Continuous Hemofiltration in Hyperthermic Septic Shock Patients

Hemofiltration Successfully Eliminates Severe Cytokine Release Syndrome Following CD19 CAR-T-Cell Therapy

Cytokine release syndrome (CRS) remains to be a major adverse effect of chimeric antigen receptor T (CAR-T) cell therapy in B-cell acute lymphoblastic leukemia (B-ALL) and lymphoma. It was urgent to explore novel strategy for managing severe CRS. We conducted a clinical trial to assess the safety and efficacy of CD19-targeting CAR-T-cells in the treatment of relapsed and chemotherapy-refractory B-ALL and lymphoma. A 10-year-old boy with B-ALL who never achieved minimal residual disease (MRD) negative status after 5 courses of chemotherapy was enrolled into our study and received a total of 3.19×10⁶/kg autologous CD19 CAR-T-cells. Before CAR-T-cell infusion, naive lymphocytes made up 41.8% of bone marrow cells, which were reduced to 1% at the 14th day after transfusion, with MRD<10⁻⁴. However, this patient developed grade 4 CRS, multiple organ failure, hemophagocytic syndrome, neurotoxicity, and severe pulmonary infection after CAR-T-cell therapy. Tocilizumab and glucocorticoids treatment were ineffective for controlling the adverse effects and in contrast, hemofiltration immediately ameliorated the severe CRS and prevented the exacerbation of multiple organ dysfunction, pneumonia, and hydrosarca caused by CAR-T-cell therapy. All side effects disappeared within days following hemofiltration. Hemofiltration helped quickly clear cytokines, speeded up patient recover, and successfully resolved the severe CRS crisis. This was the first report, reporting the successful use of hemofiltration to eliminate adverse reactions of CAR-T-cell therapy.

[Fever in the critically ill : To treat or not to treat]

Fever, arbitrarily defined as a core body temperature >38.3 °C, is present in 20-70 % of intensive care unit patients. Fever caused by infections is a physiologic reset of the thermostatic set-point and is associated with beneficial consequences, but may have negative sequelae with temperatures >39.5 °C. Fever of non-infectious and neurologic origin affects about 50 % of patients with elevated body temperature, presents as a pathologic loss of thermoregulation, and may be associated with untoward side effects at temperatures above 38.5-39.0 °C. Cooling can be achieved by physical and pharmacologic means. Evidence-based recommendations are not available. The indication for a cooling therapy can only be based on the physiologic reserve and the neurologic, hemodynamic, and respiratory state. The temperature should be lowered to the normothermic range. Hyperthermia syndromes require immediate physical cooling (and dantrolen when indicated).

Antipyretic Therapy in Critically Ill Septic Patients: A Systematic Review and Meta-Analysis

OBJECTIVE

This meta-analysis aimed to examine the impact of antipyretic therapy on mortality in critically ill septic adults.

DATA SOURCES

Literature searches were implemented in Ovid Medline, Embase, Scopus, Cumulative Index of Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, NHS Economic Evaluation Database, and ClinicalTrials.gov through February 2016.

STUDY SELECTION

Inclusion criteria were observational or randomized studies of septic patients, evaluation of antipyretic treatment, mortality reported, and English-language version available. Studies were excluded if they enrolled pediatric patients, patients with neurologic injury, or healthy volunteers. Criteria were applied by two independent reviewers.

DATA EXTRACTION

Two reviewers independently extracted data and evaluated methodologic quality. Outcomes included mortality, frequency of shock reversal, acquisition of nosocomial infections, and changes in body temperature, heart rate, and minute ventilation. Randomized and observational studies were analyzed separately.

DATA SYNTHESIS

Eight randomized studies (1,507 patients) and eight observational studies (17,432 patients) were analyzed. Antipyretic therapy did not reduce 28-day/hospital mortality in the randomized studies (relative risk, 0.93; 95% CI, 0.77-1.13; I = 0.0%) or observational studies (odds ratio, 0.90; 95% CI, 0.54-1.51; I = 76.1%). Shock reversal (relative risk, 1.13; 95% CI, 0.68-1.90; I = 51.6%) and acquisition of nosocomial infections (relative risk, 1.13; 95% CI, 0.61-2.09; I = 61.0%) were also unchanged. Antipyretic therapy decreased body temperature (mean difference, -0.38°C; 95% CI, -0.63 to -0.13; I = 84.0%), but not heart rate or minute ventilation.

