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Yan D, Yao R, Xie X, Fu X, Pei S, Wang Y, Xu D, Li N. THE THERAPEUTIC EFFICACY OF PLASMAPHERESIS FOR SEPSIS WITH MULTIPLE ORGAN FAILURE: A PROPENSITY SCORE-MATCHED ANALYSIS BASED ON THE MIMIC-IV DATABASE. Shock 2024; 61:685-694. [PMID: 37988068 DOI: 10.1097/shk.0000000000002254] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Abstract
ABSTRACT Background: Despite advancements in sepsis treatment, mortality remains high. Plasmapheresis (PE) targeting multiple pathways simultaneously seems to be a potential treatment option, but evidence is insufficient. We aimed to investigate the efficacy of PE for sepsis with multiple organ failure (MOF). Method: Septic patients with MOF were identified from the Medical Information Mart for Intensive Care IV database. Patients who received PE were matched with those receiving conventional therapy via propensity score matching. Regression analyses evaluated the association between PE and outcomes. The Kaplan-Meier (KM) method was used to analyze the survival probability. The generalized additive mixed model investigated early indexes changes' association with treatment modalities and 28-day mortality. Results: Nine hundred six septic patients with MOF were enrolled. After propensity score matching, PE and conventional groups consisted of 60 cases each. Plasmapheresis was associated with a reduced risk of 28-day mortality (hazard ratio [HR], 0.50; 95% confidence interval [CI], 0.27-0.94), 1-year mortality (HR, 0.44; 95% CI, 0.26-0.74), and in-hospital mortality (HR, 0.38; 95% CI, 0.20-0.71). The KM curves demonstrated significant differences in survival probability between groups. Compared with the conventional group, the sequential organ failure assessment, norepinephrine dosage, prothrombin time, actate dehydrogenase, total bilirubin, white blood cells, and immature granulocytes in the PE group significantly decreased over time, while platelets, red blood cells, and hemoglobin significantly increased over time. Conclusions: Plasmapheresis demonstrated an association with reduced risks of 28-day, in-hospital and 1-year mortality in septic patients with MOF. Moreover, plasmapheresis might exhibit the potential to improve outcomes by improving organ function, hemodynamics, and restoring several indicators, such as coagulation, anemia, and inflammation.
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Affiliation(s)
- Danyang Yan
- Department of Blood Transfusion, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Clinical Transfusion Research Center, Central South University, Changsha, Hunan Province, China
| | - Run Yao
- Department of Blood Transfusion, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Clinical Transfusion Research Center, Central South University, Changsha, Hunan Province, China
| | - Xi Xie
- Department of Blood Transfusion, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Clinical Transfusion Research Center, Central South University, Changsha, Hunan Province, China
| | - Xiangjie Fu
- Department of Blood Transfusion, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Clinical Transfusion Research Center, Central South University, Changsha, Hunan Province, China
| | - Siya Pei
- Department of Blood Transfusion, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Clinical Transfusion Research Center, Central South University, Changsha, Hunan Province, China
| | - Yanjie Wang
- Department of Blood Transfusion, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Clinical Transfusion Research Center, Central South University, Changsha, Hunan Province, China
| | - Daomiao Xu
- General ICU/Department of Critical Care Medicine, Xiangya Hospital, Central South University, Changsha, Hunan Province, China
| | - Ning Li
- Department of Blood Transfusion, National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Clinical Transfusion Research Center, Central South University, Changsha, Hunan Province, China
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Raina R, Nair N, Pelletier J, Nied M, Whitham T, Doshi K, Beck T, Dantes G, Sethi SK, Kim YH, Bunchman T, Alhasan K, Lima L, Guzzo I, Fuhrman D, Paden M. Concurrent use of continuous kidney replacement therapy during extracorporeal membrane oxygenation: what pediatric nephrologists need to know-PCRRT-ICONIC practice points. Pediatr Nephrol 2024:10.1007/s00467-024-06311-x. [PMID: 38386072 DOI: 10.1007/s00467-024-06311-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 01/15/2024] [Accepted: 01/27/2024] [Indexed: 02/23/2024]
Abstract
Extracorporeal membrane oxygenation (ECMO) provides temporary cardiorespiratory support for neonatal, pediatric, and adult patients when traditional management has failed. This lifesaving therapy has intrinsic risks, including the development of a robust inflammatory response, acute kidney injury (AKI), fluid overload (FO), and blood loss via consumption and coagulopathy. Continuous kidney replacement therapy (CKRT) has been proposed to reduce these side effects by mitigating the host inflammatory response and controlling FO, improving outcomes in patients requiring ECMO. The Pediatric Continuous Renal Replacement Therapy (PCRRT) Workgroup and the International Collaboration of Nephrologists and Intensivists for Critical Care Children (ICONIC) met to highlight current practice standards for ECMO use within the pediatric population. This review discusses ECMO modalities, the pathophysiology of inflammation during an ECMO run, its adverse effects, various anticoagulation strategies, and the technical aspects and outcomes of implementing CKRT during ECMO in neonatal and pediatric populations. Consensus practice points and guidelines are summarized. ECMO should be utilized in patients with severe acute respiratory failure despite the use of conventional treatment modalities. The Extracorporeal Life Support Organization (ELSO) offers guidelines for ECMO initiation and management while maintaining a clinical registry of over 195,000 patients to assess outcomes and complications. Monitoring and preventing fluid overload during ECMO and CKRT are imperative to reduce mortality risk. Clinical evidence, resources, and experience of the nephrologist and healthcare team should guide the selection of ECMO circuit.
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Affiliation(s)
- Rupesh Raina
- Department of Nephrology, Akron Children's Hospital, Akron, OH, USA.
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA.
| | - Nikhil Nair
- Case Western University School of Medicine, Cleveland, OH, USA
| | - Jonathan Pelletier
- Division of Critical Care Medicine, Department of Pediatrics, Akron Children's Hospital, Akron, OH, USA
- Department of Pediatrics, College of Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Matthew Nied
- Department of Internal Medicine, Case Western Reserve / University Hospitals, Cleveland, OH, USA
| | - Tarik Whitham
- Department of Pediatrics, College of Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Kush Doshi
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA
| | - Tara Beck
- Department of Pediatrics, University of Pittsburgh Medical Center Children's Hospital, Pittsburgh, PA, USA
| | - Goeto Dantes
- Department of Surgery, Emory University, Atlanta, GA, USA
| | - Sidharth Kumar Sethi
- Pediatric Nephrology, Kidney Institute, Medanta, The Medicity, Gurgaon, Haryana, India
| | - Yap Hui Kim
- Department of Pediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Timothy Bunchman
- Department of Pediatric Nephrology, Children's Hospital of Richmond, Richmond, VA, USA
| | - Kahild Alhasan
- Pediatric Nephrology, King Saud University, Riyadh, Saudi Arabia
| | - Lisa Lima
- Department of Pediatric Critical Care, Emory University, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Isabella Guzzo
- Division of Nephrology and Dialysis, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Dana Fuhrman
- Department of Pediatrics, University of Pittsburgh Medical Center Children's Hospital, Pittsburgh, PA, USA
| | - Matthew Paden
- Department of Pediatric Critical Care, Emory University, Children's Healthcare of Atlanta, Atlanta, GA, USA
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Keith P, Bohn RIC, Nguyen T, Scott LK, Richmond M, Day M, Choe C, Perkins L, Burnside R, Pyke R, Rikard B, Guffey A, Saini A, Park HJ, Carcillo J. Improved survival in COVID-19 related sepsis and ARDS treated with a unique "triple therapy" including therapeutic plasma exchange: A single center retrospective analysis. J Clin Apher 2024; 39:e22107. [PMID: 38404046 DOI: 10.1002/jca.22107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 02/09/2024] [Accepted: 02/10/2024] [Indexed: 02/27/2024]
Abstract
BACKGROUND Throughout the COVID-19 pandemic, the mortality of critically ill patients remained high. Our group developed a treatment regimen targeting sepsis and ARDS which we labeled "triple therapy" consisting of (1) corticosteroids, (2) therapeutic plasma exchange (TPE), and (3) timely intubation with lung protective ventilation. Our propensity analysis assesses the impact of triple therapy on survival in COVID-19 patients with sepsis and ARDS. METHODS Retrospective propensity analysis comparing triple therapy to no triple therapy in adult critically ill COVID-19 patients admitted to the Intensive Care Unit at Lexington Medical Center from 1 March 2020 through 31 October 2021. RESULTS Eight hundred and fifty-one patients were admitted with COVID-19 and 53 clinical and laboratory variables were analyzed. Multivariable analysis revealed that triple therapy was associated with increased survival (OR: 1.91; P = .008). Two propensity score-adjusted models demonstrated an increased likelihood of survival in patients receiving triple therapy. Patients with thrombocytopenia were among those most likely to experience increased survival if they received early triple therapy. Decreased survival was observed with endotracheal intubation ≥7 days from hospital admission (P < .001) and there was a trend toward decreased survival if TPE was initiated ≥6 days from hospital admission (P = .091). CONCLUSION Our analysis shows that early triple therapy, defined as high-dose methylprednisolone, TPE, and timely invasive mechanical ventilation within the first 96 hours of admission, may improve survival in critically ill septic patients with ARDS secondary to COVID-19 infection. Further studies are needed to define specific phenotypes and characteristics that will identify those patients most likely to benefit.
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Affiliation(s)
- Philip Keith
- Lexington Medical Center, West Columbia, South Carolina, USA
| | | | - Trung Nguyen
- Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - L Keith Scott
- Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Monty Richmond
- Medical Center Downtown, MUSC Health Columbia, Columbia, South Carolina, USA
| | - Matthew Day
- Lexington Medical Center, West Columbia, South Carolina, USA
| | - Carol Choe
- Lexington Medical Center, West Columbia, South Carolina, USA
| | - Linda Perkins
- Lexington Medical Center, West Columbia, South Carolina, USA
| | | | - Richard Pyke
- Lexington Medical Center, West Columbia, South Carolina, USA
| | - Ben Rikard
- Lexington Medical Center, West Columbia, South Carolina, USA
| | - Amanda Guffey
- Lexington Medical Center, West Columbia, South Carolina, USA
| | - Arun Saini
- Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - H J Park
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Joseph Carcillo
- University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Saner FH, Raptis DA, Alghamdi SA, Malagó MM, Broering DC, Bezinover D. Navigating the Labyrinth: Intensive Care Challenges for Patients with Acute-on-Chronic Liver Failure. J Clin Med 2024; 13:506. [PMID: 38256640 PMCID: PMC10816826 DOI: 10.3390/jcm13020506] [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: 11/20/2023] [Revised: 01/07/2024] [Accepted: 01/14/2024] [Indexed: 01/24/2024] Open
Abstract
Acute-on-chronic liver failure (ACLF) refers to the deterioration of liver function in individuals who already have chronic liver disease. In the setting of ACLF, liver damage leads to the failure of other organs and is associated with increased short-term mortality. Optimal medical management of patients with ACLF requires implementing complex treatment strategies, often in an intensive care unit (ICU). Failure of organs other than the liver distinguishes ACLF from other critical illnesses. Although there is growing evidence supporting the current approach to ACLF management, the mortality associated with this condition remains unacceptably high. In this review, we discuss considerations for ICU care of patients with ACLF and highlight areas for further research.
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Affiliation(s)
- Fuat H. Saner
- Organ Transplant Center of Excellence, King Faisal Specialized Hospital & Research Center, Riyadh 12111, Saudi Arabia; (D.A.R.); (S.A.A.); (M.M.M.); (D.C.B.)
| | - Dimitri A. Raptis
- Organ Transplant Center of Excellence, King Faisal Specialized Hospital & Research Center, Riyadh 12111, Saudi Arabia; (D.A.R.); (S.A.A.); (M.M.M.); (D.C.B.)
| | - Saad A. Alghamdi
- Organ Transplant Center of Excellence, King Faisal Specialized Hospital & Research Center, Riyadh 12111, Saudi Arabia; (D.A.R.); (S.A.A.); (M.M.M.); (D.C.B.)
| | - Massimo M. Malagó
- Organ Transplant Center of Excellence, King Faisal Specialized Hospital & Research Center, Riyadh 12111, Saudi Arabia; (D.A.R.); (S.A.A.); (M.M.M.); (D.C.B.)
| | - Dieter C. Broering
- Organ Transplant Center of Excellence, King Faisal Specialized Hospital & Research Center, Riyadh 12111, Saudi Arabia; (D.A.R.); (S.A.A.); (M.M.M.); (D.C.B.)
| | - Dmitri Bezinover
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA;
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Kaur J, Sharma N, Kanaujia R, Bisht K, Goel S, Biswal M, Sharma N. Molecular characterization of Orientia tsutsugamushi causing fatal scrub typhus in a young male affected by so-called "mystery fever" in North India. Indian J Med Microbiol 2023; 46:100418. [PMID: 37945112 DOI: 10.1016/j.ijmmb.2023.100418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 06/07/2023] [Accepted: 06/17/2023] [Indexed: 11/12/2023]
Abstract
Scrub typhus is a zoonotic disease caused by Orientia tsutsugamushi. Although the presence of eschar is considered pathognomic, diagnosis of scrub typhus is challenging due to overlapping presentation. The diagnosis is based on the serological and molecular assay. Here, we describe a case of a young male patient who was diagnosed with scrub typhus and developed complications in the course of the disease. We also performed molecular characterization of the strain which revealed a close relatedness to Karp-like Linh.DT strains were previously reported from Vietnam.
