Clinical Benefits of High-Volume Hemofiltration in Critically Ill Pediatric Patients with Severe Sepsis: A Retrospective Cohort Study

The therapeutic effect of continuous blood purification on sepsis in children: A systematic review and meta-analysis

BACKGROUND

Previous meta-analyses have systematically assessed the therapeutic effect of continuous blood purification (CBP) in adult patients with sepsis. Considering infection etiology and host response of sepsis is different in children, this systematic review and meta-analysis aims to evaluate the clinical efficacy of CBP in children with sepsis.

METHODS

Studies were searched from the Pubmed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI), WanFang, and VIP databases. Outcomes included vital signs, coagulation markers, organ function markers, immune markers, inflammatory markers, and prognostic markers. Heterogeneity was evaluated by the I-square statistic (I2), and sensitivity analysis was performed.

RESULTS

24 studies were included in this meta-analysis. Pooled results showed that CBP decreased levels of alanine transaminase (ALT) (weighted mean difference [WMD] = -44.867, 95%CI: 64.809 to -24.926), aspartate aminotransferase (AST) (WMD = -55.373, 95%CI: 73.286 to -37.460), blood urea nitrogen (BUN) (WMD = -2.581, 95%CI: 4.539 to -0.622), and serum creatinine (Scr) (WMD = -11.567, 95%CI: 19.509 to -3.625). The percentage of CD3+ cells (WMD = 8.242, 95%CI: 3.339 to 13.144) and CD4+ cells (WMD = 4.278, 95%CI: 3.252 to 5.303, I2 = 3.1 %) were increased in the CBP group. C-reaction protein (CRP) (WMD = -20.699, 95%CI: 34.740 to -6.657) and tumor necrosis factor-α (TNF-α) (WMD = -19.185, 95%CI: 34.133 to -4.237) were reduced after CBP treatment. Pediatric critical illness score (PCIS) was increased (WMD = 7.916, 95%CI: 4.317 to 11.516) and the risk of 28-day mortality (risk ratio [RR] = 0.781, 95%CI: 0.632 to 0.965) was lower in the CBP group.

CONCLUSIONS

CBP reduced the level of inflammatory markers, increased the level of immune markers, and improved organ function and prognosis, which may provide evidence for the use of CBP in sepsis children patients.

Pediatric Sepsis: a Summary of Current Definitions and Management Recommendations

Purpose of Review

Pediatric sepsis remains an important cause of morbidity and mortality in children. This review will summarize the main aspects of the definition, the current evidence base for interventions discuss some controversial themes and point towards possible areas of improvement.

Recent Findings

Controversy remains regarding the accurate definition, resuscitation fluid volume and type, choice of vasoactive/inotropic agents, and antibiotic depending upon specific infection risks. Many adjunctive therapies have been suggested with theoretical benefits, although definitive recommendations are not yet supported by data. We describe best practice recommendations based on international guidelines, a review of primary literature, and a discussion of ongoing clinical trials and the nuances of therapeutic choices.

Summary

Early diagnosis and timely intervention with antibiotics, fluid resuscitation, and vasoactive medications are the most important interventions in sepsis. The implementation of protocols, resource-adjusted sepsis bundles, and advanced technologies will have an impact on reducing sepsis mortality.

Continuous renal replacement therapy attenuates polymorphonuclear myeloid-derived suppressor cell expansion in pediatric severe sepsis

Background

Myeloid-derived suppressor cells (MDSCs) expansion is an important mechanism underlying immunosuppression during sepsis. Though continuous renal replacement therapy (CRRT) may attenuate hyperinflammatory response in sepsis, its role in regulating MDSCs is unknown. The aim of this study was to assess the potential role of CRRT involved in sepsis-induced MDSCs expansion in pediatric sepsis.

Method

The proportion of polymorphonuclear MDSCs (PMN-MDSCs) was detected before CRRT (pre-CRRT), at 24 hours after CRRT (CRRT 1^st day) and on the 7^th day after CRRT (CRRT 7^th day). The correlation analyses were performed to elucidate the relationship of MDSCs with clinical indexes in sepsis.

