Changes in Cytokines, Haemodynamics and Microcirculation in Patients with Sepsis/Septic Shock Undergoing Continuous Renal Replacement Therapy and Blood Purification with CytoSorb

2019 ◽  
Vol 49 (1-2) ◽  
pp. 107-113 ◽  
Author(s):  
Samuele Zuccari ◽  
Elisa Damiani ◽  
Roberta Domizi ◽  
Claudia Scorcella ◽  
Mario D’Arezzo ◽  
...  
Keyword(s):  
Septic Shock ◽  
Renal Replacement Therapy ◽  
Replacement Therapy ◽  
Plasma Levels ◽  
Significant Variation ◽  
Near Infrared ◽  
Venous Blood ◽  
Blood Purification ◽  
Sidestream Dark Field ◽  
Extracorporeal Blood Purification

Background: Extracorporeal blood purification therapies have been proposed as a strategy to remove inflammatory mediators during sepsis, thus improving outcome. Objectives: We aimed to evaluate changes in cytokines, haemodynamics and microcirculation during blood purification with Cytosorb adsorber in septic patients. Methods: Prospective observational study on critically ill adult patients with sepsis/septic shock underwent renal replacement therapy (RRT) for acute renal failure and haemoadsorption with Cytosorb as adjunctive therapy for 24 h. Measurements were taken at baseline, after 6 and 24 h: haemodynamic parameters, arterial and central venous blood gases, plasma levels of tumour necrosis factor alpha, interleukin (IL) 1-beta, IL-6, IL-8 and IL-10. The sublingual microcirculation was assessed with sidestream dark field videomicroscopy to evaluate the perfused vessel density (PVD) and microvascular flow quality. Tissue oxygenation and microvascular reactivity were assessed with thenar near infrared spectroscopy (NIRS) with a vascular occlusion test. Results: Nine patients; plasma levels of IL-8 decreased at 24 h (p < 0.05 versus 6 h); no significant variation was found for other cytokines. Haemodynamic remained stable throughout the observation. Microvascular perfusion improved over time, with an increase in PVDs at 6 and 24 h (from 13.9 [13.3–16.4] to 15.7 [15–17.3] and 17 [14.8–18.6] mm/mm2 respectively, p = 0.003) and total vessel densities at 24 h (14.9 [13.9–16.9] vs. 17.9 [15.3–20], p = 0.0015). No significant variation was detected in NIRS-derived parameters. The Sequential Organ Failure Assessment score decreased from 12 ± 3 to 10 ± 1 at 24 h (p = 0.039). Conclusions: In septic patients undergoing RRT, haemoadsorption with Cytosorb seems to determine a decreasing in plasma levels of IL-8, although levels of other cytokines did not vary significantly, and an improvement of microcirculation despite no significant variation in macro-haemodynamics.

scholarly journals Systemic anticoagulation during continuous renal replacement therapy – practical aspects

2019 ◽  
Author(s):  
Dariusz Onichimowski ◽  
Joanna Maria Wolska ◽  
Radosław Borysiuk ◽  
Marcin Mieszkowski ◽  
Zuzanna Stępień ◽  
...  
Keyword(s):  
Renal Replacement Therapy ◽  
Continuous Renal Replacement Therapy ◽  
Replacement Therapy ◽  
Intensive Therapy ◽  
Blood Purification ◽  
Routine Practice ◽  
Research Papers ◽  
Extracorporeal Blood ◽  
Extracorporeal Blood Purification ◽  
Systemic Anticoagulation

Introduction: Extracorporeal blood purification techniques have become a well-established part of routine practice in intensive therapy units. Ensuring appropriate anticoagulation to prevent the clotting of the circuit is the major concern while applying these techniques. Aim: The aim of this paper is to present methods of systemic anticoagulation which are currently used in continuous extracorporeal blood purification techniques. Ma t e r i a l and me thods : This work is based on the available literature and the experience of the authors. Re sul t s and di s cus s ion: The prevention of clotting in the extracorporeal circuit may be achieved through regional or systemic anticoagulation. Systemic anticoagulation is usually achieved by administration of unfractionated heparin. The most common complications include bleeding; additionally, there is a risk of type II thrombocytopenia occurring. Systemic anticoagulation may also be provided through administration of low molecular weight heparins. Some research papers have discussed the use of thrombin antagonists (argatroban, bivalirudin) and heparinoids (danaparoid, fondaparinux), as well as platelet inhibitors as systemic anticoagulants. It is also possible to conduct extracorporeal blood purification without anticoagulation. C o n c l u s i o n s : The introduction of continuous extracorporeal blood purification techniques into everyday practice of intensive care units has brought many unquestioned benefits to the patients treated in this setting. On the other hand, it means that doctors need to show an in-depth knowledge of the anticoagulation methods. Despite the wider use of regional anticoagulation during continuous renal replacement therapy, systemic anticoagulation is still important. This is especially when therapies with high blood flow are performed and contraindications to citrate use are present.