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Affiliation(s)
- Jasleen Kaur
- Department of Medical Microbiology, PGIMER, Chandigarh, India.
| | - Nalin Sharma
- Department of Internal Medicine, PGIMER, Chandigarh, India.
| | | | - Kamlesh Bisht
- Department of Medical Microbiology, PGIMER, Chandigarh, India.
| | - Shriya Goel
- Department of Medical Microbiology, PGIMER, Chandigarh, India.
| | - Manisha Biswal
- Department of Medical Microbiology, PGIMER, Chandigarh, India.
| | - Navneet Sharma
- Department of Internal Medicine, PGIMER, Chandigarh, India.
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Fuentes AD, Rubio GT, Acuña CA, Rubio FD, Milic FB, Troncoso PC. Near-fatal cocaine intoxication in an infant with thrombotic microangiopathy associated with multiple organ failure. REVISTA PAULISTA DE PEDIATRIA : ORGAO OFICIAL DA SOCIEDADE DE PEDIATRIA DE SAO PAULO 2023; 42:e2022159. [PMID: 37646745 PMCID: PMC10503420 DOI: 10.1590/1984-0462/2024/42/2022159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 04/21/2023] [Indexed: 09/01/2023]
Abstract
OBJECTIVE To report a pediatric case of drug-induced thrombotic microangiopathy caused by cocaine. CASE DESCRIPTION We report a nine-month-old patient who developed thrombotic microangiopathies after extreme cocaine intoxication, multiple organ dysfunction syndrome with hemodynamic dysfunction, anuric renal failure, liver failure, encephalopathy, and myocardial injury, corresponding phenotypically to thrombocytopenia-associated multiple organ failure. The patient received continuous venous hemofiltration and therapeutic plasma exchange, recovering satisfactorily. She was discharged after 30 days of hospitalization under the guidance of the childcare service, and was healthy after one year of follow-up. Toxicological samples confirmed high levels of cocaine and derivatives in blood, urine and hair. COMMENTS To our knowledge, this is the first reported pediatric case. There are particularities of cocaine intoxication pathophysiology that can trigger thrombotic microangiopathies because of vasoconstriction, direct endothelial injury, platelet activation, and increasing von Willebrand factor and fibrinogen levels. All of which results in a prothrombotic state, inflammatory dysregulation, and microvascular thrombi. The increasing use of cocaine, especially among young adults, puts children at high risk of toxicity, either by passive unintentional exposure, or abuse due to the increased availability in homes.
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Affiliation(s)
| | | | - Camila Ampuero Acuña
- Hospital Clínico Dra. Eloísa Díaz I., Pediatric Critical Care Unit, Santiago, Chile
| | - Franco Díaz Rubio
- Hospital Clínico Dra. Eloísa Díaz I., Pediatric Critical Care Unit, Santiago, Chile
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Lee OPE, Kanesan N, Leow EH, Sultana R, Chor YK, Gan CS, Lee JH. Survival Benefits of Therapeutic Plasma Exchane in Severe Sepsis and Septic Shock: A Systematic Review and Meta-analysis. J Intensive Care Med 2023:8850666231170775. [PMID: 37097910 DOI: 10.1177/08850666231170775] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2023]
Abstract
OBJECTIVES To summarize the role of therapeutic plasma exchange (TPE) in critically ill adults and children with severe sepsis. DATA COLLECTION A systematic search was performed using the following databases: Medline, EMBASE, CINAHL, and Cochrane from January 1990 till December 2022. Comparative studies of TPE in severe sepsis were selected. Adult and pediatric data were analyzed separately. DATA SYNTHESIS Eight randomized control trials and 6 observational studies (n = 50,142 patients) were included. Centrifugal TPE was the most common modality (209/280, 74.6% adults and 952/1026, 92.7% children). Every TPE study utilized different volume exchanges. Most TPE sessions (1173/1306, 89.8%) employed fresh frozen plasma (FFP) as replacement fluid and heparin as anticoagulant. Adults with severe sepsis supported with TPE using FFP had lower mortality (risk ratio, RR: 0.64 [95% confidence interval, CI: 0.49, 0.84]) compared to those who did not. In contrast, TPE was associated with increased mortality in septic children without thrombocytopenia-associated multiorgan failure (RR: 2.23, 95% CI: 1.93, 2.57). There was no difference in outcomes in patients supported with centrifugal and membrane TPE. In both populations, patients supported on TPE as a continuous regime had poorer outcome. CONCLUSION Current evidence indicates that TPE is a potential adjunct therapy in adults with severe sepsis but not in children.
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Affiliation(s)
- Olive P E Lee
- Sarawak General Hospital, Kuching, Malaysia
- Birmingham Children's Hospital, Birmingham, UK
| | | | - Esther H Leow
- KK Women's and Children's Hospital, Singapore, Singapore
| | - Rehena Sultana
- Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore, Singapore
| | - Yek K Chor
- Birmingham Children's Hospital, Birmingham, UK
| | - Chin S Gan
- Pediatric Intensive Care Unit, University Malaya Medical Centre, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Jan H Lee
- Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore, Singapore
- SingHealth Duke-NUS Paediatrics Academic Clinical Programme, Duke-NUS Medical School, Singapore, Singapore
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Fuhrman DY, Thadani S, Hanson C, Carcillo JA, Kellum JA, Park HJ, Lu L, Kim-Campbell N, Horvat CM, Arikan AA. Therapeutic Plasma Exchange Is Associated With Improved Major Adverse Kidney Events in Children and Young Adults With Thrombocytopenia at the Time of Continuous Kidney Replacement Therapy Initiation. Crit Care Explor 2023; 5:e0891. [PMID: 37066071 PMCID: PMC10097539 DOI: 10.1097/cce.0000000000000891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/18/2023] Open
Abstract
Therapeutic plasma exchange (TPE) has been shown to improve organ dysfunction and survival in patients with thrombotic microangiopathy and thrombocytopenia associated with multiple organ failure. There are no known therapies for the prevention of major adverse kidney events after continuous kidney replacement therapy (CKRT). The primary objective of this study was to evaluate the effect of TPE on the rate of adverse kidney events in children and young adults with thrombocytopenia at the time of CKRT initiation. DESIGN Retrospective cohort. SETTING Two large quaternary care pediatric hospitals. PATIENTS All patients less than or equal to 26 years old who received CKRT between 2014 and 2020. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We defined thrombocytopenia as a platelet count less than or equal to 100,000 (cell/mm3) at the time of CKRT initiation. We ascertained major adverse kidney events at 90 days (MAKE90) after CKRT initiation as the composite of death, need for kidney replacement therapy, or a greater than or equal to 25% decline in estimated glomerular filtration rate from baseline. We performed multivariable logistic regression and propensity score weighting to analyze the relationship between the use of TPE and MAKE90. After excluding patients with a diagnosis of thrombotic thrombocytopenia purpura and atypical hemolytic uremic syndrome (n = 6) and with thrombocytopenia due to a chronic illness (n = 2), 284 of 413 total patients (68.8%) had thrombocytopenia at CKRT initiation (51% female). Of the patients with thrombocytopenia, the median (interquartile range) age was 69 months (13-128 mo). MAKE90 occurred in 69.0% and 41.5% received TPE. The use of TPE was independently associated with reduced MAKE90 by multivariable analysis (odds ratio [OR], 0.35; 95% CI, 0.20-0.60) and by propensity score weighting (adjusted OR, 0.31; 95% CI, 0.16-0.59). CONCLUSIONS Thrombocytopenia is common in children and young adults at CKRT initiation and is associated with increased MAKE90. In this subset of patients, our data show benefit of TPE in reducing the rate of MAKE90.
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Affiliation(s)
- Dana Y Fuhrman
- Department of Critical Care Medicine, Division of Pediatric Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
- Department of Pediatrics, Division of Nephrology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
- The Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Sameer Thadani
- Department of Pediatrics, Division of Nephrology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Claire Hanson
- Department of Critical Care Medicine, Division of Pediatric Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Joseph A Carcillo
- Department of Critical Care Medicine, Division of Pediatric Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
- The Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - John A Kellum
- The Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Hyun Jung Park
- Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Liling Lu
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA
| | - Nahmah Kim-Campbell
- Department of Critical Care Medicine, Division of Pediatric Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Christopher M Horvat
- Department of Critical Care Medicine, Division of Pediatric Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
- Department of Pediatrics, Division of Health Informatics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Ayse Akcan Arikan
- Department of Pediatrics, Division of Nephrology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
- Department of Pediatrics, Division of Critical Care Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
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9
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Ginikopoulou E. Plasma exchange and COVID 19. Transfus Apher Sci 2022; 61:103598. [DOI: 10.1016/j.transci.2022.103598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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10
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Khodakarim N, Kalantari S, Riahi T, Moradians V, Talebi-Taher M, Yassin Z, Afshar H, Kooranifar S, Aloosh O, Ziaie S, Zamani N, Tirkan A, Ramim T. Effectiveness of Plasmapheresis Treatment in the Treatment of Patients with COVID-19 Disease. Med J Islam Repub Iran 2022; 36:83. [PMID: 36128282 PMCID: PMC9448457 DOI: 10.47176/mjiri.36.83] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 07/25/2022] [Indexed: 11/05/2022] Open
Abstract
Background: According to the World Health Organization, COVID-19 management focuses primarily on infection prevention, case management, case monitoring, and supportive care. However, due to the lack of evidence, no specific anti-SARS-CoV-2 treatment is recommended. This study aimed to evaluate the effectiveness of plasmapheresis treatment in COVID-19 patients with symptoms of pulmonary involvement on the computed tomography (CT) of the lung. Methods: In 2021, an experimental study in critically ill patients admitted to the COVID-19 ward in the Hazrat-e Rasool hospital diagnosed with COVID-19 was conducted in the second phase (pilot study). The diagnosis was confirmed according to clinical signs, CT scan of the lung, and the Polymerase chain reaction (PCR) test. All patients received the usual treatments for COVID-19 disease and underwent plasmapheresis at a dose of 40 cc/kg daily up to 4 doses. All patients were observed for 24 hours for complications of plasmapheresis treatment and simultaneously for symptoms of COVID-19, after which only routine care measures were performed. The next day and 2 weeks after resumption of the treatment, patients experienced COVID-19 symptoms, including shortness of breath, cough, and fever. Blood oxygen saturation, and treatment results were evaluated. Qualitative and rank variables were described using absolute and relative frequencies and quantitative parametric variables were used using mean and confidence interval. Frequencies were compared in groups using the chi-square test. All tests were performed in 2 directions and P > 0.05 was considered statistically significant. Results: Of the 120 patients studied, 79 (65.8%) were men and 41 (34.2%) were women. The mean age was 60.30 ± 15.61 years (22-95 years). The mean hospital stay was 12.89 days ± 7.25 days (2-38 days). Increased blood oxygen saturation levels in patients had an increasing trend. Inflammatory indices had a downward trend in patients. The frequency of plasmapheresis had no significant effect on reducing the downward trend of inflammatory markers. The greatest reduction occurred in the first plasmapheresis. Conclusion: Finally, according to the findings, plasmapheresis is one of the appropriate treatments to improve patients' symptoms and reduce cytokine storm. Recovered patients had lower levels of inflammatory markers than those who died.