Results

Totally 22 pediatric patients with sepsis were enrolled [median age 44 (IQR15, 83) months]. PMN-MDSCs were expanded in pediatric sepsis compared with healthy controls (4.30% vs. 0.37%, P=0.04). The proportion of PMN-MDSCs showed a decreased tendency on the CRRT 7^th day compared with that on the CRRT 1^st day in survivors (2.29% vs.5.32%, P = 0.088). There was no significant difference in the proportion of PMN-MDSCs between survivors and non-survivors before CRRT (4.51% vs. 3.33%, P=0.745). The levels of interleukin 6 (IL-6) was decreased on the CRRT 7^th day compared with CRRT 1^st day in survivors. In the subgroups of patients with significantly decreased IL-6 levels after CRRT, the proportion of PMN-MDSCs on the CRRT 7^th day were also significantly decreased compared with that on the CRRT 1^st day (2.21% vs. 6.67%, P = 0.033).

Conclusion

The proportion of PMN-MDSCs was down-regulated on the CRRT 7^th day in survivors with sepsis. The reduced PMN-MDSCs expansion may relate to decreased IL-6 level.

Literature Review of the Efficacy of High-Volume Hemofiltration in Critically Ill Pediatric Patients

BACKGROUND

Pediatric sepsis is a significant public health issue. This condition is exacerbated by rising serum creatinine and inflammatory cytokines that lead to deleterious effects upon the body. The current standard of care involves the use of continuous kidney replacement therapy to remove harmful cytokines until the body returns to homeostasis. In order to promote faster clearance and reduced stay in the ICU, high-volume hemofiltration (HVHF) has shown promise. However, there is a paucity of studies to fully elucidate its benefits.

METHODS

A literature search was done using PubMed/ MEDLINE and Embase. The literature was reviewed by two independent reviewers, who independently assessed the quality of randomized controlled trials by using the Cochrane risk of bias tool for RCTs and Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomized controlled trials. Data were combined from studies with a similar design.

RESULTS

The primary endpoint of all-cause mortality was found to be reduced by 40% across all of the pooled studies. For secondary endpoints, significant reductions of serum creatinine were found. Additionally, duration of ICU stays and treatment course was found to be significantly shorter in HVHF patients than the current standard of care. The rate of adverse effects was analyzed, and there was no difference in the proportion of patients developing hypokalemia, hyperkalemia, hypernatremia, or hyponatremia. The proportion of patients developing hyperglycemia was higher in patients undergoing HVHF, whereas the proportions of patients developing bleeding were significantly less in patients undergoing HVHF. One study reported a total number of adverse events between the two groups which were significantly lesser in patients undergoing HVHF.

CONCLUSION

HVHF shows promise as a modality to treat pediatric patients with sepsis. In order to confirm the benefits of this modality, future studies need significantly more patients for analysis.

Cox-LASSO Analysis for Hospital Mortality in Patients With Sepsis Received Continuous Renal Replacement Therapy: A MIMIC-III Database Study

Background

Sepsis remains the leading cause of mortality in-hospital in the intensive care unit (ICU). Continuous renal replacement therapy (CRRT) is recommended as an adjuvant therapy for hemodynamics management in patients with sepsis. The aim of this study was to develop an adaptive least absolute shrinkage and selection operator (LASSO) for the Cox regression model to predict the hospital mortality in patients with Sepsis-3.0 undergoing CRRT using Medical Information Martin Intensive Care (MIMIC)-III v1.4.

Methods

Patients who met the Sepsis-3.0 definition were identified using the MIMIC-III v1.4. Among them, patients who received CRRT during ICU hospitalization were included in this study. According to the survival status, patients were split into death or survival group. Adaptive LASSO for the Cox regression model was constructed by STATA software. At last, nomogram and Kaplan-Meier curves were drawn to validate the model.

