1
|
Lesbekov T, Nurmykhametova Z, Kaliyev R, Kuanyshbek A, Faizov L, Bekishev B, Jabayeva N, Samalavicius R, Pya Y. Hemadsorption in patients requiring V-A ECMO support: Comparison of Cytosorb versus Jafron HA330. Artif Organs 2023; 47:721-730. [PMID: 36398369 DOI: 10.1111/aor.14457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 10/13/2022] [Accepted: 11/04/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND ECMO support is associated with the development of a systemic hyper-inflammatory response, which may become quite significant and extreme in some cases. We hypothesize that Cytosorb or Jafron therapy may benefit patients on V-A ECMO in terms of levels of inflammatory markers such as IL-6, complications, and overall outcomes. METHODS We conducted a retrospective study of prospectively collected data in a single tertiary care center between January 2021 and April 2022. At the time of the analysis of this article, 20 patients on V-A ECMO had cytokine adsorption while on ECMO support: Cytosorb group (n = 10), Jafron group (n = 10). In 10 ECMO-supported patients cytokine adsorption was not used, this group served as a control group, which may be quite significant in some cases. Evaluation of the level of inflammatory markers (IL-1, 6, 8; CRP, Leukocyte, Lactate, PCT, NT-proBNP, TNF-α) was performed. RESULTS There was statistically significant longer CPB time, aortic cross-clamp time and ICU stay in cytokine adsorption groups than in the control group, but there were no differences between subgroups with different types of haemoadsorption used. Moreover, in the control group mortality rate was higher than in the cytokine adsorption groups (60% vs. 20%, p = 0.02). All patients had an elevation of inflammatory markers in the perioperative and immediate postoperative periods. After 72 h of intensive care, blood inflammation markers had a tendency to decline. CONCLUSION At the time of writing, hemadsorption in patients requiring V-A ECMO support represents a good therapeutic effect. This effect is permanent for the whole period of extracorporeal cytokine hemadsorption application for both CytoSorb and Jafron HA330 devices.
Collapse
Affiliation(s)
- Timur Lesbekov
- National Research Center for Cardiac Surgery, Nur-Sultan, Kazakhstan
| | | | - Rymbay Kaliyev
- National Research Center for Cardiac Surgery, Nur-Sultan, Kazakhstan
| | - Aidyn Kuanyshbek
- National Research Center for Cardiac Surgery, Nur-Sultan, Kazakhstan
| | - Linar Faizov
- National Research Center for Cardiac Surgery, Nur-Sultan, Kazakhstan
| | - Bolat Bekishev
- National Research Center for Cardiac Surgery, Nur-Sultan, Kazakhstan
| | - Nilufar Jabayeva
- National Research Center for Cardiac Surgery, Nur-Sultan, Kazakhstan
| | | | - Yuriy Pya
- National Research Center for Cardiac Surgery, Nur-Sultan, Kazakhstan
| |
Collapse
|
2
|
Soltesz A, Molnar ZA, Szakal-Toth Z, Tamaska E, Katona H, Fabry S, Csikos G, Berzsenyi V, Tamas C, Edes IF, Gal J, Merkely B, Nemeth E. Influence of Venoarterial Extracorporeal Membrane Oxygenation Integrated Hemoadsorption on the Early Reversal of Multiorgan and Microcirculatory Dysfunction and Outcome of Refractory Cardiogenic Shock. J Clin Med 2022; 11:jcm11216517. [PMID: 36362744 PMCID: PMC9657372 DOI: 10.3390/jcm11216517] [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: 09/15/2022] [Revised: 10/25/2022] [Accepted: 10/29/2022] [Indexed: 11/06/2022] Open
Abstract
Background: The purpose of this investigation was to evaluate the impact of venoarterial extracorporeal membrane oxygenation (VA−ECMO) integrated hemoadsorption on the reversal of multiorgan and microcirculatory dysfunction, and early mortality of refractory cardiogenic shock patients. Methods: Propensity score−matched cohort study of 29 pairs of patients. Subjects received either VA−ECMO supplemented with hemoadsorption or standard VA−ECMO management. Results: There was a lower mean sequential organ failure assessment score (p = 0.04), lactate concentration (p = 0.015), P(v−a)CO2 gap (p < 0.001), vasoactive inotropic score (p = 0.007), and reduced delta C−reactive protein level (p = 0.005) in the hemoadsorption compared to control groups after 72 h. In−hospital mortality was similar to the predictions in the control group (62.1%) and was much lower than the predicted value in the hemoadsorption group (44.8%). There were less ECMO-associated bleeding complications in the hemoadsorption group compared to controls (p = 0.049). Overall, 90-day survival was better in the hemoadsorption group than in controls without statistical significance. Conclusion: VA−ECMO integrated hemoadsorption treatment was associated with accelerated recovery of multiorgan and microcirculatory dysfunction, mitigated inflammatory response, less bleeding complications, and lower risk for early mortality in comparison with controls.