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Affiliation(s)
- Nastaran Khodakarim
- Department of Internal Medicine, School of Medicine, Hazrat- e Rasoul General Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Saeed Kalantari
- Antimicrobial Resistance Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Taghi Riahi
- Department of Internal Medicine, School of Medicine, Hazrat- e Rasoul General Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Vahan Moradians
- Department of Internal Medicine, School of Medicine, Hazrat- e Rasoul General Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Mahshid Talebi-Taher
- Department of Infectious Disease, Antimicrobial Resistance Research Center, Institute of Immunology and Infectious Diseases, Iran University of Medical Sciences, Tehran, Iran
| | - Zeynab Yassin
- Department of Infectious Disease, School of Medicine, Antimicrobial Resistance Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Hale Afshar
- Department of Pulmonary Medicine, School of Medicine, Hazrat- e Rasoul General Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Siavash Kooranifar
- Department of Internal Medicine, School of Medicine, Hazrat- e Rasoul General Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Oldooz Aloosh
- Department of Internal Medicine, School of Medicine, Hazrat- e Rasoul General Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Shirin Ziaie
- Department of Internal Medicine, School of Medicine, Hazrat- e Rasoul General Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Nazanin Zamani
- Department of Internal Medicine, School of Medicine, Hazrat- e Rasoul General Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Atefe Tirkan
- Department of Internal Medicine, School of Medicine, Hazrat- e Rasoul General Hospital, Iran University of Medical Sciences, Tehran, Iran
| | - Tayeb Ramim
- Department of Health Information Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran,Corresponding author: Tayeb Ramim,
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11
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Lallawmkima I, Vanlalruati RSC, Chongthu JL, Renthlei L. Scrub Typhus with Multi-Organ Dysfunction Syndrome and Immune Thrombocytopenia: A Case Report. INFECTIOUS DISEASES & CLINICAL MICROBIOLOGY 2022; 4:133-136. [PMID: 38633345 PMCID: PMC10986586 DOI: 10.36519/idcm.2022.95] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 03/06/2022] [Indexed: 04/19/2024]
Abstract
Scrub typhus is a mite-borne infectious disease caused by Orientia tsutsugamushi, a gram-negative intracellular bacterium. It is a severe public health problem that affects mainly Asia-Pacific areas. Scrub typhus threatens one billion people and causes illness worldwide each year. Approximately one-third of the cases may suffer from multiple organ dysfunction syndrome (MODS) during the disease course. Thrombocytopenia is another critical clinical manifestation of scrub typhus, and thrombocytopenia is one of the causes of MODS. Scrub typhus is rare and hard to diagnose and treat. Given the close similarity in the clinical presentation of several tropical illnesses, a meticulous history and detailed physical examination need to be emphasized. In this study, we reported a case of scrub typhus with thrombocytopenia and MODS, which is only the third case worldwide.
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Affiliation(s)
| | - RSC Vanlalruati
- Department of Microbiology, Civil Hospital Lunglei, Mizoram, India
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12
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Ling J, Liao T, Wu Y, Wang Z, Jin H, Lu F, Fang M. Predictive value of red blood cell distribution width in septic shock patients with thrombocytopenia: A retrospective study using machine learning. J Clin Lab Anal 2021; 35:e24053. [PMID: 34674393 PMCID: PMC8649348 DOI: 10.1002/jcla.24053] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 09/27/2021] [Accepted: 09/28/2021] [Indexed: 12/30/2022] Open
Abstract
Background Sepsis‐associated thrombocytopenia (SAT) is common in critical patients and results in the elevation of mortality. Red cell distribution width (RDW) can reflect body response to inflammation and oxidative stress. We try to investigate the relationship between the RDW and the prognosis of patients with SAT through machine learning. Methods 809 patients were retrospectively analyzed from the Medical Information Mart for Intensive Care III (MIMIC‐III) database. The eXtreme Gradient Boosting (XGBoost) and SHapley Additive exPlanations (SHAP) were used to analyze the impact of each feature. Logistic regression analysis, propensity score matching (PSM), receiver‐operating characteristics (ROC) curve analysis, and the Kaplan‐Meier method were used for data processing. Results The patients with thrombocytopenia had higher 28‐day mortality (48.2%). Machine learning indicated that RDW was the second most important in predicting 28‐day mortality. The RDW was significantly increased in non‐survivors by logistic regression and PSM. ROC curve shows that RDW has moderate predictive power for 28‐day mortality. The patients with RDW>16.05 exhibited higher mortality through Kaplan‐Meier analysis. Conclusions Interpretable machine learning can be applied in clinical research. Elevated RDW is not only common in patients with SAT but is also associated with a poor prognosis.
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Affiliation(s)
- Jianmin Ling
- Department of Emergency and Intensive Care Unit, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Tongzhou Liao
- Services Computing Technology and System Lab, Cluster and Grid Computing Lab, National Engineering Research Center for Big Data Technology and System, School of Computer Science and Technology, Huazhong University of Science and Technology, Wuhan, China
| | - Yanqing Wu
- Department of Neurology, Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhaohua Wang
- Department of Emergency and Intensive Care Unit, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hai Jin
- Services Computing Technology and System Lab, Cluster and Grid Computing Lab, National Engineering Research Center for Big Data Technology and System, School of Computer Science and Technology, Huazhong University of Science and Technology, Wuhan, China
| | - Feng Lu
- Services Computing Technology and System Lab, Cluster and Grid Computing Lab, National Engineering Research Center for Big Data Technology and System, School of Computer Science and Technology, Huazhong University of Science and Technology, Wuhan, China
| | - Minghao Fang
- Department of Emergency and Intensive Care Unit, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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13
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Kamit F, Malbora B, Atay A, Bayirli DT, Bektas M. A Fatal Case of COVID-19 in a Child with ALL: A Cytokine Storm and Hyperferritinemic MODS. JOURNAL OF CHILD SCIENCE 2021. [DOI: 10.1055/s-0040-1721513] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
AbstractSince little is known about dysregulated hyperinflammatory immunological responses causing acute severe infection and multisystem inflammatory syndrome in children associated with coronavirus disease 2019 (COVID-19), the available data on therapies for severe presentations in children are very limited. Describing experiences of severe pediatric COVID-19 presentations in more detail will help improve clinical practice.In this case report, we describe the complete clinical course of a 9-year-old girl previously diagnosed with Angelman syndrome and high-risk T cell acute lymphoblastic leukemia who had been receiving reinduction chemotherapy, presented with pneumonia and acute respiratory distress syndrome, and progressively developed hyperferritinemic multiple-organ failure, a cytokine storm, and coagulopathy associated with COVID-19. She was treated with therapeutic plasma exchange, tocilizumab, hydrocortisone, and favipiravir, but she died 7 days after her admission into our pediatric intensive care unit.The utility of therapeutic plasma exchange with other immunomodulatory therapies in severe presentations requires further trials. The spectrum of the inflammatory phenotypes associated with COVID-19 should be investigated and well defined to initiate the optimal treatment strategy on time.
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Affiliation(s)
- Fulya Kamit
- Faculty of Medicine, Pediatric Intensive Care Unit, Istanbul Yeniyuzyil University, Istanbul, Turkey
| | - Baris Malbora
- Faculty of Medicine, Pediatric Hematopoetic Stem Cell Transplant Unit, Istanbul Yeniyuzyil University, Istanbul, Turkey
| | - Avni Atay
- Faculty of Medicine, Pediatric Hematopoetic Stem Cell Transplant Unit, Istanbul Yeniyuzyil University, Istanbul, Turkey
| | - Derya Turan Bayirli
- Faculty of Medicine, Department of Infectious Diseases and Clinical Microbiology, Istanbul Yeniyuzyil University, Istanbul, Turkey
| | - Metin Bektas
- Faculty of Medicine, Department of Anesthesiology, Istanbul Yeniyuzyil University, Istanbul, Turkey
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14
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Kumar A, Ghosh SB. Emerging Treatment Options of Regenerative Medicine in Severe Corona Virus/COVID 19 Infections. Int J Stem Cells 2020; 13:305-311. [PMID: 32840231 PMCID: PMC7691858 DOI: 10.15283/ijsc20076] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/19/2020] [Accepted: 06/29/2020] [Indexed: 12/18/2022] Open
Abstract
COVID-19 pandemic has brought the whole world stand still, locked down in their homes, infecting more than 8 million people, and many thousands (449,182) -have lost their lives across the globe. Due to lack of any definitive medicine or vaccine, treatment options are supportive of oxygenation, antiviral, antiretroviral drugs, antibiotics, fluid/ electrolyte, mechanical ventilation with ICU (Intensive Care Unit) support, and chloroquine/hydroxychloroquine have been tried to fight this infection. However, mortality due to severe pneumonia, ARDS (Acute Respiratory Distress Syndrome), and multiorgan failure arising from the overactive immune response (storm) mediated by cytokines remains a treatment challenge in elderly and patients with severe medical comorbidities. Recently, anti-inflammatory, angiogenic, immune-modular, and healing properties of intravenous injections of culture derived stem cells have been proposed and shown to benefits in a small number of patients with severe COVID-19 infections. Based on previous experience with other viral infections, convalescent plasma, and serum transfusion are being used as a source of neutralizing antibody/factors to minimize the effects of inflammatory cytokines in this infection. Immunotherapy with purified monoclonal antibodies and conditioned serum with a mixture of unique cytokines are also being developed. Regenerative Medicine has emerged as a crucial adjuvant tool in promoting healing and early recovery in severe COVID-19 infections and other supportive treatments.
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Affiliation(s)
- Ashok Kumar
- Department of Orthopedics, My Doc Specialist Medical Centre DMCC, Dubai, UAE.,Department of Orthopedics, Saudi German Hospital, Dubai, UAE
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15
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Azapagasi E, Uysal Yazici M, Ari ME, Karakaya RS, Cınar HG, Tasar M, Gucer S. Giant Right Atrial Myxoma with Fulminant Progression in an Infant. J Pediatr Intensive Care 2020; 11:77-82. [DOI: 10.1055/s-0040-1715849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Accepted: 07/02/2020] [Indexed: 10/23/2022] Open
Abstract
AbstractCardiac myxoma is rare in children. Myxomas are exceedingly rare in infancy. Right atrial myxomas were recorded in a small number of case reports involving infants worldwide. We report the case of a 2-month-old infant with giant right atrial myxoma. The case presented to our hospital with respiratory distress, and had pericardial and pleural effusion. Diagnosis of cardiac tumor was made with the aid of computerized tomography scan and echocardiogram. The tumor size was 3.1 × 3.4 × 3.9 cm. The patient worsened rapidly and had sudden cardiac arrest which did not respond to interventions. Postmortem cardiac autopsy confirmed the diagnosis of myxoma on gross examination and histology. This article aims to focus attention to the atypical size and location of this atrial myxoma, causing diagnostic difficulty in this infant.
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Affiliation(s)
- Ebru Azapagasi
- Division of Pediatric Intensive Care Unit, Dr. Sami Ulus Maternity and Children’s Training and Research Hospital, Ankara, Turkey
| | - Mutlu Uysal Yazici
- Division of Pediatric Intensive Care Unit, Dr. Sami Ulus Maternity and Children’s Training and Research Hospital, Ankara, Turkey
| | - Mehmet Emre Ari
- Division of Pediatric Cardiology, Dr. Sami Ulus Maternity and Children’s Training and Research Hospital, Ankara, Turkey
| | | | - Hasibe Gökçe Cınar
- Department of Radiology, Dr. Sami Ulus Children’s Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Mehmet Tasar
- Department of Pediatric Cardiovascular Surgery, Dr. Sami Uĺus Chiĺdren’s Heaĺth and Diseases Training and Research Hospitaĺ, Ankara, Turkey
| | - Safak Gucer
- Departman of Pediatric Pathoĺogy, Hacettepe University Facuĺty of Medicine, Ankara, Turkey
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16
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Keith PD, Wells AH, Hodges J, Fast SH, Adams A, Scott LK. The therapeutic efficacy of adjunct therapeutic plasma exchange for septic shock with multiple organ failure: a single-center experience. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:518. [PMID: 32831133 PMCID: PMC7443810 DOI: 10.1186/s13054-020-03241-6] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 08/12/2020] [Indexed: 12/26/2022]
Abstract
Background Sepsis remains a common condition with high mortality when multiple organ failure develops. The evidence for therapeutic plasma exchange (TPE) in this setting is promising but inconclusive. Our study aims to evaluate the efficacy of adjunct TPE for septic shock with multiple organ failure compared to standard therapy alone. Methods A retrospective, observational chart review was performed, evaluating outcomes of patients with catecholamine-resistant septic shock and multiple organ failure in intensive care units at a tertiary care hospital in Winston-Salem, NC, from August 2015 to March 2019. Adult patients with catecholamine-resistant septic shock (≥ 2 vasopressors) and evidence of multiple organ failure were included. Patients who received adjunct TPE were identified and compared to patients who received standard care alone. A propensity score using age, gender, chronic co-morbidities (HTN, DM, CKD, COPD), APACHE II score, SOFA score, lactate level, and number of vasopressors was used to match patients, resulting in 40 patients in each arm. Results The mean baseline APACHE II and SOFA scores were 32.5 and 14.3 in TPE patients versus 32.7 and 13.8 in control patients, respectively. The 28-day mortality rate was 40% in the TPE group versus 65% in the standard care group (p = 0.043). Improvements in baseline SOFA scores at 48 h were greater in the TPE group compared to standard care alone (p = 0.001), and patients receiving adjunct TPE had a more favorable fluid balance at 48 h (p = 0.01). Patients receiving adjunct TPE had longer ICU and hospital lengths of stay (p = 0.003 and p = 0.006, respectively). Conclusions Our retrospective, observational study in adult patients with septic shock and multiple organ failure demonstrated improved 28-day survival with adjunct TPE compared to standard care alone. Hemodynamics, organ dysfunction, and fluid balance all improved with adjunct TPE, while lengths of stay were increased in survivors. The study design does not allow for a generalized statement of support for TPE in all cases of sepsis with multiple organ failure but offers valuable information for a prospective, randomized clinical trial.