Acute Renal Failure and Multiple Organ Dysfunction in the ICU: From Renal Replacement Therapy (RRT) to Multiple Organ Support Therapy (MOST)

2002 ◽  
Vol 25 (8) ◽  
pp. 733-747 ◽  
Author(s):  
C. Ronco ◽  
R. Bellomo
Keyword(s):  
Renal Failure ◽  
Acute Renal Failure ◽  
Renal Replacement Therapy ◽  
Replacement Therapy ◽  
Multiple Organ ◽  
Blood Purification ◽  
Organ Support ◽  
Extracorporeal Blood Purification ◽  
Renal Support ◽  
Single Organ

Renal replacement therapy (RRT) has evolved from the concept that we need to treat the dysfunction of a single organ (the kidney). As intensive care units have become more and more complex, it has become clear that the majority of patients with acute renal failure often have dysfunction of several other organs. In order to facilitate single organ support in this setting, continuous renal replacement therapy (CRRT) techniques have been developed. However, CRRT has opened the door to the concept that targeting renal support as the only goal of extracorporeal blood purification may be a simplistic view of our therapeutic aims. In this article we argue that it is now time to move from the simple goal of achieving adequate renal support. The proper goal of extracorporeal blood purification in ICU should be multi-organ support therapy (MOST). We explain why MOST represents the most logical future conceptual and practical evolution of CRRT and illustrates the biological rationale, supplying animal and clinical evidence that confirms the need to move rapidly in this direction theoretically, practically and technologically.

scholarly journals Use of Hemadsorption in a Case of Pediatric Toxic Shock Syndrome

2017 ◽  
Vol 2017 ◽  
pp. 1-5 ◽  
Author(s):  
Andrea Berkes ◽  
Edit Szikszay ◽  
János Kappelmayer ◽  
Adrienne Kerényi ◽  
Tamás Szabó ◽  
...  
Keyword(s):  
Renal Replacement Therapy ◽  
Replacement Therapy ◽  
Inflammatory Mediators ◽  
Clinical Management ◽  
Toxic Shock Syndrome ◽  
Immune Modulation ◽  
Blood Purification ◽  
Toxic Shock ◽  
Extracorporeal Blood ◽  
Extracorporeal Blood Purification

Background. Toxic shock syndrome is a potentially fatal toxin-mediated disease. The role of toxins in this clinical entity made us hypothesize that extracorporeal blood purification with CytoSorb® could play a beneficial role in the clinical management of toxic shock syndrome. This case report describes the successful treatment of toxic shock syndrome using a combination of renal replacement therapy and hemadsorption in a pediatric patient. Case Presentation. A 5-year-old girl with Down’s syndrome presented with an inflamed area surrounding an insect bite, signs of systemic inflammation, and multiple organ failure. As previous attempts of immune modulation therapy were unsuccessful, renal replacement therapy was supplemented by the cytokine absorber CytoSorb. Treatment using this combination was associated with a rapid and significant stabilization in the hemodynamic situation and a decrease in inflammatory mediators within hours after the initiation of therapy. The application of CytoSorb therapy was simple and safe. Conclusion. The use of extracorporeal blood purification with CytoSorb proved potentially beneficial by removing toxins and inflammatory mediators in this case and could therefore play a role in the clinical management of toxic shock syndrome. Whether CytoSorb has the potential to even positively influence mortality in patients with toxic shock syndrome still needs to be confirmed.

scholarly journals Practical issues of regional anticoagulation during continuous renal replacement therapy