Collapse
Affiliation(s)
- Adam Soltesz
- Heart and Vascular Center, Semmelweis University, H-1122 Budapest, Hungary
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, H-1085 Budapest, Hungary
| | - Zsofia Anna Molnar
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, H-1085 Budapest, Hungary
| | - Zsofia Szakal-Toth
- Heart and Vascular Center, Semmelweis University, H-1122 Budapest, Hungary
| | - Eszter Tamaska
- Heart and Vascular Center, Semmelweis University, H-1122 Budapest, Hungary
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, H-1085 Budapest, Hungary
| | - Hajna Katona
- Heart and Vascular Center, Semmelweis University, H-1122 Budapest, Hungary
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, H-1085 Budapest, Hungary
| | - Szabolcs Fabry
- Heart and Vascular Center, Semmelweis University, H-1122 Budapest, Hungary
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, H-1085 Budapest, Hungary
| | - Gergely Csikos
- Heart and Vascular Center, Semmelweis University, H-1122 Budapest, Hungary
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, H-1085 Budapest, Hungary
| | - Viktor Berzsenyi
- Heart and Vascular Center, Semmelweis University, H-1122 Budapest, Hungary
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, H-1085 Budapest, Hungary
| | - Csilla Tamas
- Heart and Vascular Center, Semmelweis University, H-1122 Budapest, Hungary
| | - Istvan Ferenc Edes
- Heart and Vascular Center, Semmelweis University, H-1122 Budapest, Hungary
| | - Janos Gal
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, H-1085 Budapest, Hungary
| | - Bela Merkely
- Heart and Vascular Center, Semmelweis University, H-1122 Budapest, Hungary
| | - Endre Nemeth
- Heart and Vascular Center, Semmelweis University, H-1122 Budapest, Hungary
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, H-1085 Budapest, Hungary
- Correspondence: ; Tel.: +36-1-4586810
| |
Collapse
|
3
|
Akil A, Napp LC, Rao C, Klaus T, Scheier J, Pappalardo F. Use of CytoSorb© Hemoadsorption in Patients on Veno-Venous ECMO Support for Severe Acute Respiratory Distress Syndrome: A Systematic Review. J Clin Med 2022; 11:jcm11205990. [PMID: 36294309 PMCID: PMC9604472 DOI: 10.3390/jcm11205990] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 09/30/2022] [Accepted: 10/04/2022] [Indexed: 11/23/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is associated with high morbidity and mortality. Adjunct hemoadsorption is increasingly utilized to target underlying hyperinflammation derived from ARDS. This article aims to review available data on the use of CytoSorb© therapy in combination with V-V ECMO in severe ARDS, and to assess the effects on inflammatory, laboratory and clinical parameters, as well as on patient outcomes. A systematic literature review was conducted and reported in compliance with principles derived from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. When applicable, a before-and-after analysis for relevant biomarkers and clinical parameters was carried out. CytoSorb© use was associated with significant reductions in circulating levels of C-reactive protein and interleukin-6 (p = 0.039 and p = 0.049, respectively). Increases in PaO2/FiO2 reached significance as well (p = 0.028), while norepinephrine dosage reductions showed a non-significant trend (p = 0.067). Mortality rates in CytoSorb© patients tended to be lower than those of control groups of most included studies, which, however, were characterized by high heterogeneity and low power. In an exploratory analysis on 90-day mortality in COVID-19 patients supported with V-V ECMO, the therapy was associated with a significantly reduced risk of death. Based on the reviewed data, CytoSorb© therapy is able to reduce inflammation and potentially improves survival in ARDS patients treated with V-V ECMO. Early initiation of CytoSorb© in conjunction with ECMO might offer a new approach to enhance lung rest and promote recovery in patients with severe ARDS.
