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Ferrari F, Husain-Syed F, Milla P, Lorenzin A, Scudeller L, Sartori M, Gramaticopolo S, D'Auria L, Guglielmi A, Cornara P, De Rosa S, Zanella M, Corradi V, De Cal M, Danzi V, Giavarina D, Brendolan A, Mojoli F, Arpicco S, Ronco C. Clinical Assessment of Continuous Hemodialysis with the Medium Cutoff EMiC®2 Membrane in Patients with Septic Shock. Blood Purif 2022; 51:912-922. [PMID: 35263746 DOI: 10.1159/000522321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 01/28/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION At the time of renal replacement therapy, approximately 20% of critically ill patients have septic shock. In this study, medium cutoff (MCO) continuous venovenous hemodialysis (CVVHD) was compared to high-flux membrane continuous venovenous hemodiafiltration (CVVHDF) in terms of hemodynamic improvement, efficiency, middle molecule removal, and inflammatory system activation. METHODS This is a monocenter crossover randomized study. Between December 31, 2017, and December 31, 2019, 20 patients with septic shock and stage 3 acute kidney injury (AKI) admitted to 2 Italian ICUs were enrolled. All patients underwent CVVHD with Ultraflux® EMiC®2 and CVVHDF with AV1000S® without washout. Each treatment lasted 24 h. RESULTS Compared to AV1000S®-CVVHDF, EMIC®2-CVVHD normalized cardiac index (β = -0.64; p = 0.02) and heart rate (β = 5.72; p = 0.01). Interleukin-8 and myeloperoxidase removal were greater with AV1000S®-CVVHDF than with EMiC®2-CVVHD (β = 0.35; p < 0.001; β = 0.43; p = 0.03, respectively). Leukocytosis improved over 24 h in EMiC®2-CVVHD-treated patients (β = 4.13; p = 0.03), whereas procalcitonin levels decreased regardless of the modality (β = 0.89; p = 0.01) over a 48-h treatment period. Reduction rates, instantaneous plasmatic clearance of urea, creatinine, and β2-microglobulin were similar across modalities. β2-Microglobulin removal efficacy was greater in the EMiC®2 group (β = 0-2.88; p = 0.002), while albumin levels did not differ. Albumin was undetectable in the effluent in both treatments. DISCUSSION In patients with septic shock and severe AKI, the efficacy of uremic toxin removal was comparable between MCO-CVVHD and CVVHDF. Further, MCO-CVVHD was associated with improved hemodynamics. Fraction of filtration and transmembrane pressure reduction and the maintenance of equal efficacy might be the key features of CVVHD with MCO membranes in critically ill patients.
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Affiliation(s)
- Fiorenza Ferrari
- Department of Anesthesia and Intensive Care Unit, I.R.C.C.S., San Matteo Hospital and University of Pavia, Pavia, Italy.,International Renal Research Institute of Vicenza (IRRIV), Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy
| | - Faeq Husain-Syed
- International Renal Research Institute of Vicenza (IRRIV), Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy.,Department of Internal Medicine II, University Hospital Giessen and Marburg, Justus-Liebig-University Giessen, Giessen, Germany
| | - Paola Milla
- Dipartimento di Scienza e Tecnologia del Farmaco, Università degli Studi di Torino, Turin, Italy
| | - Anna Lorenzin
- International Renal Research Institute of Vicenza (IRRIV), Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy
| | - Luigia Scudeller
- Research and Innovation Unit, I. R.C.C.S., Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Marco Sartori
- International Renal Research Institute of Vicenza (IRRIV), Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy
| | - Silvia Gramaticopolo
- Department of Anesthesia and Intensive Care, San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy
| | - Luigi D'Auria
- Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, Unit of Anesthesia and Intensive Care, University of Pavia, Pavia, Italy
| | - Angelo Guglielmi
- Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, Unit of Anesthesia and Intensive Care, University of Pavia, Pavia, Italy
| | - Pietro Cornara
- Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, Unit of Anesthesia and Intensive Care, University of Pavia, Pavia, Italy
| | - Silvia De Rosa
- International Renal Research Institute of Vicenza (IRRIV), Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy.,Department of Anesthesia and Intensive Care, San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy
| | - Monica Zanella
- International Renal Research Institute of Vicenza (IRRIV), Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy
| | - Valentina Corradi
- International Renal Research Institute of Vicenza (IRRIV), Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy
| | - Massimo De Cal
- International Renal Research Institute of Vicenza (IRRIV), Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy
| | - Vinicio Danzi
- Department of Anesthesia and Intensive Care, San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy
| | - Davide Giavarina