Results

A total of 181 patients who met Sepsis 3.0 criteria received CRRT were included in the study, in which, there were 31 deaths and 150 survivals during hospitalization, respectively. The overall in-hospital mortality was 17.1%. According to the results of multivariate Cox-LASSO regression analysis, use of vasopressor, international normalized ratio (INR) ≥1.5, and quick sequential organ failure assessment (qSOFA) score were associated with hospital mortality in patients with sepsis who underwent CRRT, but lactate level, mechanical ventilation (MV) support, PaO₂/FiO₂, platelet count, and indicators of acute kidney injury (AKI), such as blood urea nitrogen (BUN) and creatinine, were not independently associated with hospital mortality after adjusted by qSOFA. The risk nomogram and Kaplan-Meier curves verified that the use of vasopressor and INR ≥1.5 possess significant predictive value.

Conclusions

Using the Cox-LASSO regression model, use of vasopressor, INR ≥1.5, and qSOFA score are found to be associated with hospital mortality in patients with Sepsis-3.0 who received CRRT. This finding may assist clinicians in tailoring precise management and therapy for these patients who underwent CRRT.

Early High-dose Continuous Veno-venous Hemofiltration Alleviates the Alterations of CD4+ T Lymphocyte Subsets in Septic Patients Combined with Acute Kidney Injury

BACKGROUND

This study aims to determine whether early high-dose continuous venous-venous hemofiltration (CVVH) alleviates the alterations in CD4⁺ T lymphocyte subsets in septic patients combined with acute kidney injury.

METHODS

Enrolled septic patients combined with acute kidney injury were randomized into CVVH (n = 50) and conventional treatment (non-CVVH, n = 53) groups. Healthy volunteers (n = 21) were enrolled. CVVH was initiated within 12 h of intensive care unit (ICU) admission with the doses of 35 ~ 60 mL/kg/h and maintained for at least 72 h. Th1, Th2, Th17 and T_reg were measured by flow cytometry on days 1, 3 and 7 of ICU admission. Sequential organ failure assessment (SOFA) scores were calculated.

RESULTS

Th1 percentages and Th1/Th2 ratios were lower, and Th2, Th17 and T_reg percentages and Th17/T_reg ratios were higher in septic patients compared to healthy volunteers. CVVH significantly increased Th1 percentages and Th1/Th2 ratios, and significantly decreased Th2, Th17 and T_reg percentages and Th17/T_reg ratios compared to non-CVVH. Th1 percentages and Th1/Th2 ratios were negatively correlated with SOFA scores, while Th2, Th17 and T_reg percentages and Th17/T_reg ratios were positively correlated with SOFA scores. Patients with CVVH had significantly lower SOFA scores on day 7 of ICU admission and a shorter ICU stay compared to those with non-CVVH.

CONCLUSIONS

Septic patients combined with acute kidney injury exhibit different alterations of CD4⁺ T lymphocyte subsets. Early high-dose CVVH alleviates the alterations, which may be one of factors associated with improved sepsis severity.

Blood Filters in Children with COVID-19 and AKI: A Review

COVID-19 has challenged the global healthcare system through rapid proliferation and lack of existing treatment resulting in over 180 million cases and 3.8 million deaths since December 2019. Although pediatric patients only comprise 1-2% of diagnosed cases, their incidence of acute kidney injury ranges from 8.2% to 18.2% compared to 49% in adults. Severe infection, initiated by dysregulated host response, can lead to multiorgan failure. In this review, we focus on the use of various blood filters approved for use in pediatric kidney replacement therapy to mitigate adverse effects of severe illness. Therapeutic effects of these blood filters range from cytokine removal (CytoSorb, HA330, HCO/MCO), endotoxin removal (Toraymyxin, CPFA), both cytokine and endotoxin removal (oXiris), and non-specific removal of proteins (PMMA) that have already been established and can be used to mitigate the various effects of the cytokine storm syndrome in COVID-19.

Sepsis in children: state-of-the-art treatment

Sepsis is a common, complex condition that requires early recognition and aggressive management to improve outcomes. There has been significant improvement in the management of sepsis and septic shock in the last decade; however, it continues to be a leading cause of mortality, morbidity and burden on healthcare services globally. Several guidelines with evidence-based recommendations for the management of children with septic shock and associated organ dysfunction have been produced with the objective of helping clinicians in various settings to provide standardised high-quality care. This article aims to increase awareness among all clinicians, including those working in emergency departments, general paediatric wards and primary care physicians, about the management of sepsis in children.

