Hemodynamic impact of molecular adsorbent recirculating system in refractory vasoplegic shock due to calcium channel blocker poisoning

Objective: To report the hemodynamic effect of to the molecular adsorbent recirculating system (MARS™) therapy for patients in refractory vasoplegic shock due to calcium channel blocker (CCB) poisoning Methods: We report a retrospective cohort of patients who were hospitalized for CCB poisoning with refractory vasoplegic shock and treated by MARS therapy, at Amiens Hospital University, from January 2010 to December 2019. Improvement in hemodynamic was assessed by dynamic changes in mean arterial pressure (MAP) and norepinephrine levels over a 24-h period after MARS therapy. Cardiac function was assessed by transthoracic echocardiography. Results: MARS therapy was performed on seven patients for CCB poisoning. CCB poisoning included nicardipine ( n = 3, 43%) amlodipine ( n = 3, 43%), and verapamil ( n = 1, 14%). The median time to start MARS therapy was 24 [14–27] h after drug ingestion and 6 [2–9] h after ICU admission. Cardiac output was preserved for all patients. MAP values improved from 56 [43–58] to 65 [61–78] 16 mmHg ( p = 0.005). Norepinephrine dose significantly decreased from 3.2 [0.8–10] µg/kg/min to 1.2 [0.1–1.9] µg/kg/min ( p = 0.008) and lactate level decreased from 3.2 [2.4–3.4] mmol/l−1 to 1.6 [0.9–2.2] mmol/l−1 ( p = 0.008). The median length of ICU stay was 4 (2–7) days and hospital stay was 4 (4–16) days. No complication related to the MARS therapy were reported. No patient died and all were discharged from the hospital. Conclusion: We reported the largest case-series of MARS therapy for refractory vasoplegic shock due to CCB poisoning. We observed that MARS therapy was associated with an improvement of hemodynamic parameters.

Molecular adsorbent recirculating system (MARS) and continuous veno-venous hemodiafiltration (CVVHDF) for diltiazem removal: An in vitro study

The objective of the present study was to evaluate the efficacy of the molecular adsorbent recirculating system (MARS) vs continuous veno-venous hemodiafiltration (CVVHDF). Diltiazem poisoning was simulated in a central compartment consisting in a 5L dialysis solute spiked with diltiazem at two different toxic concentrations: 750 and 5000 µg/L. For CVVHDF, mean extraction coefficients (EC = (in concentration − out concentration)/in concentration) were concentration-dependent with a decrease all along the dialysis. At the end of the sessions the mean amounts remaining in the central compartment were 8% and 7% of the initial dose at 750 and 5000 µg/L, respectively. The mean cumulative amounts found in the effluent were 60% and 75% of the initial dose, respectively. The missing amounts accounted for 32% and 18% of the initial dose, respectively, corresponding to an adsorption to the dialysis membrane. In contrast, the different compartments of the MARS resulted in undetectable output concentration earlier that the end of the session. The mean concentrations of diltiazem remaining in the central compartment were <1 µg/L at the end of the sessions. Global ECs were around 50% all along the experiment at both concentrations, and the average charcoal cartridge ECs was 80% throughout the experiments. CVVHDF system in the developed model was efficient for diltiazem removal, mainly by diffusion, convection and to a lesser extent by adsorption to the dialysis membrane. In MARS system, resin cartridge and hemodialysis components are ineffective, charcoal cartridge is responsible for almost all drug removal.

Bleeding Complications Associated With the Molecular Adsorbent Recirculating System: A Retrospective Observational Study

Background: The molecular adsorbent recirculating system (MARS) is an artificial liver support system that supports excretory liver function in patients with liver failure and is used as bridge therapy for patients waiting for liver transplantation. However, MARS may increase the tendency for bleeding. The objective of this study was to determine how MARS affects coagulopathy and identify specific factors associated with bleeding complications. Methods: We retrospectively analyzed data from 15 patients undergoing a total of 36 MARS sessions. Complete blood count, coagulation profiles, and blood chemistry values were compared before and after MARS. To identify pre-MARS factors associated with increased bleeding after MARS, we divided patients into bleeder and non-bleeder groups and compared their pre-MARS laboratory values. Results: MARS significantly reduced bilirubin and creatinine levels. MARS also increased prothrombin time and activated partial thromboplastin time and reduced fibrinogen, thus negatively impacting coagulation. Seven patients had bleeding complications and were classified into the bleeder group. Pre MARS hemoglobin was significantly lower in the bleeder group (8.3 mg/dl) than in the non bleeder group (10.0 mg/dl, P=0.014). When comparing the upper and lower 25 % of MARS sessions based on the hemoglobin reduction rate, hemoglobin reduction was significantly greater in MARS sessions involving patients with low pre MARS hemoglobin and factor V (P=0.008 and P=0.032, respectively). Conclusions: MARS appears to alter coagulation related factors and increase the risk of bleeding complications. However, individual differences among patients were large, and various factors, such as low hemoglobin and factor V levels, appear to be involved.