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Yaroustovsky et al. Blood purification in intensive care patients

blood purification in children, it is important to prevent plasmofiltration and adsorption (CPFA), convection
hypothermia. Hypothermia can lead to cardiac output and filtration techniques using ultrahigh permeable
decrease by peripheral vasospasm and an increase membranes. [53,54]
in TPVR and post-load. To avoid heat loss during
MARS-therapy in children, it is necessary to use a Many authors have observed that LPS-adsorption
heat exchanger and other physical heating means with PMX cartridges leads to a significant decrease
and to establish a high temperature (38-39 °C) on the in endotoxin activity levels after two consecutive
[55]
bicarbonate line. [44] procedures. Positive dynamics of the endotoxin
concentration (lowering by 38%) in patients with
EXTRACORPOREAL BLOOD abdominal sepsis and septic shock were demonstrated
[56]
PURIFICATION IN COMPLEX INTENSIVE in the European multicenter study “EUPHAS”. In the
THERAPY FOR SEPSIS IN ADULT AND MEDIC study conducted in Europe and North America
on ICU patients, selective LPS-adsorption led to a
PEDIATRIC PATIENTS AFTER OPEN- decrease in the mean endotoxin activity assay (EAA)
HEART SURGERY level from 0.65 to 0.45 within 12 h after the procedure.
According to the authors, the average reduction of the
Sepsis and septic shock are among the most common endotoxin concentration (26.1%) measured with the
causes of death in critically ill patients in the ICU. Over EAA is equivalent to a 50-100-fold decrease in the
the last decade, clinics worldwide have noted a trend LPS level. [57]
towards a decrease in the frequency of Gram-positive
bacteria and an increase in the frequency of Gram- In the European multicentre trial, the EUPHAS trial,
negative bacteria within microbiological studies. 28-day survival after DHP-PMX was 53% and 32%
in the study and control groups, respectively. The
[56]
A structural component of the membrane of assessment of retrospective data on using selective
gram-negative microorganisms is bacterial LPS adsorption in 306 patients with severe sepsis
lipopolysaccharide (or endotoxin), which is the main enrolled in the EUPHAS 2 trial indicated that 28-
trigger of both sepsis and a cascade of inflammatory day mortality was 35% and 49% in the group with
reactions. When entering the systemic bloodstream abdominal surgical pathology and in the group
[46]
from a focus of infection (e.g. pneumonia, mediastinitis) with non-abdominal pathology, respectively. [58]
or natural reservoir (for example, the gastrointestinal Similar results were observed in earlier published
tract, particularly after CPB), endotoxin interacts Japanese [59-61] and European studies and in the
[62]
with competent cells of the immune system as a meta-analysis data regarding immobilized Polymyxin
hormone and activates the synthesis of a wide B use efficacy during sepsis. [52,63]
range of mediators. The excess production of which
determines the clinical manifestations of sepsis, such Our experience with combined application of various
as systemic endothelial damage, decreased vascular techniques in a single circuit (LPS-adsorption +
tone, hypotension, cardiovascular hyporeactivity, CPFA and LPS-adsorption + HD/HDF using filters
fever, microcirculatory disorder, activation of with high cut-off membranes) showed their safety
hemostatic system factors, tissue hypoperfusion, and pathogenic efficiency. [53,54] The application of
hypoxia and multi-organ failure. [47,48] The development convection and filtration techniques (CPFA, HDF
of microcirculatory disorders and tissue hypoxia in the using filters with high cut-off membranes) allows
gastrointestinal tract creates conditions for bacterial the correction of water-electrolyte and metabolic
translocation. Thus, the vicious circle initiated by disorders and azotemia, which often accompany
lipopolysaccharide is closed. [49,50] sepsis-associated MODS. [64-67]

The pathogenic chain of septic development and LPS-adsorption using Toraymyxin-PMX-20R
progression determines a need to develop and Polymyxin B immobilized fiber cartridges was found
introduce new promising technologies. [47,51,52] to be effective, simultaneously acting through sorption
and apheresis on bacterial endotoxin, systemic
Modern methods of blood purification allow inflammatory mediators and activated immune
etiopathogenic therapy application for sepsis: to cells. [59-61,68,69]
eliminate the etiotropic agent (endotoxin) by selective
lipopolysaccharide (LPS)-adsorption and to remove CPFA performs an immunomodulatory role by acting
the effector substances of systemic inflammation, on inflammatory mediators (interleukin-1β, -6, -8,
replacing the functions of the affected organs and -10, -18, tumor necrosis factor-α and others) via
recovering the body’s homeostasis by coupled various mass transfer mechanisms such as diffusion,
Vessel Plus ¦ Volume 1 ¦ June 27, 2017 55