Case Series: Efficacy and Safety of Hemoadsorption With HA-330 Adsorber in Septic Pediatric Patients With Cancer

Background: Sepsis is a frequent cause of death in hospitalized patients and, in detail, in neonatal, pediatric, and adult intensive care units (ICUs). Severe sepsis has a very poor prognosis. Indeed, the mortality rate varies between 30 and 70% during the first 7-14 days. Despite a timely and appropriate therapy, the prognosis of severe sepsis is too often negative. Therefore, new therapeutic resources are under investigation in order to further improve prognosis. Case series: Here, we reported three septic children in whom we used extracorporeal blood purification therapy with hemoadsorption device HA330 (Jafron Biomedical Co., Ltd., China), aiming to scavenge and eliminate bacterial toxins and inflammatory mediators from the blood. Discussion and Conclusion: This small case series first showed that hemoperfusion with HA330 cartridge may be an effective and relatively safe adjunctive treatment to counterbalance the cytokine storm in septic children with hematological disorders. Further studies are needed to confirm and further support its safety and efficacy in a large number of pediatric patients.

Continuous Renal Replacement Therapy in Pediatric Severe Sepsis: A Propensity Score-Matched Prospective Multicenter Cohort Study in the PICU

Supplemental Digital Content is available in the text.

Continuous renal replacement therapy becomes available utilization for pediatric critically ill, but the impact of mortality rate in severe sepsis remains no consistent conclusion. The aim of the study is to assess the effect of continuous renal replacement therapy in pediatric patients with severe sepsis and the impact this therapy may have on their mortality.

Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children

OBJECTIVES

To develop evidence-based recommendations for clinicians caring for children (including infants, school-aged children, and adolescents) with septic shock and other sepsis-associated organ dysfunction.

DESIGN

A panel of 49 international experts, representing 12 international organizations, as well as three methodologists and three public members was convened. Panel members assembled at key international meetings (for those panel members attending the conference), and a stand-alone meeting was held for all panel members in November 2018. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. Teleconferences and electronic-based discussion among the chairs, co-chairs, methodologists, and group heads, as well as within subgroups, served as an integral part of the guideline development process.

METHODS

The panel consisted of six subgroups: recognition and management of infection, hemodynamics and resuscitation, ventilation, endocrine and metabolic therapies, adjunctive therapies, and research priorities. We conducted a systematic review for each Population, Intervention, Control, and Outcomes question to identify the best available evidence, statistically summarized the evidence, and then assessed the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. We used the evidence-to-decision framework to formulate recommendations as strong or weak, or as a best practice statement. In addition, "in our practice" statements were included when evidence was inconclusive to issue a recommendation, but the panel felt that some guidance based on practice patterns may be appropriate.

RESULTS

The panel provided 77 statements on the management and resuscitation of children with septic shock and other sepsis-associated organ dysfunction. Overall, six were strong recommendations, 49 were weak recommendations, and nine were best-practice statements. For 13 questions, no recommendations could be made; but, for 10 of these, "in our practice" statements were provided. In addition, 52 research priorities were identified.

CONCLUSIONS

A large cohort of international experts was able to achieve consensus regarding many recommendations for the best care of children with sepsis, acknowledging that most aspects of care had relatively low quality of evidence resulting in the frequent issuance of weak recommendations. Despite this challenge, these recommendations regarding the management of children with septic shock and other sepsis-associated organ dysfunction provide a foundation for consistent care to improve outcomes and inform future research.

Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children

OBJECTIVES

To develop evidence-based recommendations for clinicians caring for children (including infants, school-aged children, and adolescents) with septic shock and other sepsis-associated organ dysfunction.

DESIGN

A panel of 49 international experts, representing 12 international organizations, as well as three methodologists and three public members was convened. Panel members assembled at key international meetings (for those panel members attending the conference), and a stand-alone meeting was held for all panel members in November 2018. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. Teleconferences and electronic-based discussion among the chairs, co-chairs, methodologists, and group heads, as well as within subgroups, served as an integral part of the guideline development process.