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Affiliation(s)
- Philip D Keith
- Critical Care Medicine, Lexington Medical Center, 2720 Sunset Boulevard, West Columbia, SC, 29169, USA.
| | - Adam H Wells
- Critical Care Medicine, Novant Health Forsyth Medical Center, 3333 Silas Creek Parkway, Winston-Salem, NC, 27103, USA
| | - Jeremy Hodges
- Clinical Pharmacist, Novant Health Forsyth Medical Center, 3333 Silas Creek Parkway, Winston-Salem, NC, 27103, USA
| | - Stephen H Fast
- Department of Mathematics, Limestone College, 1115 College Drive, Gaffney, SC, 29340, USA
| | - Amber Adams
- Emergency Department Clinical Pharmacist, Cabell Huntington Hospital, 1340 Hal Greer Boulevard, Huntington, WV, 25701, USA
| | - L Keith Scott
- Division of Trauma and Surgical Critical Care, Louisiana State University Health Sciences Center, 1501 Kings Highway, Shreveport, LA, 71103, USA
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17
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Hamdy SM, Abdel-Naseer M, Shehata HS, Shalaby NM, Hassan A, Elmazny A, Shaker E, Nada MAF, Ahmed SM, Hegazy MI, Mourad HS, Abdelalim A, Magdy R, Othman AS, Mekkawy DA, Kishk NA. Management Strategies of Patients with Neuromyelitis Optica Spectrum Disorder During the COVID-19 Pandemic Era. Ther Clin Risk Manag 2020; 16:759-767. [PMID: 32884277 PMCID: PMC7443007 DOI: 10.2147/tcrm.s261753] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 08/03/2020] [Indexed: 12/29/2022] Open
Abstract
The ongoing coronavirus (COVID-19) pandemic is a global health emergency of international concern and has affected management plans of many autoimmune disorders. Immunosuppressive and immunomodulatory therapies are pivotal in the management of neuromyelitis optica spectrum disorder (NMOSD), potentially placing patients at an increased risk of contracting infections such as COVID-19. The optimal management strategy of NMOSD during the COVID-19 era remains unclear. Here, however, we examined the evidence of NMOSD disease-modifying therapies (DMTs) use during the present period and highlighted different scenarios including treatment of relapses as well as initiation and maintenance of DMTs in order to optimize care of NMOSD patients in the COVID-19 era.
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Affiliation(s)
- Sherif M Hamdy
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Maged Abdel-Naseer
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Hatem S Shehata
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Nevin M Shalaby
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Amr Hassan
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Alaa Elmazny
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ehab Shaker
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mona A F Nada
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Sandra M Ahmed
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mohamed I Hegazy
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Husam S Mourad
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ahmed Abdelalim
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Rehab Magdy
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Alshimaa S Othman
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Doaa A Mekkawy
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Nirmeen A Kishk
- Neurology Department, Faculty of Medicine, Cairo University, Cairo, Egypt
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18
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Trikha A, Singh AK. Treatment Modalities in the Intensive Care Unit for Coronavirus Disease 2019. ANNALS OF THE NATIONAL ACADEMY OF MEDICAL SCIENCES (INDIA) 2020. [DOI: 10.1055/s-0040-1714328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
The last Influenza pandemic of 1918 happened before the advent of modern medicine. We have come a long way since then. But the COVID-19 pandemic has still caught us unprepared on many fronts. The review focuses on the management of critically ill COVID-19 patients and the various treatment modalities being employed to counter this incompletely understood disease.
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Affiliation(s)
- Anjan Trikha
- Department of Anaesthesiology, Pain Medicine & Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Akhil Kant Singh
- Department of Anaesthesiology, Pain Medicine & Critical Care, All India Institute of Medical Sciences, New Delhi, India
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19
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Keith P, Day M, Choe C, Perkins L, Moyer L, Hays E, French M, Hewitt K, Gravel G, Guffey A, Scott LK. The successful use of therapeutic plasma exchange for severe COVID-19 acute respiratory distress syndrome with multiple organ failure. SAGE Open Med Case Rep 2020; 8:2050313X20933473. [PMID: 32595974 PMCID: PMC7303771 DOI: 10.1177/2050313x20933473] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 05/20/2020] [Indexed: 01/08/2023] Open
Abstract
The COVID-19 pandemic has brought about an urgent need for effective treatment, while conserving vital resources such as intensive care unit beds and ventilators. Antivirals, convalescent plasma, and biologics have been used with mixed results. The profound "cytokine storm" induced endotheliopathy and microthrombotic disease in patients with COVID-19 may lead to acute respiratory distress syndrome, sepsis, and multi-organ failure. We present a case of SARS-COV2 pneumonia with septic shock and multi-organ failure that demonstrated significant clinical improvement after therapeutic plasma exchange. A 65-year-old female with multiple comorbidities presented with progressive dyspnea and dry cough. She was found to be COVID-19 positive with pneumonia, and developed progressive hypoxemia and shock requiring vasopressors, cardioversion, and non-invasive positive pressure ventilation. Given her worsening sepsis with multi-organ failure, she underwent therapeutic plasma exchange with rapid clinical improvement. Her case supports the theory that plasma exchange may help abate the "cytokine storm" induced endotheliopathy and microthrombosis associated with COVID-19. Further studies are needed to identify markers of this pathway and the potential role of plasma exchange in these critically ill patients.
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Affiliation(s)
- Philip Keith
- Critical Care Medicine, Lexington
Medical Center, West Columbia, SC, USA
| | - Matthew Day
- Critical Care Medicine, Lexington
Medical Center, West Columbia, SC, USA
| | - Carol Choe
- Critical Care Medicine, Lexington
Medical Center, West Columbia, SC, USA
| | - Linda Perkins
- Critical Care Medicine, Lexington
Medical Center, West Columbia, SC, USA
| | - Lou Moyer
- Critical Care Medicine, Lexington
Medical Center, West Columbia, SC, USA
| | - Erin Hays
- Critical Care Medicine, Lexington
Medical Center, West Columbia, SC, USA
| | - Marshall French
- Critical Care Medicine, Lexington
Medical Center, West Columbia, SC, USA
| | - Kristi Hewitt
- Critical Care Medicine, Lexington
Medical Center, West Columbia, SC, USA
| | - Gretchen Gravel
- Critical Care Medicine, Lexington
Medical Center, West Columbia, SC, USA
| | - Amanda Guffey
- Critical Care Medicine, Lexington
Medical Center, West Columbia, SC, USA
| | - L Keith Scott
- Division of Trauma and Surgical Critical
Care, Louisiana State University Health Sciences Center, Shreveport, LA, USA
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20
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Bose S, Adapa S, Aeddula NR, Roy S, Nandikanti D, Vupadhyayula PM, Naramala S, Gayam V, Muppidi V, Konala VM. Medical Management of COVID-19: Evidence and Experience. J Clin Med Res 2020; 12:329-343. [PMID: 32587649 PMCID: PMC7295552 DOI: 10.14740/jocmr4201] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 05/20/2020] [Indexed: 02/06/2023] Open
Abstract
Coronavirus disease 2019 is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and this infectious disease is termed COVID-19 in short. On a global scale, as of June 1, 2020, the World Health Organization (WHO) published statistics of 6,057,853 infected patients and 371,166 deaths worldwide. Despite reported observational data about the experimental use of certain drugs, there is no conclusively proven curative therapy for COVID-19 as of now; however, remdesivir received emergency use authorization (EUA) by the Food and Drug Administration (FDA) recently for use in patients hospitalized with COVID-19. There are several ongoing clinical trials related to the pharmacological choices of therapy for COVID-19 patients; however, drug trials related to observational studies so far have yielded mixed results and therefore have created a sense of confusion among healthcare professionals (HCPs). In this review article, we seek to collate and provide a summary of treatment strategies for COVID-19 patients with a variable degree of illness and discuss pharmacologic and other therapies intended to be used either as experimental medicine/therapy or as part of supportive care in complicated cases of COVID-19.
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Affiliation(s)
- Subhasish Bose
- Division of Nephrology, Department of Internal Medicine, University of Virginia, Lynchburg, VA 24501-1167, USA
| | - Sreedhar Adapa
- Division of Nephrology, Department of Internal Medicine, Adventist Medical Center, Hanford, CA 93230, USA
| | - Narothama Reddy Aeddula
- Division of Nephrology, Department of Internal Medicine, Deaconess Health System Inc, Evansville, IN 47710, USA
| | - Sasmit Roy
- Division of Nephrology, Department of Internal Medicine, University of Virginia, Lynchburg, VA 24501-1167, USA
| | - Deepak Nandikanti
- Kidney Specialists of Southern Nevada (KSOSN), Las Vegas, NV 89030, USA
| | | | - Srikanth Naramala
- Division of Rheumatology, Department of Internal Medicine, Adventist Medical Center, Hanford, CA 93230, USA
| | - Vijay Gayam
- Department of Medicine, Interfaith Medical Center, Brooklyn, NY 11213, USA
| | - Vijayadershan Muppidi
- Department of Internal Medicine, IU Health Ball Memorial Hospital, Muncie, IN 47303, USA
| | - Venu Madhav Konala
- Divison of Medical Oncology, Department of Internal Medicine, Ashland Bellefonte Cancer Center, Ashland, KY 41169, USA
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21
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Keith P, Day M, Perkins L, Moyer L, Hewitt K, Wells A. A novel treatment approach to the novel coronavirus: an argument for the use of therapeutic plasma exchange for fulminant COVID-19. Crit Care 2020; 24:128. [PMID: 32241301 PMCID: PMC7117947 DOI: 10.1186/s13054-020-2836-4] [Citation(s) in RCA: 110] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 03/18/2020] [Indexed: 11/25/2022] Open
Affiliation(s)
- Philip Keith
- Critical Care Medicine, Lexington Medical Center, 2720 Sunset Boulevard, West Columbia, SC, 29169, USA.
| | - Matthew Day
- Critical Care Medicine, Lexington Medical Center, 2720 Sunset Boulevard, West Columbia, SC, 29169, USA
| | - Linda Perkins
- Critical Care Medicine, Lexington Medical Center, 2720 Sunset Boulevard, West Columbia, SC, 29169, USA
| | - Lou Moyer
- Critical Care Medicine, Lexington Medical Center, 2720 Sunset Boulevard, West Columbia, SC, 29169, USA
| | - Kristi Hewitt
- Critical Care Medicine, Lexington Medical Center, 2720 Sunset Boulevard, West Columbia, SC, 29169, USA
| | - Adam Wells
- Critical Care Medicine, Novant Health Forsyth Medical Center, 3333 Silas Creek Parkway, Winston Salem, NC, 27103, USA
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22
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Li W, Huang L, Zhang W. Scrub typhus with multi-organ dysfunction syndrome and immune thrombocytopenia: a case report and review of the literature. J Med Case Rep 2019; 13:358. [PMID: 31810465 PMCID: PMC6898947 DOI: 10.1186/s13256-019-2299-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Accepted: 10/18/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Scrub typhus is an acute infectious zoonotic disease caused by Orientia tsutsugamushi. Multi-organ dysfunction secondary to scrub typhus is hard to diagnose and has a high mortality rate. Only one case of scrub typhus with multi-organ dysfunction syndrome and immune thrombocytopenia has been reported thus far. In this study, we report a second case of scrub typhus with multi-organ dysfunction syndrome and immune thrombocytopenia, and we summarize its diagnosis and treatment. CASE PRESENTATION A 43-year-old Han Chinese woman, a sanitation worker, was admitted to our hospital after 7 days of a skin infection and 5 days of a sore throat with fever and dizziness. A physical examination revealed the presence of an eschar on the right side of her neck. She had a history of insect bites during her sanitation work. A diagnostic evaluation identified scrub typhus as the primary illness, which was associated with multi-organ dysfunction syndrome and immune thrombocytopenia. She recovered completely after 15 days of treatment and extensive symptomatic supportive care. CONCLUSION We report a second case of tsutsugamushi disease with multi-organ dysfunction syndrome and immune thrombocytopenia, which resolved after treatment and extensive care.