- Department of Clinical Chemistry and Hematology Laboratory, San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy
| | - Alessandra Brendolan
- International Renal Research Institute of Vicenza (IRRIV), Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy
| | - Francesco Mojoli
- Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, Unit of Anesthesia and Intensive Care, University of Pavia, Pavia, Italy
| | - Silvia Arpicco
- Dipartimento di Scienza e Tecnologia del Farmaco, Università degli Studi di Torino, Turin, Italy
| | - Claudio Ronco
- International Renal Research Institute of Vicenza (IRRIV), Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Azienda ULSS 8 Berica, Vicenza, Italy.,Department of Medicine (DIMED), Università di Padova, Padua, Italy
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Arriagada S D, Donoso F A, Cruces R P, Díaz R F. [Septic shock in intensive care units. Current focus on treatment]. ACTA ACUST UNITED AC 2015; 86:224-35. [PMID: 26323988 DOI: 10.1016/j.rchipe.2015.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2014] [Accepted: 07/20/2015] [Indexed: 10/23/2022]
Abstract
Essential therapeutic principles in children with septic shock persist over time, although some new concepts have been recently incorporated, and fully awareness of pediatricians and intensivists is essential. Fluid resuscitation is a fundamental intervention, but the kind of ideal fluid has not been established yet, as each of these interventions has specific limitations and there is no evidence supportive of the superiority of one type of fluid. Should septic shock persists despite adequate fluid resuscitation, the use of inotropic medication and/or vasopressors is indicated. New vasoactive drugs can be used in refractory septic shock caused by vasopressors, and the use of hydrocortisone should be considered in children with suspected adrenal insufficiency, as it reduces the need for vasopressors. The indications for red blood cells transfusion or the optimal level of glycemia are still controversial, with no consensus on the threshold value for the use of these blood products or the initiation of insulin administration, respectively. Likewise, the use of high-volume hemofiltration is a controversial issue and further study is needed on the routine recommendation in the course of septic shock. Nutritional support is crucial, as malnutrition is a serious complication that should be properly prevented and treated. The aim of this paper is to provide update on the most recent advances as concerns the treatment of septic shock in the pediatric population.
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Affiliation(s)
- Daniela Arriagada S
- Programa de Medicina Intensiva en Pediatría, Facultad de Medicina Clínica Alemana-Universidad del Desarrollo, Santiago, Chile
| | - Alejandro Donoso F
- Programa de Medicina Intensiva en Pediatría, Facultad de Medicina Clínica Alemana-Universidad del Desarrollo, Santiago, Chile; Área de Cuidados Críticos, Unidad de Gestión Clínica de Niño, Hospital Padre Hurtado, Santiago, Chile.
| | - Pablo Cruces R
- Área de Cuidados Críticos, Unidad de Gestión Clínica de Niño, Hospital Padre Hurtado, Santiago, Chile; Centro de Investigación de Medicina Veterinaria, Escuela de Medicina Veterinaria, Facultad de Ecología y Recursos Naturales, Universidad Andrés Bello, Santiago, Chile
| | - Franco Díaz R
- Área de Cuidados Críticos, Unidad de Gestión Clínica de Niño, Hospital Padre Hurtado, Santiago, Chile
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Cornejo R, Romero C, Ugalde D, Bustos P, Diaz G, Galvez R, Llanos O, Tobar E. High-volume hemofiltration and prone ventilation in subarachnoid hemorrhage complicated by severe acute respiratory distress syndrome and refractory septic shock. Rev Bras Ter Intensiva 2015; 26:193-9. [PMID: 25028955 PMCID: PMC4103947 DOI: 10.5935/0103-507x.20140028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Accepted: 04/21/2014] [Indexed: 12/29/2022] Open
Abstract
We report the successful treatment of two patients with aneurismal subarachnoid
hemorrhage complicated by severe respiratory failure and refractory septic shock
using simultaneous prone position ventilation and high-volume hemofiltration. These
rescue therapies allowed the patients to overcome the critical situation without
associated complications and with no detrimental effects on the intracranial and
cerebral perfusion pressures. Prone position ventilation is now an accepted therapy
for severe acute respiratory distress syndrome, and high-volume hemofiltration is a
non-conventional hemodynamic support that has several potential mechanisms for
improving septic shock. In this manuscript, we briefly review these therapies and the
related evidence. When other conventional treatments are insufficient for providing
safe limits of oxygenation and perfusion as part of basic neuroprotective care in
subarachnoid hemorrhage patients, these rescue therapies should be considered on a
case-by-case basis by an experienced critical care team.
