salon a 14 kasim 13.30 14.45 bi̇lgi̇n cömert
TRANSCRIPT
Plasmapheresis in Sepsis
Bilgin CÖMERT, MD.
Dokuz Eylül University, School of Medicine
Department of Medical Intensive Care Unit
Terminology
• Therapeutic Plasma Exchangeseparates out plasma from other components of blood, the plasma is removed and replaced with a replacement solution such as colloid solution (e.g., albumin and/or plasma) or combination of crystalloid/colloid solution
• Plasmapheresisseparates out plasma from other components of blood and the plasma is removed (i.e. less than 15% of total plasma volume) without the use of replacement solution
Plasmapheresis/Plasma Exchange in Critical Illness
• Thrombotic Thrombocytopenic Purpura
• Atypical Hemolytic Uremic Syndrome
• Thrombotic Microangiopathy: Drug-Associated (ticlopidine and clopidogrel)
• Wilson’s disease in fulminant hepatic failure with hemolysis
• Guillain-Barre Syndrome
• Chronic Inflammatory Demyelinating Polyradiculoneuropathy
• Sydenham’s Chorea
• Multiple Sclerosis
• Myasthenia Gravis
• Goodpasture’s Syndrome
• Wegener’s Granulomatosis
Sepsis Treatment (Standart)
• Antimicrobial agents
• Control of the source of the infection
• Hemodynamic support• Fluids• Vasopressors
• Oxygenation and ventilatory support
• Avoidance of complications
Sepsis Treatment (innovative)
• Corticosteroids• Monoclonal antibodies to TNF• Antitrombin• Activated protein C• Extracorporeal Therapies• CRRT• Plasma Exchange• ECMO
Aims of the Extracorporeal Therapies• Provide immunohomeostasis of pro- and anti-inflammatory
cytokines and other sepsis mediators
• Decrease organ microthrombosis through removal of pro-coagulant factors
• Modulating the impaired septic coagulation response in sepsis
• Provide mechanical support of organ perfusion during the acute septic episode
Semin Pediatr Infect Dis 2006;17:72-9
Plasma Exchange
• Remove harmful and toxic mediators from circulation as non-selectively
• If fresh frozen plasma is used as the replacement solution, substance consumed during systemic inlammatory process would be replaced
Plsmapheresis
(n=54)
Control(n=52) P
AgeApache III
41±1556.4±18.8
48±1653.5±15.8
0.030.40
28-day survivalTotal study populationAbdominal groupOther groups
18 (33%)11/33 (33%)7/21 (33%)
28 (54%)11/16 (68%)17/36 (47%)
0.050.030.4
Intensive Care Med 2002;28:1434-9
22 Adults, 8 Children
• Filtration/PE group n=14
• Control group n=16
Continuous Plasmafiltration in sepsis syndrome
Crit Care Med 1999;27:2096-104
Survival (28-day)
Plasma Exchange (n=5) 5/5
Standard Therapy (n=5)1/5 Crit Care Med 2008;36:2878-87
*Semin Pediatr Infect Dis 2006;17:72-9
Survival 28-day 1-year
Plasma Exchange (n=60) 90%80%
Standard Therapy (n=16) 20%15%
(Unpublished data)*
• Therapeutic Plasma Exchange in Sepsis with Multiorgan Failure
Recommendation : Grade 2B
J Clin Apheresis 2010;25:83-177
Surviving Sepsis Campaign-2012
Plasma therapies in children to correct sepsis-induced thrombotic purpura disorders• Progressive DIC• Secondary Thrombotic microangiopathy• TTP
• Recommendation: Grade 2C
• No recommendations for adultsCrit Care Med 2013;41:580-637