2019 ◽  
Author(s):  
Dariusz Onichimowski ◽  
Joanna Maria Wolska ◽  
Radosław Borysiuk ◽  
Marcin Mieszkowski ◽  
Zuzanna Stępień ◽  
...  
Keyword(s):  
Renal Replacement Therapy ◽  
Continuous Renal Replacement Therapy ◽  
Replacement Therapy ◽  
Blood Purification ◽  
Bleeding Complications ◽  
Regional Citrate Anticoagulation ◽  
Extracorporeal Circuit ◽  
Extracorporeal Blood ◽  
Extracorporeal Blood Purification ◽  
Regional Anticoagulation

Introduction: Extracorporeal blood purification techniques have become a well-established part of routine practice in intensive care units. The issue of major concern while applying these techniques is to ensure appropriate anticoagulation to prevent the clotting of the circuit. Aim: The aim of this paper is to present regional anticoagulation as a method which is currently used in continuous extracorporeal blood purification techniques. Material and methods: This work is based on the available literature and the authors’ experience. Results and discussion: Anticoagulation used to prevent the clotting of the circuit in extracorporeal blood purification techniques may be regional or systemic. Regional anticoagulation inhibits clotting only in the extracorporeal circuit. In this case either sodium citrate together with calcium substitution or heparin with protamine sulfate is used. Systemic anticoagulation involves the inhibition of clotting in the extracorporeal circuit and in the patient’s body. Regional citrate anticoagulation (RCA) is obtained with the use of citrate. With this technique calcium substitution is necessary in order to prevent hypocalcemia. Other possible complications include alkalosis, metabolic acidosis, hypercalcemia and hypomagnesemia. This paper presents also some practical aspects of regional anticoagulation during continuous renal replacement therapy (CRRT) Conclusions: The application of RCA has contributed to a wider use of CRRT in intensive therapy units. The greatest advantage of this method is almost complete elimination of bleeding complications associated with the therapy. It enables effective blood purification in the patients in whom the use of heparins is contraindicated. This fact has found confirmation in Kidney Disease: Improving Global Outcomes (KDIGO) guidelines.

Heparin-based blood purification attenuates organ injury in baboons with S. pneumoniae pneumonia

2021 ◽  
Author(s):  
Lingye Chen ◽  
Bryan D Kraft ◽  
Victor L Roggli ◽  
Zachary R Healy ◽  
Christopher W Woods ◽  
...  
Keyword(s):  
Septic Shock ◽  
Pneumococcal Pneumonia ◽  
Kidney Injury ◽  
Blood Purification ◽  
Dose Finding ◽  
Organ Injury ◽  
Inflammasome Activation ◽  
Post Inoculation ◽  
Extracorporeal Blood ◽  
Extracorporeal Blood Purification

Background: Bacterial pneumonia is a major cause of morbidity and mortality worldwide despite the use of antibiotics, and novel therapies are urgently needed. Building on previous work, we aimed to 1) develop a baboon model of severe pneumococcal pneumonia and sepsis with organ dysfunction; and 2) test the safety and efficacy of a novel extracorporeal blood filter to remove pro-inflammatory molecules and improve organ function. Methods: After a dose-finding pilot study, twelve animals were inoculated with S. pneumoniae (5x109 CFU), given ceftriaxone at 24 hours post-inoculation, and randomized to extracorporeal blood purification using a filter coated with surface-immobilized heparin sulfate (n=6) or sham treatment (n=6) for 4 hours at 30 hours post-inoculation. For safety analysis, four uninfected animals also underwent purification. At 48 hours, necropsy was performed. Results: Inoculated animals developed severe pneumonia and septic shock. Compared with sham animals, septic animals treated with purification displayed significantly less kidney injury, metabolic acidosis, hypoglycemia, and shock (P<0.05). Purification blocked the rise in peripheral blood S. pneumoniae DNA, attenuated BAL CCL4, CCL2, and IL-18 levels, and reduced renal oxidative injury and classical NLRP3-inflammasome activation. Purification was safe in both uninfected and infected animals and produced no adverse effects. Conclusions: We demonstrate that heparin-based blood purification significantly attenuates levels of circulating S. pneumoniae DNA and BAL cytokines, and is renal-protective in baboons with severe pneumococcal pneumonia and septic shock. Purification was associated with less severe acute kidney injury, metabolic derangements, and shock. These results support future clinical studies in critically ill septic patients.