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Affiliation(s)
- Rodrigo Cornejo
- Unidade de Terapia Intensiva, Departamento de Medicina, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Carlos Romero
- Unidade de Terapia Intensiva, Departamento de Medicina, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Diego Ugalde
- Unidade de Terapia Intensiva, Departamento de Medicina, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Patricio Bustos
- Departamento de Neurologia e Neurocirurgia, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Gonzalo Diaz
- Unidade de Terapia Intensiva, Departamento de Medicina, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Ricardo Galvez
- Unidade de Terapia Intensiva, Departamento de Medicina, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Osvaldo Llanos
- Unidade de Terapia Intensiva, Departamento de Medicina, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Eduardo Tobar
- Unidade de Terapia Intensiva, Departamento de Medicina, Hospital Clínico Universidad de Chile, Santiago, Chile
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Bourquin V, Ponte B, Pugin J, Martin PY, Saudan P. Use of high-volume haemodiafiltration in patients with refractory septic shock and acute kidney injury. Clin Kidney J 2012; 6:40-44. [PMID: 27818750 PMCID: PMC5094390 DOI: 10.1093/ckj/sfs166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2011] [Accepted: 10/25/2012] [Indexed: 11/12/2022] Open
Abstract
Background High-volume haemofiltration (HVHF) has been used successfully in animal models with sepsis, and preliminary data have shown that this technique may improve the haemodynamics in patients with refractory septic shock. We used high-volume continuous venovenous haemodiafiltration (CVVHDF) in patients with acute kidney injury (AKI) and refractory septic shock to evaluate their outcome when compared with their prognosis predicted by scores of severity. Methods This is a cohort study in a Medical and Surgical Intensive Care Unit. Fifty-five patients with refractory septic shock and AKI were included in the study. Results High-volume CVVHDF was started in patients with AKI and septic shock requiring norepinephrine dose >0.2 µg/kg/min. AKI was classified according to the RIFLE criteria. Treatment was implemented within the first 24 h of refractory septic shock with a dialysis dose of 70 mL/kg/h until reversal of shock or death. Fifty-five patients were treated with high-volume CVVHDF with an observed mortality of 63%, similar to the mortality predicted by the APACHE II and SAPS II scores. Conclusion Survival rate in our patients with AKI and refractory septic shock treated with high-volume CVVHDF was identical to survival predicted by the severity scores. Treatment with high-volume haemodiafiltraton is applicable to severely ill patients with septic shock but does not confer any clear advantage in terms of survival. This therapy should not be implemented on a routine basis in patients with AKI and refractory septic shock.
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Affiliation(s)
- Vincent Bourquin
- Service de Néphrologie, Département des Spécialités de Médecine , Hôpitaux Universitaires de Genève , Geneva , Switzerland
| | - Belén Ponte
- Service de Néphrologie, Département des Spécialités de Médecine , Hôpitaux Universitaires de Genève , Geneva , Switzerland
| | - Jérôme Pugin
- Service des Soins Intensifs, Département d'Anesthésiologie, de Pharmacologie et des Soins Intensifs , Hôpitaux Universitaires de Genève , Geneva , Switzerland
| | - Pierre-Yves Martin
- Service de Néphrologie, Département des Spécialités de Médecine , Hôpitaux Universitaires de Genève , Geneva , Switzerland
| | - Patrick Saudan
- Service de Néphrologie, Département des Spécialités de Médecine , Hôpitaux Universitaires de Genève , Geneva , Switzerland
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He Y, Qu QC, Wang BX, DU FY, Guo ZH. FOS protein expression and role of the vagus nerve in the rat medullary visceral zone in multiple organ dysfunction syndrome caused by subarachnoid hemorrhage. Exp Ther Med 2012; 5:223-228. [PMID: 23251272 PMCID: PMC3523947 DOI: 10.3892/etm.2012.770] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2012] [Accepted: 10/03/2012] [Indexed: 02/01/2023] Open
Abstract
This study was designed to observe the role of FOS protein expression in the rat medullary visceral zone (MVZ) in multiple organ dysfunction syndrome (MODS) caused by subarachnoid hemorrhage (SAH), with and without severing the vagus nerve. We also investigated the regulatory and control mechanisms of the MVZ and the vagus nerve in MODS following SAH. A model of MODS following SAH was established by injecting arterial blood into the Willis’ circle. The vagus nerve was cut off and blocked. The FOS protein expression in the MVZ was detected by immunohistochemistry. The positive expression levels of FOS in the MVZ in the SAH and SAH + severed-down vagus nerve (SDV) groups were higher than those in the normal control, sham surgery and SDV groups (P<0.01). However, expression in the SAH+SDV group was lower than that in the SAH group (P<0.01). Inflammatory damage was observed in each visceral organ at every time-phased point in the SAH group and the SAH+SDV group. The most apparent damage was at 24–36 h, consistent with the peak of FOS protein expression; the SAH+SDV group presented a greater level of damage. The inflammatory changes in surrounding visceral organs following SAH correlated with FOS protein expression in the MVZ, which indicates that the MVZ participates in the functional control of surrounding visceral organs following SAH. Severing the subphrenic vagus nerve increases the incidence of MODS following SAH and enhances SAH-induced inflammatory damage to the surrounding visceral organs, which indicates that the vagus nerve plays a role in the protection of the surrounding visceral organs in MODS following SAH.
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Affiliation(s)
- Yan He
- Department of Neurology, Provincial Hospital Affiliated to Shandong University, Jinan, Shandong 250021; ; Department of Neurology, Second Affiliated Hospital of Shandong University of Traditional Chinese Medicine
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