A successful application of adult polymyxin B-immobilized fiber column hemoperfusion to a neonate with septic shock

Polymyxin B Hemoperfusion in Pediatric Septic Shock: Single-Center Observational Case Series

OBJECTIVES

To evaluate the use of direct hemoperfusion with polymyxin B-immobilized fiber (PMX-DHP) as adjunctive therapy during pediatric patients with septic shock.

DESIGN

Prospective observational study.

SETTING

Nine-bed PICUs at university referral hospital.

PATIENTS

Children (30 d to 15 yr) with septic shock and Pediatric Logistic Organ Dysfunction (PELOD)-2 score greater than or equal to 10 or Pediatric Risk of Mortality (PRISM) 3 score greater than or equal to 15, who were also receiving at least one inotrope.

INTERVENTION

Patients received 2-4 hour treatment with PMX-DHP 20R column on 2 consecutive days.

MEASUREMENTS AND MAIN RESULTS

We enrolled six children aged 21-167 months old (median, 99-mo old), with a body weight of 10-50 kg (median, 28 kg). All six patients had both PELOD-2 greater than or equal to 10 and PRISM-3 greater than or equal to 15, required invasive mechanical ventilation, and received standard treatment for septic shock before enrollment. We observed significant improvement in PELOD-2 score from baseline to 72 hours after the start of PMX-DHP (mean [95% CI] from 14.3 [12.2-16.5] to 6.0 [0.3-11.7]; p = 0.006). The vasoactive inotropic score (VIS) and lactate concentration also significantly decreased from baseline to 72 hours (VIS, 60 mmol/L [25-95 mmol/L] to 4.0 mmol/L [44.1-12 mmol/L]; p = 0.003; lactate, 2.4 mmol/L [1.0-3.8 mmol/L] to 1.0 mmol/L [0.5-1.5 mmol/L]; p = 0.01). Five of six patients survived. There was no device-related adverse event in these patients.

CONCLUSIONS

In this case series of treatment with PMX-DHP as adjunctive therapy in children with refractory septic shock and high baseline severity, we have shown that patient recruitment is feasible. We have also found that clinical hemodynamic and severity of illness scores at 72 hours may be potential end points for testing in future randomized controlled trials.

Controlling an Outbreak of Multidrug-resistant Acinetobacter baumannii in a Pediatric Intensive Care Unit: a Retrospective Analysis

BACKGROUND

Multidrug-resistant Acinetobacter baumannii (MDRAB) is widespread among intensive care units worldwide, posing a threat to patients and the health system. We describe the successful management of a MDRAB outbreak by implementing an infection-control strategy in a pediatric intensive care unit (PICU).

METHODS

This retrospective study investigated the patients admitted to the PICU in periods 1 (8 months) and 2 (7 months), from the index MDRAB case to intervention implementation, and from intervention implementation to cessation of MDRAB spread. An infection-control strategy was designed following six concepts: 1) cohort isolation of colonized patients, 2) enforcement of hand hygiene, 3) universal contact precautions, 4) environmental management, 5) periodic surveillance culture study, and 6) monitoring and feedback.

RESULTS

Of the 427 patients, 29 were confirmed to have MDRAB colonization, of which 18 had MDRAB infections. Overall incidence per 1,000 patient days decreased from 7.8 (period 1) to 5.8 (period 2). The MDRAB outbreak was declared terminated after the 6-month follow-up following period 2. MDRAB was detected on the computer keyboard and in condensed water inside the ventilator circuits. The rate of hand hygiene performance was the lowest in the three months before and after index case admission and increased from 84% (period 1) to 95% (period 2). Patients with higher severity, indicated by a higher Pediatric Risk of Mortality III score, were more likely to develop colonization (P = 0.030), because they had invasive devices and required more contact with healthcare workers. MDRAB colonization contributed to an increase in the duration of mechanical ventilation and PICU stay (P < 0.001), but did not affect mortality (P = 0.273).

CONCLUSION

The MDRAB outbreak was successfully terminated by the implementation of a comprehensive infection-control strategy focused on the promotion of hand hygiene, universal contact precautions, and environmental management through multidisciplinary teamwork.

Effects of continuous renal replacement therapy with the AN69ST membrane for septic shock and sepsis-induced AKI in an infant: a case report with literature review of cytokine/mediator removal therapy in children

Background

Septic shock is a life-threatening condition and one of the most common causes of acute kidney injury (AKI). The acrylonitrile-co-methallyl sulfonate surface-treated (AN69ST) membrane used in severe sepsis was formally launched in Japan in 2014, as a non-renal indication. This membrane provides hemofiltration in dialysis and improves hemodynamics in patients with sepsis and hypercytokinemia. However, the clinical literature regarding continuous renal replacement therapy (CRRT) with the AN69ST membrane is very limited, especially in infants.

Case presentation

A 3-month-old female infant weighing 4.2 kg was hospitalized for septic shock and AKI secondary to necrotizing enterocolitis. Although she underwent palliative surgery, her vital signs did not recover from shock, and she developed reduced urine output. Her pediatric sequential organ failure assessment score was 10 points. Thus, we strongly suspected septic shock and sepsis-induced AKI, which were refractory to conservative treatment, and we decided to introduce CRRT with the AN69ST membrane for both renal replacement and anti-hypercytokinemic indications. After initiating CRRT for 72 h, her blood pressure increased sufficiently to maintain urine output, and improvements in the electrolyte abnormalities and metabolic acidosis were observed. Notably, her serum inflammatory cytokine levels decreased in parallel with improvement in her general condition. Despite successfully recovering from the AKI and being stable enough to allow discontinuing CRRT, she died of multiple organ dysfunction syndrome 3 weeks after CRRT was discontinued.

Conclusions

CRRT may complement standard treatment in patients with sepsis-induced AKI to control the amplitude of the systemic inflammatory response regarding acute tissue and organ damage. We expect that CRRT with the AN69ST membrane will be recognized as an option for the treatment of septic shock and sepsis-induced AKI, even in infants.

Case Report: Successful Use of Extracorporeal Therapies After ECMO Resuscitation in a Pediatric Kidney Transplant Recipient

The combination of extracorporeal membrane oxygenation (ECMO) and extracorporeal blood purification in children is rarely used due to small total blood volumes, risks of hemodynamic instability and a negative association between volume of blood transfusion and patient outcome. To our knowledge, this is the first description of a multimodal extracorporeal detoxication in the setting of ECMO in a post-kidney-transplant child on immunosuppression. We describe a case of a 30-months old child, who was extracorporeally resuscitated after cardiac arrest during kidney transplantation surgery and additionally treated with a number of extracorporeal blood purification methods (plasma exchange, CytoSorb, and lipopolysaccharide adsorption) in the setting of immunosuppression therapy. This case report shows the successful use of multimodal extracorporeal therapies for a good patient outcome. The lack of response to CytoSorb therapy might suggest an occult infection and not necessarily failure of treatment.