Collapse
Affiliation(s)
- Ali Akil
- Department of Thoracic Surgery and Lung Support, Ibbenbueren General Hospital, 49477 Ibbenbueren, Germany
| | - L. Christian Napp
- Department of Cardiology and Angiology, Hannover Medical School, 30625 Hannover, Germany
| | | | | | | | - Federico Pappalardo
- Cardiothoracic and Vascular Anesthesia and Intensive Care, AO SS. Antonio e Biagio e Cesare Arrigo, 15100 Alessandria, Italy
- Correspondence:
| |
Collapse
|
4
|
Jackson R, Trus RM, El-Diasty M. Hemadsorption for removal of ticagrelor and direct oral anticoagulants in cardiac surgery. Expert Rev Cardiovasc Ther 2022; 20:141-150. [PMID: 35179425 DOI: 10.1080/14779072.2022.2044306] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Cardiac patients on antiplatelets or oral anticoagulation undergoing emergent cardiac surgery without appropriate washout periods are at increased risk for developing perioperative bleeding. CytoSorb is a commercially available hemadsorption filter that can simultaneously remove a wide range of substances including ticagrelor, and direct oral anticoagulants (DOACs). Areas covered: Although CytoSorb has been used to remove various protein-bound substances, this review will specifically evaluate and review current evidence for applying CytoSorb in removing ticagrelor and DOACs using 4 in vivo studies, 3 case reports, one retrospective clinical study and 2 cost analysis studies. Based on limited evidence, CytoSorb may be effective in reducing perioperative bleeding as demonstrated by reducing chest tube output, blood product transfusions, and re-thoracotomy rates. CytoSorb can also reduce length of intensive care unit (ICU) and hospital stay. Although, CytoSorb has an initial upfront cost, it was proven to be cost effective due to potential health resource savings on both short- and long-term projections.Expert Commentary: CytoSorb provides a novel strategy to remove ticagrelor and DOACs in patients requiring emergency cardiac surgery. Although promising results, more solid evidence is required to establish its clinical effectiveness in reducing perioperative bleeding, bleeding-related complications, mortality, and finally, its overall safety.
Collapse
Affiliation(s)
- Robyn Jackson
- Department of Cardiology, Queen's University, Ontario, Canada
| | | | | |
Collapse
|
5
|
Köhler T, Schwier E, Praxenthaler J, Kirchner C, Henzler D, Eickmeyer C. Therapeutic Modulation of the Host Defense by Hemoadsorption with CytoSorb ®-Basics, Indications and Perspectives-A Scoping Review. Int J Mol Sci 2021; 22:12786. [PMID: 34884590 PMCID: PMC8657779 DOI: 10.3390/ijms222312786] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/21/2021] [Accepted: 11/22/2021] [Indexed: 01/08/2023] Open
Abstract
The "normal" immune response to an insult triggers a highly regulated response determined by the interaction of various immunocompetent cells with pro- and anti-inflammatory cytokines. Under pathologic conditions, the massive elevation of cytokine levels ("cytokine storm") could not be controlled until the recent development of hemoadsorption devices that are able to extract a variety of different DAMPs, PAMPs, and metabolic products from the blood. CytoSorb® has been approved for adjunctive sepsis therapy since 2011. This review aims to summarize theoretical knowledge, in vitro results, and clinical findings to provide the clinician with pragmatic guidance for daily practice. English-language and peer-reviewed literature identified by a selective literature search in PubMed and published between January 2016 and May 2021 was included. Hemoadsorption can be used successfully as adjunct to a complex therapeutic regimen for various conditions. To the contrary, this nonspecific intervention may potentially worsen patient outcomes in complex immunological processes. CytoSorb® therapy appears to be safe and useful in various diseases (e.g., rhabdomyolysis, liver failure, or intoxications) as well as in septic shock or cytokine release syndrome, although a conclusive assessment of treatment benefit is not possible and no survival benefit has yet been demonstrated in randomized controlled trials.
