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Yaroustovsky et al. Blood purification in intensive care patients

convection and adsorption. The advantages of 8.2 to 2.44 pg/mL, P = 0.01) in patients with sepsis
CPFA include the passage of plasma (and not blood) after two procedures of combined LPS-adsorption
through the sorption column, which increases the and HDF with EMiC2. Similar dynamics of the
contact time with the sorption surface and improves infectious markers were observed when conducting
the efficiency of the procedure. [65,70] LPS-adsorption with CPFA: EAA decreased by 30%
(from 0.77 to 0.53, P = 0.003) and procalcitonin
HDF, which is carried out using filters with high cut- by 55% (from 6.23 to 2.83 pg/mL, P = 0.005). We
off membranes (EMiC2, Fresenius, Germany; 40 kDa also observed positive dynamics in leukocytosis
cut-off), eliminates substances of low and medium and hyperthermia. Both variants of combined blood
molecular weight without albumin or coagulation purification contributed to decreases in C-reactive
factor loss. The permeability of these filters is similar protein (CRP) and pro-inflammatory cytokine levels,
to that of the kidney glomerular basement membrane, thus confirming the decrease in the intensity of the
suggesting that the therapeutic effect of HDF is more systemic inflammation response. [53,54]
physiological. [66,71-73]
Including combined blood purification methods into
Several studies have demonstrated the beneficial the complex therapy for sepsis allowed the results of
effect of selective LPS-adsorption, HD/HDF (with high treatment to be optimized. The 28-day survival was
cut-off membranes) and CPFA in sepsis. [58,64-66] 65% in the LPS-adsorption + HDF with EMiC2 group
and 75% in the LPS-adsorption + CPFA group.
We proposed two new techniques of combined
blood purification methods in single circuit: (1) The efficiency of the proposed concept of
LPS-adsorption + HDF using filters with high cut- etiopathogenetic extracorporeal therapy for gram-
off membranes; and (2) LPS-adsorption + CPFA. negative sepsis is confirmed by the favorable results
In the available literature, there was no information obtained in cardiac surgical patients characterized
about a similar extracorporeal therapy protocol for by their initially severe condition and more severe
sepsis in cardiac surgical patients. A study of adults course of septic complications. The combined
enrolled in these protocols, carried out at the A.N. methods of blood purification can affect either the
Bakulev NSPCCS in 2009-2016, showed the safety starting factor in the early development of sepsis
and efficacy of the combined therapies mentioned by endotoxin removal or the subsequent release of
above. [53,54] inflammatory mediators after immune cell activation.
These therapeutic methods also maintain vital organ
We observed that the combination of LPS-adsorption function in MODS development.
and HDF filters with high cut-off EMiC2 membranes
led to a 34% MAP increase [from 76 (65-81) to 90 Our experience from using selective LPS-adsorption
(85-102) mmHg, P < 0.001] with reduced vasopressor in adult patients with sepsis allowed us to use this
and inotropic support. The increase in MAP during method for sepsis treatment in children. Blood
LPS-adsorption with CPFA was 12% with the purification in children with sepsis is limited to RRT
significant decrease in vasopressor support [the dose technologies. The principle of selective sorption use
[74]
of noradrenaline was halved from 0.2 (0.15-0.3) to in children is absolutely innovative. No information
0.1 (0.05-0.15) µg/kg/min, P = 0.024]. The improved was found in the database of the US National Library
oxygenation was confirmed by an increase in the of Medicine National Institutes of Health on the use
oxygenation index increase (by 36% and 28% in LPS- of selective LPS-adsorption for sepsis treatment in
adsorption with HDF in single circuit using EMiC2 children after cardiac surgery.
and LPS-adsorption with CPFA in single circuit,
respectively). One of the mechanisms that have a The application of the smaller volume and sorption
favorable effect on blood oxygenation is a decrease in capacity of the Polymyxin B-immobilized cartridge
the intensity of the infiltrative-inflammatory lung tissue (Toraymyxin-PMX-0.5R) is a new and promising
process during blood purification. extracorporeal technology that aims to reduce
mortality from sepsis in children. Experience in
We also evaluated the efficiency of blood purification selective endotoxin sorption is available only in
in sepsis by monitoring the dynamics of EAA, Japan, where a study group enrolled children with
procalcitonin level, bacteriological blood and sputum abdominal pathology. The authors identified the safety
examination and the clinical state of patients during and high efficiency of using Toraymyxin-PMX-0.5R
the procedures. The obtained results showed a cartridges. [75,76]
decrease of 20% in EAA (from 0.74 to 0.59, P = 0.03)
and of approximately 70% in procalcitonin (from Today, the A.N. Bakulev NSPCCS has gained initial
56 Vessel Plus ¦ Volume 1 ¦ June 27, 2017