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Affiliation(s)
- Weijia Li
- Department of Intensive Care Unit, Peking University Shenzhen Hospital, Shenzhen, 518036, People's Republic of China
| | - Lei Huang
- Department of Intensive Care Unit, Peking University Shenzhen Hospital, Shenzhen, 518036, People's Republic of China.
| | - Weixing Zhang
- Department of Intensive Care Unit, Peking University Shenzhen Hospital, Shenzhen, 518036, People's Republic of China.
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23
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Yokoyama J, Yoshioka D, Toda K, Matsuura R, Suzuki K, Samura T, Miyagawa S, Yoshikawa Y, Takano H, Matsumiya G, Sakaguchi T, Fukuda H, Takahashi T, Izutani H, Funatsu T, Nishi H, Sawa Y. Surgery-first treatment improves clinical results in infective endocarditis complicated with disseminated intravascular coagulation†. Eur J Cardiothorac Surg 2019; 56:785-792. [PMID: 30932157 DOI: 10.1093/ejcts/ezz068] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 02/02/2019] [Accepted: 02/12/2019] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVES Infective endocarditis (IE) is a critical infection with a high mortality rate, and it usually causes sepsis. Though disseminated intravascular coagulation (DIC) sometimes occurs in IE patients, no definitive treatment strategy for IE patients with DIC as a complication exists. Therefore, we evaluated the prevalence, surgical results and treatment strategy for IE complicated with DIC. METHODS Between 2009 and 2017, a total of 585 patients undergoing valve surgery for active IE were enrolled at 14 institutions, of whom 116 (20%) had DIC as a complication. For further evaluation, we divided DIC patients into medical treatment-first (n = 45, group M) and valve surgery-first (n = 51, group S) groups after excluding 20 patients with intracranial haemorrhage. RESULTS The overall survival rates at 1 and 5 years were 91% and 85% in the non-DIC group and 65% and 55% in the DIC group, respectively (P < 0.001). Recurrence-free survival rates at 1 and 5 years were 99% and 95% in the non-DIC group and 94% and 74% in the DIC group, respectively (P < 0.001). The overall survival rates at 1 and 5 years were 77% and 64% in group S and 51% and 46% in group M, respectively (P = 0.032). Multivariable analysis revealed that 'medical treatment first' was an exclusive independent risk factor [hazards ratio 2.26 (1.13-4.75), P = 0.024] for overall mortality. CONCLUSIONS Mortality and IE recurrence were statistically significantly higher in DIC patients. Valve surgery should not be delayed because most patients proceeding with medical treatment eventually require emergency surgery and their clinical outcomes are worse than those of patients undergoing early surgery.
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Affiliation(s)
- Junya Yokoyama
- Department of Cardiovascular Surgery, Osaka University Hospital, Osaka, Japan
| | - Daisuke Yoshioka
- Department of Cardiovascular Surgery, Osaka University Hospital, Osaka, Japan
| | - Koichi Toda
- Department of Cardiovascular Surgery, Osaka University Hospital, Osaka, Japan
| | - Ryohei Matsuura
- Department of Cardiovascular Surgery, Osaka University Hospital, Osaka, Japan
| | - Kota Suzuki
- Department of Cardiovascular Surgery, Osaka University Hospital, Osaka, Japan
| | - Takaaki Samura
- Department of Cardiovascular Surgery, Osaka University Hospital, Osaka, Japan
| | - Shigeru Miyagawa
- Department of Cardiovascular Surgery, Osaka University Hospital, Osaka, Japan
| | - Yasushi Yoshikawa
- Department of Cardiovascular Surgery, Osaka University Hospital, Osaka, Japan
| | - Hiroshi Takano
- Department of Cardiovascular Surgery, Dokkyo Koshigaya Medical Center, Saitama, Japan
| | - Goro Matsumiya
- Department of Cardiovascular Surgery, Chiba University Hospital, Chiba, Japan
| | - Taichi Sakaguchi
- Department of Cardiovascular Surgery, Hyogo College of Medicine, Hyogo, Japan
| | - Hirotsugu Fukuda
- Department of Cardiovascular Surgery, Dokkyo University Medical School Hospital, Tochigi, Japan
| | - Toshiki Takahashi
- Department of Cardiovascular Surgery, Osaka Police Hospital, Osaka, Japan
| | - Hironori Izutani
- Department of Cardiovascular Surgery, Ehime University Hospital, Matsuyama, Japan
| | - Toshihiro Funatsu
- Department of Cardiovascular Surgery, Rinku General Medical Center, Osaka, Japan
| | - Hiroyuki Nishi
- Department of Cardiovascular Surgery, Osaka Police Hospital, Osaka, Japan
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Hospital, Osaka, Japan
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Chang JC. Sepsis and septic shock: endothelial molecular pathogenesis associated with vascular microthrombotic disease. Thromb J 2019; 17:10. [PMID: 31160889 PMCID: PMC6542012 DOI: 10.1186/s12959-019-0198-4] [Citation(s) in RCA: 115] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 04/26/2019] [Indexed: 12/15/2022] Open
Abstract
In addition to protective “immune response”, sepsis is characterized by destructive “endothelial response” of the host, leading to endotheliopathy and its molecular dysfunction. Complement activation generates membrane attack complex (MAC). MAC causes channel formation to the cell membrane of pathogen, leading to death of microorganisms. In the host, MAC also may induce channel formation to innocent bystander endothelial cells (ECs) and ECs cannot be protected. This provokes endotheliopathy, which activates two independent molecular pathways: inflammatory and microthrombotic. Activated inflammatory pathway promotes the release of inflammatory cytokines and triggers inflammation. Activated microthrombotic pathway mediates platelet activation and exocytosis of unusually large von Willebrand factor multimers (ULVWF) from ECs and initiates microthrombogenesis. Excessively released ULVWF become anchored to ECs as long elongated strings and recruit activated platelets to assemble platelet-ULVWF complexes and form “microthrombi”. These microthrombi strings trigger disseminated intravascular microthrombosis (DIT), which is the underlying pathology of endotheliopathy-associated vascular microthrombotic disease (EA-VMTD). Sepsis-induced endotheliopathy promotes inflammation and DIT. Inflammation produces inflammatory response and DIT orchestrates consumptive thrombocytopenia, microangiopathic hemolytic anemia, and multiorgan dysfunction syndrome (MODS). Systemic inflammatory response syndrome (SIRS) is a combined phenotype of inflammation and endotheliopathy-associated (EA)-VMTD. Successful therapeutic design for sepsis can be achieved by counteracting the pathologic microthrombogenesis.
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Affiliation(s)
- Jae C Chang
- Department of Medicine, University of California Irvine School of Medicine, Irvine, CA USA
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25
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Horvat CM, Carcillo JA. Why do we give "orphan" approval to biologic therapies but not to extracorporeal blood purification therapies for hyperinflammatory syndromes? Minerva Anestesiol 2019; 85:465-467. [DOI: 10.23736/s0375-9393.19.13711-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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26
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Therapeutic Plasma Exchange in Children With Thrombocytopenia-Associated Multiple Organ Failure. Crit Care Med 2019; 47:e173-e181. [DOI: 10.1097/ccm.0000000000003559] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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27
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Vasileiadis I, Politou M, Dimopoulos S, Rovina N, Kyriakopoulou M, Kyriakoudi A, Tripodaki ES, Koutsouri T, Terpos E, Koulouris N, Koutsoukou A. Variation of endothelium-related hemostatic factors during sepsis. Microcirculation 2018; 25:e12500. [PMID: 30159948 DOI: 10.1111/micc.12500] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 08/23/2018] [Accepted: 08/24/2018] [Indexed: 02/05/2023]
Abstract
OBJECTIVE The thrombomodulin/protein C and VWF/ADAMTS-13 pathways are disturbed in sepsis and have been implicated in the coagulation disorders that characterize the septic syndrome. We aimed to assess the variation of these endothelial parameters during sepsis and their putative association with outcome, in critically ill, septic patients. METHODS We monitored 34 septic patients, 23 of whom improved (group A) while 11 deteriorated (group B). We assessed ADAMTS-13 levels, VWF activity, soluble thrombomodulin, and protein C activity upon admission to the ICU (time point 0) and at the time of a change in the clinical condition (remission or deterioration, time point 1). RESULTS In group A, thrombomodulin and VWF increased at time point 1 compared to time point 0 (P = 0.011, P = 0.028, respectively). In group B, protein C and ADAMTS-13 significantly decreased (P = 0.023, P = 0.026, respectively), while VWF, VWF/ADAMTS-13 ratio, and the thrombomodulin/protein C ratio increased (P = 0.02, P = 0.002, P = 0.01, respectively). Protein C (> or ≤17%) and ADAMTS-13 percentage difference (> or ≤22%) were independently associated with sepsis outcome among the endothelial variables tested. CONCLUSIONS An ongoing endothelial/hemostatic disorder was established during sepsis, observed even at clinical improvement. Among the variables tested, protein C and ADAMTS-13 change were associated with outcome.
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Affiliation(s)
- Ioannis Vasileiadis
- Intensive Care Unit, 1st Department of Respiratory Medicine, Sotiria Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Marianna Politou
- Haematology Laboratory-Blood Bank, Aretaieion Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Stavros Dimopoulos
- Cardiothoracic Intensive Care Unit, Onasseio Cardiac Surgery Center, Athens, Greece
| | - Nikoletta Rovina
- Intensive Care Unit, 1st Department of Respiratory Medicine, Sotiria Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Magdalini Kyriakopoulou
- Intensive Care Unit, 1st Department of Respiratory Medicine, Sotiria Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Anna Kyriakoudi
- Intensive Care Unit, 1st Department of Respiratory Medicine, Sotiria Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Elli-Sophia Tripodaki
- First Department of Internal Medicine, Agios Savvas Regional Cancer Hospital, Athens, Greece
| | - Theodora Koutsouri
- Haematology Laboratory-Blood Bank, Aretaieion Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Evangelos Terpos
- Therapeutics Clinic, National and Kapodistrian University of Athens, Alexandra Hospital, Athens, Greece
| | - Nikolaos Koulouris
- Intensive Care Unit, 1st Department of Respiratory Medicine, Sotiria Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Antonia Koutsoukou
- Intensive Care Unit, 1st Department of Respiratory Medicine, Sotiria Hospital, National and Kapodistrian University of Athens, Athens, Greece
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Smeets NJL, Fijnheer R, Sebastian S, De Mast Q. Secondary thrombotic microangiopathy with severely reduced ADAMTS13 activity in a patient with Capnocytophaga canimorsus sepsis: a case report. Transfusion 2018; 58:2426-2429. [PMID: 30222856 DOI: 10.1111/trf.14829] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 03/25/2018] [Accepted: 03/30/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND The Gram-negative bacillus Capnocytophaga canimorsus may cause a severe illness resembling thrombotic thrombocytopenic purpura (TTP). The pathogenesis and optimal therapy of this secondary thrombotic microangiopathy (TMA) remain uncertain. CASE REPORT A 63-year-old Caucasian man was admitted with suspicion for TTP, but blood cultures grew C. canimorsus. Initial investigations revealed severe thrombocytopenia, a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS13) activity level of less than 1%, and strongly elevated D-dimer and lactate dehydrogenase levels. He made a full recovery with antibiotics and plasma infusion for 3 days. Plasmapheresis was not performed. Retrospective determination of serial ADAMTS13 activity levels revealed that ADAMTS13 activity had already increased to 25% at the start of plasma infusion. CONCLUSION This case highlights that a C. canimorsus sepsis may cause a secondary TMA with a severe ADAMTS13 deficiency. It also illustrates that the adjunctive role of plasma exchange or plasma infusion is doubtful as ADAMTS13 activity levels increased with antibiotics alone.