Collapse
Affiliation(s)
- Thomas Köhler
- Department of Anesthesiology, Surgical Intensive Care, Emergency and Pain Medicine, Ruhr University Bochum, Klinikum Herford, 32120 Herford, Germany; (E.S.); (J.P.); (D.H.); (C.E.)
| | - Elke Schwier
- Department of Anesthesiology, Surgical Intensive Care, Emergency and Pain Medicine, Ruhr University Bochum, Klinikum Herford, 32120 Herford, Germany; (E.S.); (J.P.); (D.H.); (C.E.)
| | - Janina Praxenthaler
- Department of Anesthesiology, Surgical Intensive Care, Emergency and Pain Medicine, Ruhr University Bochum, Klinikum Herford, 32120 Herford, Germany; (E.S.); (J.P.); (D.H.); (C.E.)
| | - Carmen Kirchner
- Department of General and Visceral Surgery, Thoracic Surgery and Proctology, Ruhr University Bochum, Klinikum Herford, 32120 Herford, Germany;
| | - Dietrich Henzler
- Department of Anesthesiology, Surgical Intensive Care, Emergency and Pain Medicine, Ruhr University Bochum, Klinikum Herford, 32120 Herford, Germany; (E.S.); (J.P.); (D.H.); (C.E.)
| | - Claas Eickmeyer
- Department of Anesthesiology, Surgical Intensive Care, Emergency and Pain Medicine, Ruhr University Bochum, Klinikum Herford, 32120 Herford, Germany; (E.S.); (J.P.); (D.H.); (C.E.)
| |
Collapse
|
6
|
Hawchar F, Rao C, Akil A, Mehta Y, Rugg C, Scheier J, Adamson H, Deliargyris E, Molnar Z. The Potential Role of Extracorporeal Cytokine Removal in Hemodynamic Stabilization in Hyperinflammatory Shock. Biomedicines 2021; 9:biomedicines9070768. [PMID: 34356830 PMCID: PMC8301410 DOI: 10.3390/biomedicines9070768] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 06/26/2021] [Accepted: 06/27/2021] [Indexed: 02/06/2023] Open
Abstract
Hemodynamic instability due to dysregulated host response is a life-threatening condition requiring vasopressors and vital organ support. Hemoadsorption with Cytosorb has proven to be effective in reducing cytokines and possibly in attenuating the devastating effects of the cytokine storm originating from the immune over-response to the initial insult. We reviewed the PubMed database to assess evidence of the impact of Cytosorb on norepinephrine needs in the critically ill. We further analyzed those studies including data on control cohorts in a comparative pooled analysis, defining a treatment effect as the standardized mean differences in relative reductions in vasopressor dosage at 24 h. The literature search returned 33 eligible studies. We found evidence of a significant reduction in norepinephrine requirement after treatment: median before, 0.55 (IQR: 0.39-0.90); after, 0.09 (0.00-0.25) μg/kg/min, p < 0.001. The pooled effect size at 24 h was large, though characterized by high heterogeneity. In light of the importance of a quick resolution of hemodynamic instability in the critically ill, further research is encouraged to enrich knowledge on the potentials of the therapy.
Collapse
Affiliation(s)
- Fatime Hawchar
- Department of Anaesthesiology and Intensive Therapy, University of Szeged, 6 Semmelweis Str., H-6725 Szeged, Hungary;
| | - Cristina Rao
- Cytosorbents Europe GmbH, Müggelseedamm 131, 12587 Berlin, Germany; (C.R.); (J.S.); (H.A.)
