3.33) s, there was no significant difference in all parameters between any two groups (P>0.05). Conclusions Quantitative measurement of hepatic blood supply can be obtained by CT perfusion. Some parameters will be helpful in staging fibrosis to a certain extent. But its clinical usefulness for the evaluation of the early diagnosis may not be affirmed yet. Key words: Liver cirrhosis; Tomography, spiral computed; Hemoperfusion

Effects of hemoperfusion on toxic ingredients in plasma and histopathology in acute rabbits with acute intoxication of Radix Aconiti Kusmezoffii Monkshood

Objective To explore effects of hcmoperfusion on toxic ingredients in plasma of rabbiis with a-cute intoxication of Radix Aconiti Kusmezoffii Monkshood.Method Sixteen male Japanese Giant Ear Rabbits were randomly divided into acute poisoning(AP)group and acute poisoning + hemoperfusion(AH)group(8 an-hnals in each group).Acute poisoning models were established in rabbits of both groups with intragastric adminis-tration of Radix Aconiti Kusmezoffii Monkshood liquid in dose of 1 mL/kg in order to produce arrhythm which oc-curred within ode hour after intragastric administration was regarded as the criteria of successful animal model.and then hemoperfusion with active carbon was performed for 2 hours in AH group.The pathological chanses of brain,myocardium and hepatic tissues were observed.The plasma concentrations of toxicants including mesaconitine,a-conitine and hypaconitine were measured by using HPLC-MS at 1 h,2 h,3 h,and 6 h after poisoning.Student's T test was used to identify the significance.Results The brain.myocardium and hepatic tissues of the rabbits in AP group showed hyperemia and edema which were attenuated after hemoperfusion.The plasma concentrations of mesaconitine,aconitine and hypaconitine revealed no significant differences between AP group and AH group with-in one hour after poisoning(P＞0.05),while at 2 h and 3 h after poisoning,the plasma concentrations of mesaconitine were(2.11±1.08)ng/mL,(2.02±1.46)ng/mL,respectively,aconitine(39.70±9.31)ng/mL,(19.71±16.06)ng/mL,respectively,and hypaconitine(1.70±0.71)ng/mL,(2.12±1.33)ng/mL,respec-fively in AH group,and they were significantly lower than those in AP group(P＜0.05).Conclusions The the plasma concentrations of mesaconitine,aconitine and hypaconitine were lower and the histopathological changes were attenuated after hemoperfusion.Hemoperfusion is a good intervention for acute intoxication of Radix Aconiti Kusmezoffii Monkshood. Key words: Radix Aconiti Kusmezoffii Monkshood; Hemoperfusion; Histopathology; HPLC-MS

Study on the adsorption of endotoxin and proinflammatory cytokines with HB-H-7 resin in vitro

To study the efficacy and safety of adsorption of endotoxin and proinflammatory cytokines with HB-H-7 resin in vitro. Static adsorption experiment: HB-H-7 resin was added into plasma of endotoxin-positive patients according to the ratio of 1;10. Then, they were put in a constant temperature water bath oscillator, and oscillated for 2 hours. Before and after the experiment, plasma endotoxin, proinflammatory cytokines, protein and electrolytes were detected, and the rate of 2-hour absorption was calculated. The experiment was repeated 10 times. Dynamic adsorption experiment: 5 ml resin was put into a self-made perfusion unit. Endotoxin-positive patients plasma (50 ml) was perfused for 2 hours. The flow rate of plasma was controlled at 4 ml/min with the infusion pump, and the plasma endotoxin was determined at 0, 30, 60 and 120 minutes after plasma hemoperfusion, and the absorption rates were calculated. The results were compared with static adsorption. The influence of temperature during adsorption was determined as follows. Perfusion method was similar with dynamic adsorption experiment. The perfusion units were either placed in a 37 centigrade water path or 25 centigrade (room temperature). Then, the plasma endotoxin was measured 2 hours after plasma perfusion, and the absorption rates were calculated. In static adsorption experiment, the plasma endotoxin and proinflammatory cytokines were significantly lower after adsorption with HB-H-7 resin adsorption (all P<0.05). The adsorption rates of endotoxin, tumor necrosis factor-alpha and interleukin-1, 6, 8 were 99.2%, 55.0%, 57.0%, 75.0%, 42.0%, respectively. Changes in protein were small (all P<0.05) , and there was no significant change in plasma electrolytes (all P>0.05). Dynamic adsorption rate was higher than that of static, but the differences were not significant (99.8% vs. 99.1%, P>0.05). There was no statistically significant difference between difference in temperature (37 centigrade vs. 25 centigrade, 99.8% vs. 99.9%, P>0.05). HB-H-7 resin effectively absorbs endotoxin and proinflammatory cytokines in vitro. Its adsorption rate for protein is lower, and it has no obvious effects on electrolytes.