METHODS

The panel consisted of six subgroups: recognition and management of infection, hemodynamics and resuscitation, ventilation, endocrine and metabolic therapies, adjunctive therapies, and research priorities. We conducted a systematic review for each Population, Intervention, Control, and Outcomes question to identify the best available evidence, statistically summarized the evidence, and then assessed the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. We used the evidence-to-decision framework to formulate recommendations as strong or weak, or as a best practice statement. In addition, "in our practice" statements were included when evidence was inconclusive to issue a recommendation, but the panel felt that some guidance based on practice patterns may be appropriate.

RESULTS

The panel provided 77 statements on the management and resuscitation of children with septic shock and other sepsis-associated organ dysfunction. Overall, six were strong recommendations, 52 were weak recommendations, and nine were best-practice statements. For 13 questions, no recommendations could be made; but, for 10 of these, "in our practice" statements were provided. In addition, 49 research priorities were identified.

CONCLUSIONS

A large cohort of international experts was able to achieve consensus regarding many recommendations for the best care of children with sepsis, acknowledging that most aspects of care had relatively low quality of evidence resulting in the frequent issuance of weak recommendations. Despite this challenge, these recommendations regarding the management of children with septic shock and other sepsis-associated organ dysfunction provide a foundation for consistent care to improve outcomes and inform future research.

Hemofiltration in Patients with Severe Acute Pancreatitis (Review)

Questions regarding the application of extracorporeal detoxification to patients with severe acute pancreatitis have been considered. Hemodialysis, the historically first method of extracorporeal detoxification for such patients, has been also described in the review. Appropriateness of using renal replacement therapy methods and among them continued renal replacement therapy has been shown. Hemofiltration and hemodiafiltration technologies are described in detail including different modes of their application and the possibility of using various types of filters. Available data on hemofiltration for patients with severe acute pancreatitis have been analyzed. Great attention is paid to the unsolved aspects of hemofiltration in severe acute pancreatitis such as determining renal and extrarenal indices; time of starting hemofiltration; selection of volume replacement modes and a buffer system; procedure duration; anticoagulation measures, defining criteria to assess the adequacy of hemofiltration, state severity, and organ dysfunction degree. Further multicenter investigations are necessary to be able to assess the efficacy of the hemofiltration procedures on the basis of the thoroughly worked out and pathogenically grounded protocol using adequate control methods taking into consideration endogenic intoxication phases and intensity of the multiple organ failure syndrome.

Continuous hemodiafiltration as a rescue therapy for patients with cardiopulmonary failure caused by enterovirus-71: a retrospective observational study in a PICU

Background

Hand, foot and mouth disease (HFMD) remains a burdensome health issue in mainland China. Enterovirus71 (EV-A71) is the main pathogen of severe HFMD. Continuous hemofiltration improves fluid overload, restores kidney function and alleviates inflammatory reactions. The aim of the present study was to evaluate the effects of continuous veno-venous hemodiafiltration (CVVHDF) on severe HFMD caused by EV-A71(EV-A71-HFMD) in a pediatric intensive care unit (PICU).

Methods

A retrospective observational study was performed in a tertiary university PICU from January 2012 to December 2016. Children with severe EV-A71-HFMD complicated by cardiopulmonary failure were included. The patients were divided into a CVVHDF group and a conventional therapy (control) group (non-CVVHDF). The demographics, characteristics, and outcomes between the groups were collected and analyzed.

Results

Twenty-nine patients with severe EV-A71-HFMD were enrolled. The 28-day mortality was 17.6% (3/17) in the CVVHDF group and 33.3% (4/12) in the non-CVVHDF group, with no statistical significance between the two groups (P = 0.403). The median interval between CVVHDF initiation and PICU admission was 6 (4,8.5) hrs, and the median duration of CVVHDF was 48 (36, 64) hrs. The left ventricular ejection fraction (LVEF) and cardiac index (CI) in the CVVHDF group were improved after treatment. The plasma levels of catecholamines and renin-angiotensin-aldosterone system (RAAS) substances in the CVVHDF group were significantly decreased after treatment. The decreased catecholamines and RAAS substances included adrenalin (169.8 [145.5, 244.6] vs. 148.0 [109.0, 208.1] ng/L, P = 0.033), dopamine (152.7 [97.0, 191.1] vs. 96.0 [68.0, 160.9] ng/L, P = 0.026), angiotensin II (185.9 [125.2, 800.0] vs. 106.0 [90.8, 232.5] ng/L, P = 0.047), aldosterone (165.7 [94.0, 353.3] vs. 103.3 [84.3, 144.3] ng/L, P = 0.033), and renin (1.12 [0.74, 3.45] vs. 0.79 [0.52, 1.25] μg/L/h, P = 0.029),