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Affiliation(s)
- Nori J L Smeets
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Rob Fijnheer
- Department of Internal Medicine, Meander Medical Center, Amersfoort, the Netherlands.,Department of Clinical Chemistry and Haematology, University Medical Center, Utrecht, the Netherlands
| | - Silvie Sebastian
- Department of Clinical Chemistry and Haematology, University Medical Center, Utrecht, the Netherlands
| | - Quirijn De Mast
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, the Netherlands
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29
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Ramsi M, Al Ali AS. Thrombocytopenia-associated multiple-organ failure (TAMOF): recognition and management. BMJ Case Rep 2018; 2018:bcr-2018-225594. [PMID: 30150343 DOI: 10.1136/bcr-2018-225594] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Thrombocytopenia-associated multiple-organ failure (TAMOF) is an increasingly fatal phenomenon that may be associated with sepsis. TAMOF results from immune dysregulation and impaired activity of A Disintegrin And Metalloproteinase with ThromboSpondin type 1 motif, member 13. Early recognition of this premorbid condition and specific management results in a significantly improved outcome. Herein, we report the presentation and management of a 2-year-old child with TAMOF who was successfully treated with plasma exchange and recovered without long-term sequelae.
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Affiliation(s)
- Musaab Ramsi
- Paediatric Critical Care Medicine, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Alyaa Saeed Al Ali
- Paediatric Critical Care Medicine, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
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30
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Chang JC. TTP-like syndrome: novel concept and molecular pathogenesis of endotheliopathy-associated vascular microthrombotic disease. Thromb J 2018; 16:20. [PMID: 30127669 PMCID: PMC6087012 DOI: 10.1186/s12959-018-0174-4] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 06/07/2018] [Indexed: 02/07/2023] Open
Abstract
TTP is characterized by microangiopathic hemolytic anemia and thrombocytopenia associated with brain and kidney dysfunction. It occurs due to ADAMTS13 deficiency. TTP-like syndrome occurs in critically ill patients with the similar hematologic changes and additional organ dysfunction syndromes. Vascular microthrombotic disease (VMTD) includes both TTP and TTP-like syndrome because their underlying pathology is the same disseminated intravascular microthrombosis (DIT). Microthrombi are composed of platelet-unusually large von Willebrand factor multimers (ULVWF) complexes. TTP occurs as a result of accumulation of circulating ULVWF secondary to ADAMTS13 deficiency. This protease deficiency triggers microthrombogenesis, leading to "microthrombi" formation in microcirculation. Unlike TTP, TTP-like syndrome occurs in critical illnesses due to complement activation. Terminal C5b-9 complex causes channel formation to endothelial membrane, leading to endotheliopathy, which activates two different molecular pathways (i.e., inflammatory and microthrombotic). Activation of inflammatory pathway triggers inflammation. Activation of microthrombotic pathway promotes platelet activation and excessive endothelial exocytosis of ULVWF from endothelial cells (ECs). Overexpressed and uncleaved ULVWF become anchored to ECs as long elongated strings to recruit activated platelets, and assemble "microthrombi". In TTP, circulating microthrombi typically be lodged in microvasculature of the brain and kidney, but in TTP-like syndrome, microthrombi anchored to ECs of organs such as the lungs and liver as well as the brain and kidneys, leading to multiorgan dysfunction syndrome. TTP occurs as hereditary or autoimmune disease and is the phenotype of ADAMTS13 deficiency-associated VMTD. But TTP-like syndrome is hemostatic disorder occurring in critical illnesses and is the phenotype of endotheliopathy-associated VMTD. Thus, this author's contention is TTP and TTP-like syndrome are two distinctly different disorders with dissimilar underlying pathology and pathogenesis.
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Affiliation(s)
- Jae C. Chang
- Department of Medicine, University of California Irvine School of Medicine, Irvine, CA USA
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31
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Use of plasma exchange in pediatric severe sepsis in children's hospitals. J Crit Care 2018; 45:114-120. [DOI: 10.1016/j.jcrc.2018.01.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Revised: 01/29/2018] [Accepted: 01/30/2018] [Indexed: 11/19/2022]
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32
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Tufan-Pekkucuksen N, Gazzaneo MC, Afonso NS, Swartz SJ, Angelo JR, Srivaths P. Thrombocytopenia-associated multi-organ failure secondary to hyperglycemic, hyperosmolar non-ketotic syndrome: A case report. Pediatr Diabetes 2018; 19:574-577. [PMID: 29165898 DOI: 10.1111/pedi.12608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 09/28/2017] [Accepted: 10/17/2017] [Indexed: 11/30/2022] Open
Abstract
Thrombocytopenia associated multi-organ failure (TAMOF) is a clinical syndrome with features of new onset thrombocytopenia, increased lactate dehydrogenase, and multi-organ failure in critically ill patients. TAMOF can be the initial presentation of an underlying disease process or can develop during the course of illness either during the hospital stay. TAMOF has a high mortality rate if not treated; therefore, early detection is critical. TAMOF has been rarely reported in diabetic ketoacidosis. We are describing the first case of a patient diagnosed with hyperglycemic, hyperosmolar non-ketotic syndrome who developed TAMOF on the third day of his hospital course. In addition to supportive care in the intensive care unit the patient received serial therapeutic plasma exchanges and improved quickly after treatment. Early diagnosis and treatment of TAMOF decreases morbidity and mortality.
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Affiliation(s)
| | | | | | - Sarah J Swartz
- Pediatric Nephrology, Baylor College of Medicine, Houston, Texas
| | - Joseph R Angelo
- Pediatric Nephrology, Baylor College of Medicine, Houston, Texas
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33
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Emr BM, Alcamo AM, Carcillo JA, Aneja RK, Mollen KP. Pediatric Sepsis Update: How Are Children Different? Surg Infect (Larchmt) 2018; 19:176-183. [PMID: 29394150 DOI: 10.1089/sur.2017.316] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Although there are some commonalities between pediatric and adult sepsis, there are important differences in pathophysiology, clinical presentation, and therapeutic approaches. The recognition and diagnosis of sepsis is a significant challenge in pediatric patients as vital sign aberrations and examination findings are often subtle as compared to those observed in adults. Gaps in knowledge that have been studied in depth in adult sepsis are still being investigated in pediatric patients such as best practices in ventilation, invasive monitoring, and resuscitation. DISCUSSION In this review, we address key differences in the etiology, presentation, resuscitation, and outcomes of sepsis in children compared with adults.
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Affiliation(s)
- Bryanna M Emr
- 1 Department of Surgery, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania.,2 Division of Pediatric Surgery, Children's Hospital of Pittsburgh of UPMC , Pittsburgh, Pennsylvania
| | - Alicia M Alcamo
- 3 Department of Critical Care Medicine, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania
| | - Joseph A Carcillo
- 3 Department of Critical Care Medicine, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania
| | - Rajesh K Aneja
- 3 Department of Critical Care Medicine, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania
| | - Kevin P Mollen
- 1 Department of Surgery, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania.,2 Division of Pediatric Surgery, Children's Hospital of Pittsburgh of UPMC , Pittsburgh, Pennsylvania
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34
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Peng ZY, Kiss JE, Cortese-Hasset A, Carcillo JA, Nguyen TC, Kellum JA. Plasma Filtration on Mediators of Thrombotic Microangiopathy: An in Vitro Study. Int J Artif Organs 2018; 30:401-6. [PMID: 17551903 DOI: 10.1177/039139880703000507] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives. Sepsis-induced thrombotic microangiopathy is successfully treated by plasma exchange therapy However, certain putative mediators of thrombotic microangiopathy may not be removed by plasma filtration. Methods. We conducted an in vitro study to determine whether plasma filtration can remove ultra-large von Willebrand factor (ULvWF) multimers and other mediators. In separate experiments, human umbilical venous endothelial cell (HUVEC) supernatant enriched with ULvWF or human whole blood was passed through a therapeutic plasma exchange (TPE 2000, PRISMA) filter and samples were taken for measurement of ULvWF, vWF ristocetin cofactor, vWF antigen and PAI-1. Results. The sieving coefficients for vWF and PAI-1 were above 0.9. The ULvWF was gradually eliminated, and nearly disappeared after four circulations. Conclusion. The TPE 2000 filter can directly remove potential mediators of sepsis-induced thrombotic microangiopathy.
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Affiliation(s)
- Z Y Peng
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15261, USA
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35
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Canter MO, Daniels J, Bridges BC. Adjunctive Therapies During Extracorporeal Membrane Oxygenation to Enhance Multiple Organ Support in Critically Ill Children. Front Pediatr 2018; 6:78. [PMID: 29670870 PMCID: PMC5893897 DOI: 10.3389/fped.2018.00078] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 03/14/2018] [Indexed: 12/17/2022] Open
Abstract
Since the advent of extracorporeal membrane oxygenation (ECMO) over 40 years ago, there has been increasing interest in the use of the extracorporeal circuit as a platform for providing multiple organ support. In this review, we will examine the evidence for the use of continuous renal replacement therapy, therapeutic plasma exchange, leukopheresis, adsorptive therapies, and extracorporeal liver support in conjunction with ECMO.
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Affiliation(s)
- Marguerite Orsi Canter
- Division of Pediatric Critical Care, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, United States
| | - Jessica Daniels
- Division of Pediatric Critical Care, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, United States
| | - Brian C Bridges
- Division of Pediatric Critical Care, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, United States
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36
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Ittyachen AM, Abraham SP, Krishnamoorthy S, Vijayan A, Kokkat J. Immune thrombocytopenia with multi-organ dysfunction syndrome as a rare presentation of scrub typhus: a case report. BMC Res Notes 2017; 10:496. [PMID: 28985768 PMCID: PMC5639588 DOI: 10.1186/s13104-017-2826-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 09/30/2017] [Indexed: 11/18/2022] Open
Abstract
Background Scrub typhus is an acute infectious illness caused by Orientia tsutsugamushi. It is endemic to a part of the world known as the “tsutsugamushi triangle”. Humans are accidental hosts in this zoonotic disease. About a third of patients admitted with scrub typhus have evidence of multi-organ dysfunction. Multi-organ dysfunction secondary to scrub typhus carries a high mortality rate. Case presentation We report a 65-year old lady who was admitted in a Tertiary Care Center in the state of Kerala in India, with 7 day history of fever, myalgia and reduced urine output. Head to foot examination revealed the presence of an eschar on her chest. One week prior to the onset of her illness she had gone trekking through a hilly forest area. She was clinically suspected to have scrub typhus, which was later confirmed with laboratory tests. She developed multi-organ dysfunction syndrome secondary to this illness. Though there was an improvement in the multi-organ dysfunction, thrombocytopenia alone failed to improve. Bone marrow study was done which was suggestive of immune thrombocytopenia. Patient was given a course of steroids with which the thrombocytopenia improved. Conclusion Failure of platelet count to normalize even after there has been a general improvement of other markers of multi-organ dysfunction in scrub typhus should prompt the clinician to consider other potential causes of thrombocytopenia. An unusual finding as this calls for further research to understand the molecular mechanisms behind such an event. Further, considering the close similarity in clinical presentation of several tropical illnesses, meticulous history taking and a detailed physical examination needs to be emphasized.
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Affiliation(s)
- Abraham M Ittyachen
- M.O.S.C Medical College & Hospital, Ernakulam District, Kolenchery, Kerala, 682311, India. .,Department of Medicine, M.O.S.C Medical College & Hospital, Ernakulam District, Kolenchery, Kerala, 682311, India.
| | - Saramma P Abraham
- M.O.S.C Medical College & Hospital, Ernakulam District, Kolenchery, Kerala, 682311, India.,Department of Anaesthesiology, M.O.S.C Medical College & Hospital, Ernakulam District, Kolenchery, Kerala, 682311, India
| | - Smitha Krishnamoorthy
- M.O.S.C Medical College & Hospital, Ernakulam District, Kolenchery, Kerala, 682311, India.,Department of Medicine, M.O.S.C Medical College & Hospital, Ernakulam District, Kolenchery, Kerala, 682311, India
| | - Anuroopa Vijayan
- M.O.S.C Medical College & Hospital, Ernakulam District, Kolenchery, Kerala, 682311, India.,Department of Medicine, M.O.S.C Medical College & Hospital, Ernakulam District, Kolenchery, Kerala, 682311, India
| | - Jayamohan Kokkat
- M.O.S.C Medical College & Hospital, Ernakulam District, Kolenchery, Kerala, 682311, India.,Department of Medicine, M.O.S.C Medical College & Hospital, Ernakulam District, Kolenchery, Kerala, 682311, India
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Abstract
Adjunctive therapies have been proposed for use in at least 5 inflammation pathobiology phenotypes in pediatric sepsis-induced multiple organ failure. This article discusses host-pathogen interaction prototypes to facilitate understanding of the rationale for personalized therapy in these phenotypes. The article discusses the literature on adjunctive antiinflammatory and immune modulation therapies that, in addition to traditional organ support and infection source control, might be part of a personalized precision medicine approach to the reversal of each of these inflammatory pathobiology phenotypes.