CONCLUSIONS

Antipyretic treatment does not significantly improve 28-day/hospital mortality in adult patients with sepsis.

Fever Is Associated with Reduced, Hypothermia with Increased Mortality in Septic Patients: A Meta-Analysis of Clinical Trials

Background

Sepsis is usually accompanied by changes of body temperature (T_b), but whether fever and hypothermia predict mortality equally or differently is not fully clarified. We aimed to find an association between T_b and mortality in septic patients with meta-analysis of clinical trials.

Methods

We searched the PubMed, EMBASE, and Cochrane Controlled Trials Registry databases (from inception to February 2016). Human studies reporting T_b and mortality of patients with sepsis were included in the analyses. Average T_b with SEM and mortality rate of septic patient groups were extracted by two authors independently.

Results

Forty-two studies reported T_b and mortality ratios in septic patients (n = 10,834). Pearson correlation analysis revealed weak negative linear correlation (R² = 0.2794) between T_b and mortality. With forest plot analysis, we found a 22.2% (CI, 19.2–25.5) mortality rate in septic patients with fever (T_b > 38.0°C), which was higher, 31.2% (CI, 25.7–37.3), in normothermic patients, and it was the highest, 47.3% (CI, 38.9–55.7), in hypothermic patients (T_b < 36.0°C). Meta-regression analysis showed strong negative linear correlation between T_b and mortality rate (regression coefficient: -0.4318; P < 0.001). Mean T_b of the patients was higher in the lowest mortality quartile than in the highest: 38.1°C (CI, 37.9–38.4) vs 37.1°C (CI, 36.7–37.4).

Conclusions

Deep T_b shows negative correlation with the clinical outcome in sepsis. Fever predicts lower, while hypothermia higher mortality rates compared with normal T_b. Septic patients with the lowest (< 25%) chance of mortality have higher T_b than those with the highest chance (> 75%).

Anti-inflammatory effect of Qingwen Baidu Decoction (清瘟败毒饮) in sepsis rats

OBJECTIVE

To explore the pharmacological anti-inflammatory mechanism of Chinese formula Qingwen Baidu Decoction (清瘟败毒饮, QBD) from the view of holistic biology.

METHODS

The rats were randomly divided into a normal conrol group, a lipopolysaccharide (LPS) group, the low- and high-dose QBD groups, and a dexamethasone (DXM) group. NR8383 cells were treated with culture fluid containing 6% serum from rats of each group respectively. Inflammatory mediators were detected by reverse transcription polymerase chain reaction (RT-PCR), Western blotting hybridization, enzyme linked immunosorbent assay (ELISA), polymerase chain reaction (PCR) gene array and antibody array.

RESULTS

It is showed that the levels of interleukin (IL)-1α, IL-4 and IL-12 were enhanced in the low-dose QBD group; levels of IL-1α, IL-12 and IL-18 were augmented in the high-dose QBD group, compared with the LPS group after ELISA detection. Western blot showed that IL-1β and tumor necrosis factor (TNF)-α expression of the control group were lower than other groups. IL-1β level of the low-dose and high-dose QBD groups detected by RT-PCR was higher in early stage but lower after 24 h than that of the control group (P<0.01). Expression of 84 main inflammatory cytokines and receptors was detected by rat inflammatory cytokines and receptors PCR array. Up-regulation genes were 22 in both the LPS group and the low-dose QBD group, among which 16 up-regulating genes were the same. In these 16 genes, the up-regulating amplitude of 9 genes in the low-dose QBD group was less than that in the LPS group, 4 were similar to and 3 were more. Twenty-nine main cytokines were inspected by rat cytokine antibody array. Intergroup gray value differences were found in 7 expressed cytokines. The levels of these 7 cytokines in the low-dose QBD group were all lower than those in the the LPS group.

CONCLUSIONS

QBD has anti-inflammatory effect on sepsis by changing the level of inflammatory mediators.