Conclusions

CVVHDF reduced the levels of catecholamines and RAAS substances and improved cardiovascular function. Continuous hemodiafiltration may represent a potential therapy in patients with severe EV-A71-HFMD complicated with cardiopulmonary failure.

Translational gap in pediatric septic shock management: an ESPNIC perspective

Background

The Surviving Sepsis Campaign and the American College of Critical Care Medicine guidelines have provided recommendations for the management of pediatric septic shock patients. We conducted a survey among the European Society of Pediatric and Neonatal Intensive Care (ESPNIC) members to assess variations to these recommendations.

Methods

A total of 114 pediatric intensive care physicians completed an electronic survey. The survey consisted of four standardized clinical cases exploring seven clinical scenarios.

Results

Among the seven different clinical scenarios, the types of fluids were preferentially non-synthetic colloids (albumin) and crystalloids (isotonic saline) and volume expansion was not limited to 60 ml/kg. Early intubation for mechanical ventilation was used by 70% of the participants. Norepinephrine was stated to be used in 94% of the PICU physicians surveyed, although dopamine or epinephrine is recommended as first-line vasopressors in pediatric septic shock. When norepinephrine was used, the addition of another inotrope was frequent. Specific drugs such as vasopressin or enoximone were used in < 20%. Extracorporeal life support was used or considered by 91% of the physicians audited in certain specific situations, whereas the use of high-flow hemofiltration was considered for 44%.

Conclusions

This pediatric septic shock management survey outlined variability in the current clinician-reported practice of pediatric septic shock management. As most recommendations are not supported by evidence, these findings outline some limitation of existing pediatric guidelines in regard to context and patient’s specificity.

Electronic supplementary material

The online version of this article (10.1186/s13613-019-0545-4) contains supplementary material, which is available to authorized users.

Continuous hemofiltration improves the prognosis of bacterial sepsis complicated by liver dysfunction in children

BACKGROUND

Liver dysfunction is an independent risk factor for poor prognosis of patients with sepsis. The aim of this study is to evaluate the effects of continuous hemofiltration in patients with bacterial sepsis complicated by liver dysfunction.

METHODS

We retrospectively analyzed the medical records of 27 cases of bacterial sepsis with liver dysfunction admitted to pediatric intensive care unit (PICU) of Shanghai Children's Hospital between January 2013 and December 2016.

RESULTS

28-day mortality and length of PICU stay were significantly reduced in the continuous hemofiltration group (n = 16) compared with the conventional management group (n = 11) (31.3% vs. 72.7%, 9 [4-23] vs. 14 [4-36], respectively, both P < 0.05). The interval time between PICU admission and continuous hemofiltration initiation was (22.06 ± 17.68) h, and the median time of continuous hemofiltration duration was 48 h (31-70 h). After 72 h hemofiltration, the levels of total bilirubin (TBIL), direct bilirubin (DBIL), total bile acids (TBA), ammonia, lactate (Lac), TNF-α and IL-6 were significantly decreased in the continuous hemofiltration group. Moreover, multivariate logistic regression analysis indicated that continuous hemofiltration treatment and the TBIL level were independently associated with 28-day mortality of patients with bacterial sepsis complicated by liver dysfunction.

CONCLUSIONS

Continuous hemofiltration significantly decreases the serum levels of TBIL, DBIL, TBA, Lac, ammonia, TNF-α, IL-6, and improves 28-day mortality of patients with bacterial sepsis complicated by liver dysfunction.