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38
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Hebert SA, Bohan TP, Erikson CL, Swinford RD. Thrombotic microangiopathy associated with Valproic acid toxicity. BMC Nephrol 2017; 18:262. [PMID: 28774273 PMCID: PMC5543430 DOI: 10.1186/s12882-017-0677-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 07/26/2017] [Indexed: 12/18/2022] Open
Abstract
Background Thrombotic microangiopathy (TMA) is a serious, sometimes life-threatening disorder marked by the presence of endothelial injury and microvascular thrombi. Drug-induced thrombotic microangiopathy (DI-TMA) is one specific TMA syndrome that occurs following drug exposure via drug-dependent antibodies or direct tissue toxicity. Common examples include calcineurin inhibitors Tacrolimus and Cyclosporine and antineoplastics Gemcitabine and Mitomycin. Valproic acid has not been implicated in DI-TMA. We present the first case of a patient meeting clinical criteria for DI-TMA following admission for valproic acid toxicity. Case presentation An adolescent male with difficult to control epilepsy was admitted for impaired hepatic function while on valproic acid therapy. On the third hospital day, he developed severe metabolic lactic acidosis and multiorgan failure, prompting transfer to the pediatric intensive care unit. Progressive anemia and thrombocytopenia instigated an evaluation for thrombotic microangiopathy, where confirmed by concomitant hemolysis, elevated lactate dehydrogenase (LDH), low haptoglobin, and concurrent oliguric acute kidney injury. Thrombotic thrombocytopenic purpura was less likely with adequate ADAMTS13. Discontinuing valproic acid reversed the anemia, thrombocytopenia, and normalized the LDH and haptoglobin, supporting a drug-induced cause for the TMA. Conclusion To the best of our knowledge, this is the first report of drug-induced TMA from valproic acid toxicity.
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Affiliation(s)
- Sean A Hebert
- Department of Internal Medicine and Pediatrics, Division of Nephrology, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Children's Memorial Hermann Hospital, 6431 Fannin Street, MSB 3.121, Houston, TX, USA.
| | - Timothy P Bohan
- Pediatric Neurology, Memorial Hermann Texas Medical Center, Children's Memorial Hermann Hospital, 6400 Fannin Street, Ste 2740, Houston, TX, USA
| | - Christian L Erikson
- Department of Pediatrics, Division of Critical Care Medicine, Texas Children's Hospital, The Woodlands 17600 I-45 South, WL 640, Conroe, TX, USA
| | - Rita D Swinford
- Department of Pediatrics, Division of Nephrology, McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth), Children's Memorial Hermann Hospital, 6431 Fannin Street, MSB 3. 121, Houston, TX, USA
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Abstract
OBJECTIVE To describe the pathophysiology associated with multiple organ dysfunction syndrome in children. DATA SOURCES Literature review, research data, and expert opinion. STUDY SELECTION Not applicable. DATA EXTRACTION Moderated by an experienced expert from the field, pathophysiologic processes associated with multiple organ dysfunction syndrome in children were described, discussed, and debated with a focus on identifying knowledge gaps and research priorities. DATA SYNTHESIS Summary of presentations and discussion supported and supplemented by relevant literature. CONCLUSIONS Experiment modeling suggests that persistent macrophage activation may be a pathophysiologic basis for multiple organ dysfunction syndrome. Children with multiple organ dysfunction syndrome have 1) reduced cytochrome P450 metabolism inversely proportional to inflammation; 2) increased circulating damage-associated molecular pattern molecules from injured tissues; 3) increased circulating pathogen-associated molecular pattern molecules from infection or endogenous microbiome; and 4) cytokine-driven epithelial, endothelial, mitochondrial, and immune cell dysfunction. Cytochrome P450s metabolize endogenous compounds and xenobiotics, many of which ameliorate inflammation, whereas damage-associated molecular pattern molecules and pathogen-associated molecular pattern molecules alone and together amplify the cytokine production leading to the inflammatory multiple organ dysfunction syndrome response. Genetic and environmental factors can impede inflammation resolution in children with a spectrum of multiple organ dysfunction syndrome pathobiology phenotypes. Thrombocytopenia-associated multiple organ dysfunction syndrome patients have extensive endothelial activation and thrombotic microangiopathy with associated oligogenic deficiencies in inhibitory complement and a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13. Sequential multiple organ dysfunction syndrome patients have soluble Fas ligand-Fas-mediated hepatic failure with associated oligogenic deficiencies in perforin and granzyme signaling. Immunoparalysis-associated multiple organ dysfunction syndrome patients have impaired ability to resolve infection and have associated environmental causes of lymphocyte apoptosis. These inflammation phenotypes can lead to macrophage activation syndrome. Resolution of multiple organ dysfunction syndrome requires elimination of the source of inflammation. Full recovery of organ functions is noted 6-18 weeks later when epithelial, endothelial, mitochondrial, and immune cell regeneration and reprogramming is completed.
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Chong M, Lopez-Magallon AJ, Saenz L, Sharma MS, Althouse AD, Morell VO, Munoz R. Use of Therapeutic Plasma Exchange during Extracorporeal Life Support in Critically Ill Cardiac Children with Thrombocytopenia-Associated Multi-Organ Failure. Front Pediatr 2017; 5:254. [PMID: 29250516 PMCID: PMC5716972 DOI: 10.3389/fped.2017.00254] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 11/14/2017] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Thrombocytopenia-associated multi-organ failure (TAMOF) in children is a well-described factor for increased hospital mortality. Low cardiac output syndrome (LCOS) and the effects of cardiopulmonary bypass may manifest with several adverse physiologic and immunologic effects, with varying degrees of thrombocytopenia and multi-organ dysfunction, sometimes very similar to TAMOF. LCOS is a common occurrence in children with critical heart disease, presenting in as much as 23.8% of infants postoperative of congenital heart surgery. Therapeutic plasma exchange (TPE) has been offered as a promising therapy for TAMOF; however, the therapeutic implications of this modality in children with critical heart disease and a clinical diagnosis of TAMOF are unknown. OBJECTIVES We describe our institutional experience with TPE as an adjuvant rescue therapy for children with critical heart disease and a clinical diagnosis of TAMOF, while supported by extracorporeal membrane oxygenation (ECMO). METHODS Single-center retrospective analysis of children with critical heart disease admitted to the CICU and supported by ECMO, undergoing TPE for a clinical diagnosis of TAMOF between January 2006 and June 2015. RESULTS Forty-one patients were included for analysis. Median age and weight of patients was 0.6 years (range 0.0-17.2) and 8.5 kg (range 1.5-80.0). TPE was initiated at a median of 1 day (0-13) after initiation of ECMO. Modified organ failure index (MOFI) and platelet count improved after TPE start (p < 0.001). Patients with early TPE initiation after ECMO cannulation (<1 day) showed more improvement in MOFI and platelet counts than patients with late TPE initiation (p < 0.001 for each). Overall survival to hospital discharge was 53.7%. The within-groups hospital survival was 73.3% for patients with heart failure, 34.8% for patients with congenital heart disease, and 100% for those with other cardiac disease (p = 0.016). CONCLUSION In children with critical cardiac disease and clinical diagnosis of TAMOF necessitating ECMO for hemodynamic support, concurrent TPE may be associated with an improvement in organ failure and platelet count, particularly when started early. Further studies are warranted to establish the most effective use of TPE and its effect on survival in this population.
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Affiliation(s)
- Mei Chong
- Department of Critical Care Medicine, Division of Cardiac Intensive Care, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, United States.,Department of Pediatric Heart Center, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing, China
| | - Alejandro J Lopez-Magallon
- Department of Critical Care Medicine, Division of Cardiac Intensive Care, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, United States
| | - Lucas Saenz
- Department of Critical Care Medicine, Division of Cardiac Intensive Care, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, United States
| | - Mahesh S Sharma
- Department of Cardiothoracic Surgery, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, United States
| | | | - Victor O Morell
- Department of Cardiothoracic Surgery, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, United States
| | - Ricardo Munoz
- Department of Critical Care Medicine, Division of Cardiac Intensive Care, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, United States
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41
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Pediatric Therapeutic Apheresis: A Critical Appraisal of Evidence. Transfus Med Rev 2016; 30:217-22. [DOI: 10.1016/j.tmrv.2016.08.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 08/04/2016] [Accepted: 08/04/2016] [Indexed: 01/04/2023]
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42
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Yeşilbaş O, Kıhtır HS, Yıldırım HM, Hatipoğlu N, Şevketoğlu E. Pediatric Fulminant Leptospirosis Complicated by Pericardial Tamponade, Macrophage Activation Syndrome and Sclerosing Cholangitis. Balkan Med J 2016; 33:578-580. [PMID: 27761292 DOI: 10.5152/balkanmedj.2016.151240] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Accepted: 02/03/2016] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Leptospirosis is a zoonotic infectious disease caused by pathogenic spirochetes of the genus Leptospira. Although it is usually asymptomatic and self-limited, severe potentially fatal illness accompanied by multi-organ failure may occur. CASE REPORT Here we report an unusual case of severe leptospirosis successfully treated with continuous venovenous hemofiltration (CVVHF) and therapeutic plasma exchange (TPE). The patient presented with pericardial tamponade, renal failure and macrophage activation syndrome, and later suffered prolonged jaundice and sclerosing cholangitis during hospitalization in the pediatric intensive care unit (PICU). To the best of our knowledge, sclerosing cholangitis due to leptospirosis has not been reported in the literature. CONCLUSION Leptospirosis should be kept in mind in the differential diagnosis of sepsis and septic shock with fever, thrombocytopenia, jaundice and renal failure. TPE and CVVHF should start early after the diagnosis of leptospirosis with multiorgan failure.
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Affiliation(s)
- Osman Yeşilbaş
- Pediatric Intensive Care Unit, Pediatric Critical Care Medicine, Bakırköy Dr. Sadi Konuk Research and Training Hospital, İstanbul, Turkey
| | - Hasan Serdar Kıhtır
- Pediatric Intensive Care Unit, Pediatric Critical Care Medicine, Bakırköy Dr. Sadi Konuk Research and Training Hospital, İstanbul, Turkey
| | - Hamdi Murat Yıldırım
- Pediatric Intensive Care Unit, Pediatric Critical Care Medicine, Bakırköy Dr. Sadi Konuk Research and Training Hospital, İstanbul, Turkey
| | - Nevin Hatipoğlu
- Division of Pediatric Infectious Disease, Department of Pediatrics, Bakırköy Dr. Sadi Konuk Research and Training Hospital, İstanbul, Turkey
| | - Esra Şevketoğlu
- Pediatric Intensive Care Unit, Pediatric Critical Care Medicine, Bakırköy Dr. Sadi Konuk Research and Training Hospital, İstanbul, Turkey
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43
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Guthoff M, Heyne N. [Clinical course and differential diagnosis of thrombotic microangiopathy]. Med Klin Intensivmed Notfmed 2016; 113:293-298. [PMID: 27405938 DOI: 10.1007/s00063-016-0193-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 05/24/2016] [Accepted: 05/26/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Thrombotic microangiopathies are complex diseases, requiring early differential diagnosis and targeted intervention. OBJECTIVES Presentation of clinical phenotype and diagnostic algorithm, discussion of underlying pathophysiology, clinical management and therapy. METHODS Summary of current knowledge from literature and expert opinion. RESULTS Our understanding of pathophysiology and therapeutic options have changed substantially in recent years. Early differential diagnosis and targeted therapy are of prognostic relevance. CONCLUSIONS A better understanding of underlying pathophysiology, increased clinical awareness and novel therapeutic options allow for a better prognosis of patients with thrombotic microangiopathy.