| | - Ali Akil
- Department of Thoracic Surgery and Lung Support, Klinikum Ibbenbueren, Grosse Strasse 41, 49477 Ibbenbueren, Germany;
| | - Yatin Mehta
- Institute of Critical Care and Anesthesiology, Medanta the Medicity, CH Baktawar Singh Rd, Gurugram 122001, Haryana, India;
| | - Christopher Rugg
- Department of Anesthesiology and Critical Care Medicine, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria;
| | - Joerg Scheier
- Cytosorbents Europe GmbH, Müggelseedamm 131, 12587 Berlin, Germany; (C.R.); (J.S.); (H.A.)
| | - Harriet Adamson
- Cytosorbents Europe GmbH, Müggelseedamm 131, 12587 Berlin, Germany; (C.R.); (J.S.); (H.A.)
| | - Efthymios Deliargyris
- Cytosorbents Corporation, 7 Deer Park Drive Suite K, Monmouth Junction, NJ 08852, USA;
| | - Zsolt Molnar
- Department of Anaesthesiology and Intensive Therapy, University of Szeged, 6 Semmelweis Str., H-6725 Szeged, Hungary;
- Institute for Translational Medicine, School of Medicine, University of Pécs, Szigeti Str. 12, H-7624 Pécs, Hungary
- Department of Anaesthesiology and Intensive Therapy and Pain Management, Poznan University for Medical Sciences, 61-701 Poznan, Poland
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, 1085 Budapest, Hungary
- Correspondence:
| |
Collapse
|
7
|
Bottari G, Guzzo I, Marano M, Stoppa F, Ravà L, Di Nardo M, Cecchetti C. Hemoperfusion with Cytosorb in pediatric patients with septic shock: A retrospective observational study. Int J Artif Organs 2020; 43:587-593. [PMID: 32003289 DOI: 10.1177/0391398820902469] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To determine the clinical effect of continuous hemoperfusion with Cytosorb associated with standard Continuous Renal Replacement Therapy on hemodynamics and on clinically relevant outcome parameters in children with septic shock. DESIGN Retrospective analysis. SETTING Pediatric intensive care unit. PATIENTS Eight consecutive children with septic shock who received hemoperfusion with Cytosorb while on Continuous Renal Replacement Therapy. INTERVENTIONS Continuous hemoperfusion with Cytosorb (adsorber was changed every 24 h). MEASUREMENTS AND MAIN RESULTS Vasoactive-Inotropic Score was measured before and after the extracorporeal blood purification treatment. Bedside refractory septic shock score was calculated before the onset of the extracorporeal blood purification treatment. Time course of cytokines interleukin-6, interleukin-10, and tumor necrosis factor-alpha was measured at Time 0, then every 12 h until the end of blood purification treatment (72 or 96 h). Pediatric intensive care unit survival in our cohort was 90%. Median bedside refractory septic shock score was 2.1. Patients showed improved Vasoactive-Inotropic Score following blood purification (pre: 40.00 post: 8.89 p = 0.0076). Measurement of cytokines level showed a significant reduction of interleukin-6 plasma levels (7977.27-210.18 pg/mL, p = 0.0077) and interleukin-10 plasma levels (from 687.19 to 36.95 pg/mL, p = 0.0180). In those patients with detectable tumor necrosis factor-alpha plasma level, its reduction was not significant (p = 0.138). The median removal ratio was 80% for interleukin-6, 90% for interleukin-10, and 29% for tumor necrosis factor-alpha. CONCLUSION The use of Cytosorb in combination with Continuous Renal Replacement Therapy as blood purification strategy in pediatric septic shock is associated with a rapid hemodynamic stabilization in the first 48 h of treatment and a significant reduction of interleukin-6 and interleukin-10.