Progress of the study on the treatment of endotoxemia by hemoperfusion

Endotoxemia is due to the infection of bacteria or lesions which release a lot of toxins into the blood,or the infusing of large amount of endotoxin-contaminated liquid.It can cause systemic inflammatory response syndrome,sepsis,or multiple organ dysfunction syndrome.Endotoxemia is a common and complex problem in modern emergency medicine.Early diagnosis and timely blocking not only can prevent further infection but also plays a positive role in the prevention and treatment of sepsis and its complications.In recent years,progresses have been made in the treatments of endotoxemia by hemoporfusion.The direct adsorption of endotoxin and inflammatory cytokines in blood can quickly reduce their concentration.This can not only weaken their own activity but also inhibit the release of other harmful cytokines,so as to improve the symptoms of infection.So far,the specific hishaffinity adsorbents having the clinical value are still at the exploratory stage.Although these materials were found effective in the treatments of endotoxemia,in-depth study need to be carried out on their clinical criteria in order to acquiremore satisfied results. Key words: Endotoxin; Cytokines; Endotoxemia; Hemoperfusion; Adsorption

Comparison between Kidney and Hemoperfusion for Paraquat Elimination

The mortality rate of acute paraquat (PQ) poisoning depends on the PQ concentration in the blood. It has been shown that the kidneys eliminate PQ effectively. However, early renal function deterioration is frequently observed in acute PQ intoxication. This study is designed to compare the efficacy of PQ elimination with hemoperfusion (HP) and kidneys, taking into account the functional deterioration of the kidneys. The amount of renal and HP excretion of PQ were measured during the procedure of HP in patients with acute PQ intoxication. The PQ clearance and the actual amount of PQ elimination by the HP cartridge during the HP procedure were 111±11 mL/min (range; 13.2-162.2 mL/min) and 251.4±506.3 mg (range; 4.6-1,655.7) each. While, the renal clearance and actual amount of renal elimination of PQ was 79.8±56.0 mL/min (range; 9.7-177.0) and 75.4±73.6 mg (range; 4.9-245.8). As the creatinine clearance decreased, the PQ elimination by HP was as effective as or more effective than the renal elimination. In conclusion, early HP must be provided for life saving treatment in patients with acute PQ intoxication.

Get the Toxin Out

In Japan, treatment of severe sepsis frequently includes hemoperfusion using immobilized polymyxin B, an endotoxin binder. However, data supporting this therapy are limited. Now, investigators in Italy have conducted a multicenter, controlled trial of polymyxin B hemoperfusion in patients with severe sepsis stemming from an intra-abdominal infection that had required emergency surgery. …

Combined use of different blood purification methods to treat severe acute pancreatitis: an analysis of 32 cases

AIM:To investigate the efficacy of combined use of different blood purification methods in the treatment of severe acute pancreatitis(SAP)and explore the therapeutic mechanisms involved. METHODS:Sixty-one SAP patients were randomly divided into control group(n=29)and treatment group(n=32).Patients in the control group underwent conventional therapy,while those in the treatment group underwent conventional therapy and blood purification[including continuous high-volume hemofiltration(CHVHF),hemoperfusion(HP),and peritoneal dialysis(PD)].The efficacy was compared between the two groups. RESULTS:Compared with the control group, the duration of abdominal pain relief was sig-nificantly shortened,ascitic amylase level was significantly reduced,and APACHE II score and CT severity index(CTSI)were significantly improved in the treatment group.The response rate achieved in the control group was significant lower than that in the treatment group (72.41%vs 90.63%,P0.05),while the mortality rate in the control group was significant higher than that in the treatment group(27.59%vs 9.38%,P0.01). CONCLUSION:Blood purification can rapidly improve clinical symptoms and reduce mortality rate in SAP patients,and is therefore effective for treatment of SAP.Combined use of CHVHF, HP and PD has better efficacy in the treatment of extremely severe cases of SAP than either method alone.

