Critical Care Medicine Division, Department of Pediatrics and Medicine, Louisiana State University Health Sciences Center, Shreveport, LA, USA.
Pediatr Crit Care Med. 2011 Mar;12(2):e87-9. doi: 10.1097/PCC.0b013e3181e2a569.
Acute pneumonitis with acute lung injury is a cause of significant mortality related to the 2009 pH1N1 influenza A virus. Widespread lung inflammation and increased pulmonary vascular permeability has been noted on autopsy. Also, many of these patients present with significant hemodynamic compromise suggesting systemic cytokine release. Therefore, attenuating circulating cytokines, and other mediators, by blood purification techniques is a theoretically attractive strategy. We report the use therapeutic plasma exchange in three children with 2009 H1N1 related acute lung injury with severe hemodynamic compromise that had failed conventional therapeutic interventions.
Case series.
Pediatric intensive care unit in a university children's hospital.
Three children, aged 8, 11, and 17 yrs, with acute respiratory distress syndrome and hemodynamic compromise related to the 2009 pH1N1 influenza A virus documented by polymerase chair reaction. All patients were on mechanical ventilation and inhaled nitric oxide, and one patient was on extracorporeal membrane oxygenation. Therapeutic plasma exchange was used as a rescue strategy.
Each patient received three exchanges of 35-40 mL/kg on consecutive days.
All three patients had dramatic reduction in pediatric logistic organ dysfunction scores, oxygen requirements, and vasopressor requirements after two exchanges. All survived with good functional recovery.
In this small series of patients with H1N1/acute respiratory distress syndrome and hemodynamic compromise, therapeutic plasma exchange appeared to benefit as a method of mitigating the associated cytokine storm. The procedure was well tolerated with no reported side effects. All three patients survived, defying the predicted mortality. Because these procedures used the filtration exchange method, it was performed in a timely fashion by intensive care unit personnel and on equipment already available in the intensive care unit for renal support.
This very limited case series suggest there may be a role for therapeutic plasma exchange as a rescue therapy in severe shock and acute lung injury related to pH1N1 that has not responded to traditional therapy.
急性肺炎伴急性肺损伤是与 2009 年 pH1N1 甲型流感病毒相关的高死亡率原因。尸检发现肺部广泛炎症和肺血管通透性增加。此外，许多此类患者表现出明显的血流动力学障碍，表明全身细胞因子释放。因此，通过血液净化技术减轻循环细胞因子和其他介质是一种具有吸引力的理论策略。我们报告了三例 2009 年 H1N1 相关急性肺损伤伴有严重血流动力学障碍的儿童使用治疗性血浆置换的情况，这些儿童对常规治疗干预无效。
病例系列。
大学儿童医院的儿科重症监护病房。
3 例年龄分别为 8、11 和 17 岁的儿童，其急性呼吸窘迫综合征和血流动力学障碍与聚合酶链反应证实的 2009 年 pH1N1 甲型流感病毒有关。所有患者均接受机械通气和吸入性一氧化氮治疗，1 例患者接受体外膜氧合治疗。治疗性血浆置换被用作挽救策略。
每位患者连续 3 天接受 35-40ml/kg 的 3 次交换。
两次交换后，所有 3 名患者的儿科逻辑器官功能障碍评分、氧需求和血管加压素需求均明显降低。所有患者均存活且功能恢复良好。
在这组患有 H1N1/急性呼吸窘迫综合征和血流动力学障碍的患者中，治疗性血浆置换似乎是一种减轻相关细胞因子风暴的方法。该程序耐受性良好，无不良反应报告。所有患者均存活，这与预测的死亡率相悖。由于这些程序使用过滤交换方法，因此可以由重症监护病房的工作人员在重症监护病房中已经可用的设备上及时进行。
这项非常有限的病例系列研究表明，在对传统治疗无反应的 pH1N1 相关严重休克和急性肺损伤中，治疗性血浆置换可能作为一种挽救性治疗方法发挥作用。