Collapse
Affiliation(s)
- Gabriella Bottari
- Pediatric Intensive Care Unit, Children's Hospital Bambino Gesù, Rome, Italy
| | - Isabella Guzzo
- Division of Nephrology and Dialysis, Department of Pediatrics, Children's Hospital Bambino Gesù, Rome, Italy
| | - Marco Marano
- Pediatric Intensive Care Unit, Children's Hospital Bambino Gesù, Rome, Italy
| | - Francesca Stoppa
- Pediatric Intensive Care Unit, Children's Hospital Bambino Gesù, Rome, Italy
| | - Lucilla Ravà
- Clinical Epidemiology Unit, Children's Hospital Bambino Gesù, Rome, Italy
| | - Matteo Di Nardo
- Pediatric Intensive Care Unit, Children's Hospital Bambino Gesù, Rome, Italy
| | - Corrado Cecchetti
- Pediatric Intensive Care Unit, Children's Hospital Bambino Gesù, Rome, Italy
| |
Collapse
|
8
|
Träger K, Skrabal C, Fischer G, Schroeder J, Marenski L, Liebold A, Reinelt H, Datzmann T. Hemoadsorption treatment with CytoSorb ® in patients with extracorporeal life support therapy: A case series. Int J Artif Organs 2019; 43:422-429. [PMID: 31868089 DOI: 10.1177/0391398819895287] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Extracorporeal life support is an increasingly used technique for respiratory and cardiocirculatory support. Besides primary organ dysfunction, an excessive systemic hyperinflammatory response can be the underlying cause for acute organ failure necessitating extracorporeal life support therapy, or it may be associated with the extracorporeal life support itself. Controlling this overwhelming inflammatory response using CytoSorb® hemoadsorption has been shown to be associated with improved hemodynamics and restored metabolic balance resulting in preserved organ functions. METHODS In this retrospective case series, we describe 23 patients undergoing extracorporeal life support therapy and CytoSorb hemoadsorption. Cytokine levels were monitored, hemodynamic and metabolic variables were recorded, and outcome measures such as duration of organ support, intensive care unit mortality, and hospital mortality were noted. RESULTS CytoSorb treatment was associated with a trend toward a reduction in plasma cytokine levels (first treatment median interleukin-6 pre 595 vs post 350 pg/mL (n.s.); second treatment median interleukin-6 317 vs 108 pg/mL, p < 0.05), a reduced vasoplegic response resulting in a reduction in vasopressor requirements (first treatment median norepinephrine pre 0.15 vs post 0.02 µg/kg/min (n.s.); second treatment median norepinephrine 0.1 vs 0.02 µg/kg/min, p < 0.05) as well as rebalancing of deranged metabolic parameters (first treatment median lactate pre-treatment 6 vs post-treatment median lactate 2 mmol/L, p < 0.05). The hemoperfusion treatment was well tolerated and safe, without the occurrence of any CytoSorb device-related adverse events. CONCLUSION Hemoadsorption may offer a potentially promising therapeutic option for critically ill patients undergoing extracorporeal life support therapy, with cytokine reduction and a consecutively mitigated inflammatory response, decreased vasoplegia, and improved organ function as seen in our patients.
Collapse
Affiliation(s)
- Karl Träger
- Department of Cardiac Anesthesiology and Interdisciplinary Surgical Intensive Care, University Hospital Ulm, Ulm, Germany
| | - Christian Skrabal
- Clinic of Cardiothoracic and Vascular Surgery, University Hospital Ulm, Ulm, Germany
| | - Guenther Fischer
- Department of Cardiac Anesthesiology and Interdisciplinary Surgical Intensive Care, University Hospital Ulm, Ulm, Germany
| | - Janpeter Schroeder
- Department of Cardiac Anesthesiology and Interdisciplinary Surgical Intensive Care, University Hospital Ulm, Ulm, Germany
| | - Larissa Marenski
- Department of Cardiac Anesthesiology and Interdisciplinary Surgical Intensive Care, University Hospital Ulm, Ulm, Germany
| | - Andreas Liebold
- Clinic of Cardiothoracic and Vascular Surgery, University Hospital Ulm, Ulm, Germany
| | - Helmut Reinelt
- Department of Cardiac Anesthesiology and Interdisciplinary Surgical Intensive Care, University Hospital Ulm, Ulm, Germany
| | - Thomas Datzmann
- Department of Cardiac Anesthesiology and Interdisciplinary Surgical Intensive Care, University Hospital Ulm, Ulm, Germany
| |
Collapse
|
9
|
