Hadem Johannes, Hafer Carsten, Schneider Andrea S, Wiesner Olaf, Beutel Gernot, Fuehner Thomas, Welte Tobias, Hoeper Marius M, Kielstein Jan T
Department of Gastroenterology, Hepatology, and Endocrinology, Hannover Medical School, Carl-Neuberg-Strasse 1, D-30625 Hannover, Germany.
BMC Anesthesiol. 2014 Apr 7;14:24. doi: 10.1186/1471-2253-14-24.
Several case series and small randomized controlled trials suggest that therapeutic plasma exchange (TPE) improves coagulation, hemodynamics and possibly survival in severe sepsis. However, the exact role of TPE in modern sepsis therapy remains unclear.
We performed a retrospective observational single-centre study on the use of TPE as rescue therapy in 23 consecutive patients with severe sepsis or septic shock from 2005 to 2012. Main surrogate markers of multiple organ failure (MOF) before, during and after TPE as well as survival rates are reported.
At baseline, mean SOFA score was 13 (standard deviation [SD] 4) and median number of failed organ-systems was 5 (interquartile range [IQR] 4-5). TPEs were performed 3 days (IQR 2-10) after symptom onset and 1 day (IQR 0-8) after ICU admission. The median total exchange volume was 3750 ml (IQR 2500-6000), which corresponded to a mean of 1.5 times (SD 0.9) the individual plasma volume. Fresh frozen plasma was used in all but one treatments as replacement fluid. Net fluid balance decreased significantly within 12 hrs following the first TPE procedure by a median of 720 mL (p = 0.002), irrespective of outcome. Reductions of norepinephrine dose and improvement in cardiac index were observed in individual survivors, but this was not significant for the overall cohort (p = 0.574). Platelet counts decreased irrespective of outcome between days 0 and 2 (p < 0.003), and increased thereafter in many survivors. There was a non-significant trend towards younger age and higher procalcitonin levels among survivors. Nine out of 23 TPE treated patients (39%) survived until ICU discharge (among them 3 patients with baseline SOFA scores of 15, 17, and 20).
Our data suggest that some patients with severe sepsis and septic shock may experience hemodynamic stabilisation by early TPE therapy.
多项病例系列研究和小型随机对照试验表明，治疗性血浆置换（TPE）可改善严重脓毒症患者的凝血功能、血流动力学，可能还会提高生存率。然而，TPE在现代脓毒症治疗中的确切作用仍不明确。
我们对2005年至2012年期间连续23例严重脓毒症或脓毒性休克患者使用TPE作为挽救治疗进行了一项单中心回顾性观察研究。报告了TPE治疗前、治疗期间和治疗后的多器官功能衰竭（MOF）主要替代指标以及生存率。
基线时，平均序贯器官衰竭评估（SOFA）评分为13（标准差[SD]4），器官系统功能衰竭的中位数为5（四分位间距[IQR]4 - 5）。TPE在症状出现后3天（IQR 2 - 10）和入住重症监护病房（ICU）后1天（IQR 0 - 8）进行。血浆置换总量中位数为3750 ml（IQR 2500 - 6000），相当于个体血浆量均值的1.5倍（SD 0.9）。除1例治疗外，其余所有治疗均使用新鲜冰冻血浆作为置换液。无论治疗结果如何，首次TPE治疗后12小时内净液体平衡显著下降，中位数为720 mL（p = 0.002）。个别存活患者去甲肾上腺素剂量减少，心脏指数改善，但对整个队列而言无显著意义（p = 0.574）。无论治疗结果如何，血小板计数在第0天至第2天之间均下降（p < 0.003），此后许多存活患者血小板计数升高。存活患者有年龄较轻和降钙素原水平较高的非显著趋势。23例接受TPE治疗的患者中有9例（39%）存活至ICU出院（其中3例基线SOFA评分为15、17和20）。
我们的数据表明，一些严重脓毒症和脓毒性休克患者可能通过早期TPE治疗实现血流动力学稳定。