Evaluation of plasma levels of meropenem in septic patients during extracorporeal blood purification

2021 ◽  
Vol 20 (4) ◽  
pp. 81-94
Author(s):  
Artem V. Marukhov ◽  
Elena V. Murzina ◽  
Mikhail V. Zakharov ◽  
Genrikh A. Sofronov ◽  
Lyudmila V. Buryakova ◽  
...  
Keyword(s):  
Septic Shock ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Selective Adsorption ◽  
Plasma Concentrations ◽  
Blood Purification ◽  
Continuous Hemodiafiltration ◽  
Extracorporeal Blood ◽  
Extracorporeal Blood Purification ◽  
Extracorporeal Support

The relevance. Meropenem is a broad-spectrum carbapenem antibiotic widely used to treat patients with sepsis / septic shock. Critically ill patients are usually supported with one of the forms extracorporeal blood purification. However, data on the effect of various extracorporeal support techniques on the pharmacokinetics and pharmacodynamics of meropenem are insufficient or contradictory. Aim: To evaluate the effectiveness of meropenem dosage regimens in the treatment of septic patients during extracorporeal blood purification. Materials and methods. Plasma concentrations of meropenem were monitored in three critically ill patients with sepsis or septic shock. Patients were treated using various extracorporeal support techniques. Meropenem was used as empirical antibacterial mono- or complex therapy (1 g every 8 or 12 hours). Meropenem concentrations in plasma were determined by validated assay methods on Acquity ultraefficient liquid chromatography (UPLC) H-Class system. Results. It is shown that the meropenem plasma concentration in critically ill patients changes significantly. It was found that the standard meropenem dosing regimens in patients with sepsis / septic shock during continuous hemodiafiltration do not ensure the achievement of the PK/PD target of 100% TMIC for sensitive strains (MIC2 mg/L) and for intermediate resistance pathogens (2MIC8 mg/L). Continuous hemofiltration and selective adsorption of lipopolysaccharide have a less pronounced effect on the clearance of meropenem. Conclusion. To increase the effectiveness of antibacterial therapy, it is necessary to conduct research aimed at developing protocols for dosing antibacterial drugs for the treatment of sepsis during extracorporeal blood purification.

scholarly journals Septic shock after liver transplantation successfully treated with endotoxin and cytokine adsorption continuous renal replacement therapy: a case report and literature review

2020 ◽  
Vol 48 (7) ◽  
pp. 030006052094043
Author(s):  
Yining Li ◽  
Linshan Zhou ◽  
Lingzhi Yang ◽  
Fang Yuan
Keyword(s):  
Septic Shock ◽  
Liver Transplantation ◽  
Renal Replacement Therapy ◽  
Liver Failure ◽  
Continuous Renal Replacement Therapy ◽  
Replacement Therapy ◽  
Chronic Liver ◽  
Inflammatory Factors ◽  
Decompensated Cirrhosis ◽  
Chronic Liver Failure

Endotoxins and cytokines play an important role in multiple organ failure pathogenesis in patients with severe Gram-negative bacterial infection. We present a clinical case where an oXiris hemofilter was used for continuous renal replacement therapy (CRRT) treatment in a patient with septic shock after liver transplantation. A 35-year-old man with a 20-year history of hepatitis B presented with jaundice, loss of appetite, and decreased urine output. He was diagnosed with decompensated cirrhosis with acute-on-chronic liver failure, and liver transplantation was indicated. The day after surgery, he developed hyperthermia, hypotension, anuria, and a progressive increase in blood inflammatory markers and creatinine. Combined with the donor source and blood culture results, septic shock after transplantation was considered. The patient was immediately treated with endotoxin and cytokine adsorption CRRT (oXiris hemofilter) with tigecycline, caspofungin, and ganciclovir as anti-infectives. After 48 hours on CRRT, his blood pressure gradually stabilized, the CLIF Consortium Acute-on-Chronic Liver Failure score decreased from 63 to 43. Procalcitonin, endotoxin, and the inflammatory factors interleukin (IL)-6 and IL-10 also decreased gradually. The patient’s liver and kidney functions were completely restored. Our experience suggests that oXiris CRRT combined with antibacterial therapy is an effective treatment for septic shock after liver transplantation.

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