Han L, Zhang Y, Zhang Y, Wu W, He P. Risk factors for refractory septic shock treated with VA ECMO. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:476. [PMID: 31700912 DOI: 10.21037/atm.2019.08.07] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background Refractory septic shock is a serious disorder with high mortality. There is currently limited evidence to support the use of extracorporeal membrane oxygenation (ECMO) in adult septic shock. We describe the outcome of patients with refractory septic shock in our hospital and try to identify prognostic factors. Methods We studied a total of 23 (14 males and 9 females) refractory septic shock patients treated with venoarterial (VA) ECMO in our hospital. Clinical parameters of survival and death groups, laboratory parameters before and after ECMO placement were analyzed. Results Eight patients were successfully weaned off ECMO and five patients were discharged. The sepsis-related organ failure assessment (SOFA) score and shock-to-ECMO interval before ECMO placement in the survival group were significantly lower than those in the death group (12.0 vs. 15.0, P=0.007; 23.5 vs. 42.2 h, P=0.037). The number of cases who had the normal range of ScvO2% between the survival group and the death group at 12 h (4 vs. 4, P=0.033), 18 h (5 vs. 7, P=0.016) and 24 h (5 vs. 9, P=0.043) during ECMO was significantly different. In univariate logistic regression analysis, the case of patients with normal central venous oxygen saturation (ScvO2) % at 12 h during ECMO [odds ratio (OR) 14.0, 95% confidence interval (CI): 1.200-163.367, P=0.035] was significantly associated with risk of the prognosis of patients. Conclusions In adult refractory septic shock patients, ScvO2% at 12 h during ECMO may be a risk factor for patient prognosis.
Collapse
Affiliation(s)
- Lei Han
- Medical and Education Department, Southwest Hospital, the First Hospital Affiliated to Army Medical University, Chongqing 400038, China
| | - Yan Zhang
- Critical Care Medicine, Southwest Hospital, the First Hospital Affiliated to Army Medical University, Chongqing 400038, China
| | - Yonghui Zhang
- Critical Care Medicine, Southwest Hospital, the First Hospital Affiliated to Army Medical University, Chongqing 400038, China
| | - Wei Wu
- Thoracic Surgery Department, Southwest Hospital, the First Hospital Affiliated to Army Medical University, Chongqing 400038, China
| | - Ping He
- Cardiac Surgery Department, Southwest Hospital, the First Hospital Affiliated to Army Medical University, Chongqing 400038, China
| |
Collapse
|
10
|
Lother A, Benk C, Staudacher DL, Supady A, Bode C, Wengenmayer T, Duerschmied D. Cytokine Adsorption in Critically Ill Patients Requiring ECMO Support. Front Cardiovasc Med 2019; 6:71. [PMID: 31275944 PMCID: PMC6593298 DOI: 10.3389/fcvm.2019.00071] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 05/13/2019] [Indexed: 12/12/2022] Open
Abstract
Systemic inflammation is a key characteristic of sepsis but also also in non-infectious conditions such as post-cardiac arrest syndrome. Cytokine adsorption and extracorporeal membrane oxygenation are emerging therapies applied in these critically ill patients, but the experience with their concurrent use is limited. We evaluated cytokine adsorption in critically ill patients requiring support with either veno-venous (vv) or veno-arterial (va) extracorporeal membrane oxygenation (ECMO) support and hypothesized that adsorber incorporation into the ECMO circuit was technically feasible and not associated with imminent risk. We analyzed data from the first six cases of a prospective single-center registry of patients undergoing veno-venous (vv) or veno-arterial (va) ECMO therapy. While in most published cases cytokine adsorbers were inserted into a hemofiltration circuit, we directly incorporated the adsorber into the ECMO circuit without interruption of continuous ECMO support. We observed no relevant side effects attributable to cytokine adsorption. Thirty-day mortality was 83% (predicted mortality 87%), indicating that the decision for adding cytokine adsorption may have been considered as an ultima ratio decision in severe cases with poor prognosis. Vasopressor or inotrope use, lactate level, and fluid balance did not change significantly when comparing pre- vs. post-cytokine adsorption values. Interestingly, the real-time course of the mentioned three surrogate parameters remained unaltered in all but two cases, regardless of cytokine removal. Beneficial effects of cytokine adsorption are plausible in two va-ECMO-treated patient, where increasing lactate began to drop after initiation of cytokine adsorption. Taken together, these data suggest that incorporation of cytokine adsorption into the management of critically ill patients requiring continued ECMO support is feasible and easy to handle. Whether cytokine removal improves clinical outcome in ECMO-treated patients should now be investigated in randomized controlled trials.