Therapeutic efficacy of hemoperfusion combined with comtinuous vein-vein hemofiltration in treatment of acute severe organophosphorus pesticide poisoning

目的 评价血液灌流加连续性静脉-静脉血液滤过治疗重度有机磷中毒的价值.方法 53例AOPP患者分为两组,对照组21例行传统治疗,治疗组32例在常规治疗基础上联合运用血液灌流及持续静-静脉血液滤过治疗.观察比较两组的治疗效果.结果 治疗组的昏迷持续时间、胆碱酯酶活力恢复时间、住院时间、阿托品应用总量均小于对照组,有显著性差异(P＜0.01).反跳发生率、中间综合症发生率均小于对照组,有显著性差异(P＜0.0 5).结论 血液灌流加连续性静脉-静脉血液滤过治疗重度有机磷中毒更为安全而有效。

Nursing of the Patients of Paraquat Poisoning Treated with Hemoperfusion

目的 探讨应用血液灌流救治百草枯患者过程中的监测及护理的相关问题.方法 入院后对患者进行生命体征监测,24 h内开始血液灌流,观察凝血、出血及低血压等并发症的发生,及时处理.结果 22例样本中4例患者出现多器官功能障碍死亡,16例遗留有不同程度的肺部纤维化未愈出院,2例痊愈出院;血液灌流过程中发生静脉穿刺管堵管5例,低血压4例,皮下出血3例,血尿1例.结论 血液灌流对百草枯清除率较高,可缩短昏迷时间,减少并发症,提高治愈率,降低死亡率.血液灌流过程中应加强护理,严密观察病情,严格执行各项操作规程,防止并发症发生。

Charcoal haemoperfusion in Amitriptyline poisoning: Experience in 20 children

Tricyclic antidepressant (TCA) toxicity is common among children and adults due to widespread use. Amitriptyline (AT) is one of the most commonly prescribed TCAs. Current guidelines do not recommend charcoal haemoperfusion (HP) for AT overdose due to high protein binding and large volume of distribution. However evidence regarding the efficacy of charcoal HP in addition to supportive measures is accumulating in the published reports. Here we report our experience in 20 children (15 girls, 5 boys) with acute AT overdose aged between 1.5 and 15 years, successfully managed with HP in our institution between January 2000 and February 2007. The HP indications were mainly severe initial cardiac and respiratory involvement. After HP, all patients recovered dramatically with a mean hospital stay of 4 days (range: 2-12). Only one patient developed neurological sequelae due to prolonged hypoxia secondary to respiratory arrest. To our knowledge this is the largest case series reporting the efficacy of charcoal HP in acute AT overdose in children. Based on our findings, charcoal HP seems to be an effective treatment modality, especially in prompt correction of severe life-threatening cardiac and respiratory findings in children with serious AT overdose and resulting in a reduction of morbidity and mortality.

Hemoperfusion in the Treatment of Acute Clozapine Intoxication in China

No systematic study has focused on the characteristics and outcome of acute clozapine intoxication, although clozapine is the most widely used antipsychotic agent in China. The study reported herein examined the features of clozapine intoxication and the therapeutic effect of hemoperfusion (HP). In a retrospective chart review, the notes of 47 patients who attempted suicide by ingesting large amounts of clozapine and were treated at the only psychiatric emergency service in Beijing were analyzed. Of the 20 unconscious patients with plasma clozapine concentrations of more than 2000 ng/mL, 14 received a combination of HP and symptomatic treatment, whereas the other 6 and the remaining 27 patients received only symptomatic treatment. Patients' psychiatric conditions and both plasma clozapine and norclozapine concentrations were closely monitored and registered. One patient died of pulmonary edema and subsequent heart failure, but the rest of the patients recovered without any sequelae. Patients who received HP regained consciousness significantly faster than their counterparts with the same level of clozapine plasma concentration (>2000 ng/mL) who did not receive HP. A combination of HP and symptomatic treatment is the best therapeutic option when plasma clozapine concentration is high.