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Affiliation(s)
- M Guthoff
- Medizinische Klinik IV, Abteilung für Endokrinologie und Diabetologie, Angiologie, Nephrologie und Klinische Chemie, Universitätsklinikum Tübingen, Otfried-Müller-Str. 10, 72076, Tübingen, Deutschland.
| | - N Heyne
- Medizinische Klinik IV, Abteilung für Endokrinologie und Diabetologie, Angiologie, Nephrologie und Klinische Chemie, Universitätsklinikum Tübingen, Otfried-Müller-Str. 10, 72076, Tübingen, Deutschland
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44
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Kumar R, McSharry B, Bradbeer P, Wiltshire E, Jefferies C. Thrombocytopenia-associated multiorgan failure occurring in an infant at the onset of type 1 diabetes successfully treated with fresh frozen plasma. Clin Case Rep 2016; 4:671-4. [PMID: 27386126 PMCID: PMC4929803 DOI: 10.1002/ccr3.587] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2015] [Revised: 02/02/2016] [Accepted: 02/23/2016] [Indexed: 01/10/2023] Open
Abstract
TAMOF is a devastating microangiopathy that can occur in association with the new onset of T1DM, and should be considered with the onset of thrombocytopenia, renal failure, and raised LDH. Treatment with fresh frozen plasma should be considered as a first‐line option in such cases prior to plasma exchange.
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Affiliation(s)
| | - Brent McSharry
- Department of Pediatric Intensive care Starship Children's Hospital Auckland New Zealand
| | - Peter Bradbeer
- Starship Blood and Cancer Centre Starship Children's Hospital Auckland New Zealand
| | - Esko Wiltshire
- Departments of Paediatrics and Child Health University of Otago Wellington Wellington New Zealand
| | - Craig Jefferies
- Department of Pediatric Diabetes and Endocrinology Starship Children's Hospital Auckland New Zealand
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45
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Alsaied T, Goldstein SL, Kaddourah A, Poynter SE. Thrombocytopenia-associated multi-organ failure caused by diabetic ketoacidosis. Pediatr Int 2016; 58:232-4. [PMID: 26712331 DOI: 10.1111/ped.12780] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Revised: 06/30/2015] [Accepted: 07/21/2015] [Indexed: 01/19/2023]
Abstract
Thrombocytopenia-associated multi-organ failure (TAMOF) is an increasingly reported entity in the pediatric intensive care unit. The clinical presentation is similar to thrombotic thrombocytopenic purpura, but with no evidence of hemolysis and no schistocytes on peripheral smear. We report a case of TAMOF induced by diabetic ketoacidosis and treated with therapeutic plasma exchange (TPE). Early diagnosis and initiation of TPE significantly decrease the morbidity associated with TAMOF.
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Affiliation(s)
- Tarek Alsaied
- Pediatric Residency Training Program, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Stuart L Goldstein
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Ahmad Kaddourah
- Center for Acute Care Nephrology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Sue E Poynter
- Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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46
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Al Harbi SA, Tamim HM, Al-Dorzi HM, Sadat M, Arabi YM. Association between aspirin therapy and the outcome in critically ill patients: a nested cohort study. BMC Pharmacol Toxicol 2016; 17:5. [PMID: 26850706 PMCID: PMC4743206 DOI: 10.1186/s40360-016-0047-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2015] [Accepted: 01/14/2016] [Indexed: 12/25/2022] Open
Abstract
Background Antiplatelet therapy may attenuate the undesirable effects of platelets on the inflammatory cascades in critical illness. The objective of this study was to evaluate the association between aspirin therapy during intensive care unit (ICU) stay and all-cause mortality. Methods This was a nested cohort study within two randomized controlled trials in which all enrolled patients (N = 763) were grouped according to aspirin intake during ICU stay. The primary endpoints were all-cause ICU mortality and hospital mortality. Secondary endpoints included the development of severe sepsis during the ICU stay, ICU and hospital length of stay and the duration of mechanical ventilation. Propensity score was used to adjust for clinically and statistically relevant variables. Results Of the 763 patients, 154 patients (20 %) received aspirin. Aspirin therapy was not associated with a reduction in ICU mortality (adjusted OR 1.18, 95 % CI 0.69–2.02, P = 0.55) nor with hospital mortality (adjusted OR 0.95, 95 % CI 0.61–1.50, P = 0.82). Aspirin use had no preferential association with mortality among any of the study subgroups. Additionally, aspirin therapy was associated with higher risk of ICU-acquired severe sepsis, and increased mechanical ventilation duration and ICU length of stay. Conclusion Our study showed that the use of aspirin in critically ill patients was not associated with lower mortality, but rather with an increased morbidity. Trial Registration Number ISRCTN07413772 and ISRCTN96294863.
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Affiliation(s)
- Shmeylan A Al Harbi
- Pharmaceutical Care Department, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Hani M Tamim
- Department of Internal Medicine, American University of Beirut-Medical Center, Beirut, Lebanon
| | - Hasan M Al-Dorzi
- Intensive Care Department, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, PO Box 22490, MC 1425, Riyadh, 1426 K S A
| | | | - Yaseen M Arabi
- Intensive Care Department, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, PO Box 22490, MC 1425, Riyadh, 1426 K S A.
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47
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Habr B, Charpentier J, Champigneulle B, Dechartres A, Daviaud F, Geri G, Cariou A, Chiche JD, Mira JP, Pène F. Platelet transfusions in cancer patients with hypoproliferative thrombocytopenia in the intensive care unit. Ann Intensive Care 2015; 5:46. [PMID: 26621198 PMCID: PMC4666191 DOI: 10.1186/s13613-015-0088-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Accepted: 11/13/2015] [Indexed: 12/04/2022] Open
Abstract
Background Thrombocytopenia is a frequent finding in critically ill cancer patients for whom indications of platelet transfusions are unclear. We herein addressed the current practices in platelet transfusion and the risk of bleeding in cancer patients with hypoproliferative thrombocytopenia in the intensive care unit (ICU). Methods A retrospective monocenter study over a 7-year period was conducted in a medical ICU. Adult patients with malignancies and hypoproliferative thrombocytopenia, and who received at least one platelet concentrate during their ICU stay, were included. Results 296 patients were included and received a total of 904 platelet transfusions, for prophylactic indications in 300 (33.2 %) episodes, for securing an invasive procedure in 257 (28.4 %), and for treatment of minor to major bleeding manifestations in 347 (38.4 %). Most prophylactic transfusions (80 %) were performed at platelet count thresholds below 10–20 × 109/L. Platelet increments were generally low in all three indications, 10 (interquartile range 2–25), 11 (2–25), and 8 (0–21) × 109/L, respectively. A total of 97 major ICU-acquired bleeding events occurred in 40 patients. About half of those bleeding episodes (54.7 %) occurred at platelet counts below 20 × 109/L. However, neither low admission platelet count nor low nadir platelet counts were predictive of ICU-acquired bleeding. The in-ICU mortality rate tended to be higher in patients with severe ICU-acquired bleeding events (50 vs. 36 %). Conclusions Most prophylactic platelet transfusions were given using thresholds of 10–20 × 109/L in critically ill thrombocytopenic cancer patients. The individual risk of ICU-acquired severe bleeding appears hardly predictable with the depth of thrombocytopenia.
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Affiliation(s)
- Bassem Habr
- Réanimation Médicale, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France.
| | - Julien Charpentier
- Réanimation Médicale, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France.
| | - Benoît Champigneulle
- Réanimation Médicale, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France. .,Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, Paris, France.
| | - Agnès Dechartres
- Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, Paris, France. .,Centre d'épidémiologie et de recherche clinique, Hôtel-Dieu, Assistance Publique-Hôpitaux de Paris, Paris, France.
| | - Fabrice Daviaud
- Réanimation Médicale, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France. .,Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, Paris, France.
| | - Guillaume Geri
- Réanimation Médicale, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France. .,Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, Paris, France.
| | - Alain Cariou
- Réanimation Médicale, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France. .,Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, Paris, France.
| | - Jean-Daniel Chiche
- Réanimation Médicale, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France. .,Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, Paris, France. .,Institut Cochin, INSERM U1016, CNRS UMR8104, Paris, France.
| | - Jean-Paul Mira
- Réanimation Médicale, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France. .,Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, Paris, France. .,Institut Cochin, INSERM U1016, CNRS UMR8104, Paris, France.
| | - Frédéric Pène
- Réanimation Médicale, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, 27 rue du Faubourg Saint-Jacques, 75014, Paris, France. .,Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, Paris, France. .,Institut Cochin, INSERM U1016, CNRS UMR8104, Paris, France.
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48
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Wang TL, Guo DH, Bai Y, Wen K, Han WY, Wang R. Thrombocytopenia in Patients Receiving Prolonged Linezolid May be Caused by Oxidative Stress. Clin Drug Investig 2015; 36:67-75. [DOI: 10.1007/s40261-015-0352-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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49
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Izzedine H, Perazella MA. Thrombotic microangiopathy, cancer, and cancer drugs. Am J Kidney Dis 2015; 66:857-68. [PMID: 25943718 DOI: 10.1053/j.ajkd.2015.02.340] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2014] [Accepted: 02/13/2015] [Indexed: 02/07/2023]
Abstract
Thrombotic microangiopathy (TMA) is a complication that can develop directly from certain malignancies, but more often results from anticancer therapy. Currently, the incidence of cancer drug-induced TMA during the last few decades is >15%, primarily due to the introduction of anti-vascular endothelial growth factor (VEGF) agents. It is important for clinicians to understand the potential causes of cancer drug-induced TMA to facilitate successful diagnosis and treatment. In general, cancer drug-induced TMA can be classified into 2 types. Type I cancer drug-induced TMA includes chemotherapy regimens (ie, mitomycin C) that can potentially promote long-term kidney injury, as well as increased morbidity and mortality. Type II cancer drug-induced TMA includes anti-VEGF agents that are not typically associated with cumulative dose-dependent cell damage. In addition, functional recovery of kidney function often occurs after drug interruption, assuming a type I agent was not given prior to or during therapy. There are no randomized controlled trials to provide physician guidance in the management of TMA. However, previously accumulated information and research suggest that endothelial cell damage has an underlying immunologic basis. Based on this, the emerging trend includes the use of immunosuppressive agents if a refractory or relapsing clinical course that does not respond to plasmapheresis and steroids is observed.
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Affiliation(s)
- Hassan Izzedine
- Department of Nephrology, Monceau Park International Clinic, Paris, France.
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50
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Therapeutic plasma exchange may improve hemodynamics and organ failure among children with sepsis-induced multiple organ dysfunction syndrome receiving extracorporeal life support. Pediatr Crit Care Med 2015; 16:366-74. [PMID: 25599148 PMCID: PMC4424057 DOI: 10.1097/pcc.0000000000000351] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To determine the effect of therapeutic plasma exchange on hemodynamics, organ failure, and survival in children with multiple organ dysfunction syndrome due to sepsis requiring extracorporeal life support. DESIGN A retrospective analysis. SETTING A PICU in an academic children's hospital. PATIENTS Fourteen consecutive children with sepsis and multiple organ dysfunction syndrome who received therapeutic plasma exchange while on extracorporeal life support from 2005 to 2013. INTERVENTIONS Median of three cycles of therapeutic plasma exchange with median of 1.0 times the estimated plasma volume per exchange. MEASUREMENTS AND MAIN RESULTS Organ Failure Index and Vasoactive-Inotropic Score were measured before and after therapeutic plasma exchange use. PICU survival in our cohort was 71.4%. Organ Failure Index decreased in patients following therapeutic plasma exchange (mean ± SD: pre, 4.1 ± 0.7 vs post, 2.9 ± 0.9; p = 0.0004). Patients showed improved Vasoactive-Inotropic Score following therapeutic plasma exchange (median [25th-75th]: pre, 24.5 [13.0-69.8] vs post, 5.0 [1.5-7.0]; p = 0.0002). Among all patients, the change in Organ Failure Index was greater for early therapeutic plasma exchange use than late use (early, -1.7 ± 1.2 vs late, -0.9 ± 0.6; p = 0.14), similar to the change in Vasoactive-Inotropic Score (early, -67.5 [28.0-171.2] vs late, -12.0 [7.2-18.5]; p = 0.02). Among survivors, the change in Organ Failure Index was greater among early therapeutic plasma exchange use than late use (early, -2.3 ± 1.0 vs late, -0.8 ± 0.8; p = 0.03), as was the change in Vasoactive-Inotropic Score (early, -42.0 [16.0-76.3] vs late, -12.0 [5.3-29.0]; p = 0.17). The mean duration of extracorporeal life support after therapeutic plasma exchange according to timing of therapeutic plasma exchange was not statistically different among all patients or among survivors. CONCLUSIONS The use of therapeutic plasma exchange in children on extracorporeal life support with sepsis-induced multiple organ dysfunction syndrome is associated with organ failure recovery and improved hemodynamic status. Initiating therapeutic plasma exchange early in the hospital course was associated with greater improvement in organ dysfunction and decreased requirement for vasoactive and/or inotropic agents.
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