Collapse
Affiliation(s)
- Achim Lother
- Department of Cardiology and Angiology I, Faculty of Medicine, Heart Center Freiburg University, University of Freiburg, Freiburg, Germany.,Department of Medicine III (Interdisciplinary Medical Intensive Care), Faculty of Medicine, Medical Center, University of Freiburg, Freiburg, Germany.,Institute of Experimental and Clinical Pharmacology and Toxicology, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph Benk
- Department of Cardiovascular Surgery, Heart Center Freiburg University, University of Freiburg, Freiburg, Germany
| | - Dawid L Staudacher
- Department of Cardiology and Angiology I, Faculty of Medicine, Heart Center Freiburg University, University of Freiburg, Freiburg, Germany.,Department of Medicine III (Interdisciplinary Medical Intensive Care), Faculty of Medicine, Medical Center, University of Freiburg, Freiburg, Germany
| | - Alexander Supady
- Department of Cardiology and Angiology I, Faculty of Medicine, Heart Center Freiburg University, University of Freiburg, Freiburg, Germany.,Department of Medicine III (Interdisciplinary Medical Intensive Care), Faculty of Medicine, Medical Center, University of Freiburg, Freiburg, Germany
| | - Christoph Bode
- Department of Cardiology and Angiology I, Faculty of Medicine, Heart Center Freiburg University, University of Freiburg, Freiburg, Germany.,Department of Medicine III (Interdisciplinary Medical Intensive Care), Faculty of Medicine, Medical Center, University of Freiburg, Freiburg, Germany
| | - Tobias Wengenmayer
- Department of Cardiology and Angiology I, Faculty of Medicine, Heart Center Freiburg University, University of Freiburg, Freiburg, Germany.,Department of Medicine III (Interdisciplinary Medical Intensive Care), Faculty of Medicine, Medical Center, University of Freiburg, Freiburg, Germany
| | - Daniel Duerschmied
- Department of Cardiology and Angiology I, Faculty of Medicine, Heart Center Freiburg University, University of Freiburg, Freiburg, Germany.,Department of Medicine III (Interdisciplinary Medical Intensive Care), Faculty of Medicine, Medical Center, University of Freiburg, Freiburg, Germany
| |
Collapse
|
11
|
Napp LC, Ziegeler S, Kindgen-Milles D. Rationale of Hemoadsorption during Extracorporeal Membrane Oxygenation Support. Blood Purif 2019; 48:203-214. [PMID: 31096211 PMCID: PMC6878728 DOI: 10.1159/000500015] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 03/29/2019] [Indexed: 12/14/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) and extracorporeal life support are increasingly used for treating various forms of shock, lung failure, protected interventions and life support including resuscitation. Most patients on ECMO are affected by a systemic inflammatory response caused by the underlying disease as well as the ECMO support itself, which contributes to vasoplegia, multi-organ failure, deterioration and death. Unfortunately, effective strategies for control of inflammation and related organ failure and shock on ECMO are lacking. Recently, a new polystyrene-based device for hemoadsorption, which aims to reduce excessive levels of inflammatory molecules such as interleukins, cytokines as well as damage- and pathogen-associated molecular patterns, has become available. Here we summarize the rationale, available data and technical aspects of polystyrene-based hemoadsorption during ECMO support, and give recommendations based on existing experience.
Collapse
Affiliation(s)
- L Christian Napp
- Department of Cardiology and Angiology, Cardiac Arrest Center, Advanced Heart Failure Unit, Hannover Medical School, Hannover, Germany,
| | - Stephan Ziegeler
- Department of Anesthesiology, Operative Intensive Care Medicine, Pain Management and Emergency Medicine, Hospital Ibbenbüren, Ibbenbüren, Germany
| | - Detlef Kindgen-Milles
- Department of Anesthesiology, University Hospital Düsseldorf, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| |
Collapse
|