Adsorption of Middle Molecular Weight Toxins on Carbon Nanotubes

The adsorption properties of middle molecular weight toxins on two types of carbon nanotubes (CNTs) (i.e., multi-walled carbon nanotubes (MWCNTs) and aligned multi-walled carbon nanotubes (ACNTs)) were studied and compared with two commercial haemoadsorbents (i.e., activated carbon (AC) and macroporous resin (MR)). The results showed that it took only 10 and 15 min for MWCNTs and ACNTs to achieve the adsorption equilibrium, respectively. The adsorption amount of MWCNTs reached 47.18 mg·g –1, which was 5.5 and 10.8 times of that of macroporous resin and activated carbon, respectively. Pore structure analyses indicated that the high adsorption efficiency should be attributed to the higher mesopore volumes of CNTs. All of the results implied the great potential applications of CNTs in haemoperfusion (HP).

Clinical observation of bedside hemoperfusion and repeated gastrolavage and purgation on acute severe organophosphorus pesticide poisoning

目的 研究血液灌流联合洗胃、导泻治疗急性重度有机磷农药中毒的效果.方法 回顾性分析自2003年7月至2006年6月重度有机磷农药中毒病历资料完整的72例临床资料.全部病例均在急诊科洗胃及内科常规处理后转入ICU并给予血液灌流治疗,将内科常规治疗、血液灌流同时再次反复洗胃、导泻的34例作为治疗组,将仅内科常规治疗、血液灌流,未再次洗胃、导泻的38例作为对照组.结果 治疗组治疗开始至清醒时间,氯磷定、阿托品用量,住院时间均较对照组明显减少,治愈率提高,两组比较差异有统计学意义.结论 内科常规治疗加早期血液灌流治疗急性重度有机磷农药中毒安全有效,早期血液灌流同时反复洗胃、导泻,可以进一步提高治愈率。

Sequential Hemoperfusion and Continuous Venovenous Hemofiltration in Treatment of Severe Tetramine Poisoning

Objective: It was the aim of this study to observe the effects of sequential hemoperfusion (HP) and continuous venovenous hemofiltration (CVVH) on patients with severe tetramine poisoning and to evaluate the ability of these modalities to remove tetramine. Methods: Eighteen patients diagnosed as having severe tetramine poisoning were treated by blood purification, additional to routine medical therapy. Blood purification procedures included HP using activated charcoal for 3–5 h and consecutive CVVH for 24–36 h. Patients’ clinical conditions, blood routine tests and serum chemical tests were evaluated every day after admission. Plasma tetramine concentrations were determined before and after HP. During CVVH, tetramine concentrations in plasma before and after passing through the filter and ultrafiltration at 2 and 12 h were also determined. Results: Eight patients received blood purification within 12 h after onset of poisoning, and 10 patients received blood purification more than 12 h later. Early-treated patients showed a higher cure rate (100 vs. 60.0%; p < 0.05, χ² test) and shorter coma time than late-treated patients (26.0 ± 23.2 h, range 5–70, vs. 59.7 ± 27.7 h, range 20–96; p < 0.01, rank test). The mean plasma tetramine concentrations in early- and late-treated patients were comparable (0.095 ± 0.036 vs. 0.134 ± 0.110 mg/l; p > 0.05). Mean plasma tetramine concentration was reduced from 0.124 ± 0.082 to 0.080 ± 0.055 mg/l after HP. At 2 h of CVVH, mean plasma tetramine concentration was 0.078 ± 0.064 mg/l, at 12 h of CVVH, 0.074 ± 0.059 mg/l, and the ultrafiltration sieving coefficient at 2 and 12 h was 0.839 ± 0.409 and 0.686 ± 0.253 mg/l, respectively. Conclusion: Early sequential HP and CVVH therapy may significantly improve the outcome of patients with severe tetramine intoxication. HP can rapidly reduce the plasma concentration of tetramine, and CVVH can attenuate the plasma tetramine concentration rebound after HP by continuously removing tetramine from the plasma.