Kawai Yu, Cornell Timothy T, Cooley Elaine G, Beckman Craig N, Baldridge Paula K, Mottes Theresa A, Luckritz Kera E, Plomaritas Kathryn S, Meade J Michael, Odetola Folafoluwa O, Han Yong Y, Blatt Neal B, Annich Gail M
1Division of Pediatric Critical Care Medicine, Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI. 2Extracorporeal Life Support Program, University of Michigan, Ann Arbor, MI. 3Divisions of Nephrology, Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI. 4Apheresis Procedure Unit, University of Michigan, Ann Arbor, MI.
Pediatr Crit Care Med. 2015 May;16(4):366-74. doi: 10.1097/PCC.0000000000000351.
To determine the effect of therapeutic plasma exchange on hemodynamics, organ failure, and survival in children with multiple organ dysfunction syndrome due to sepsis requiring extracorporeal life support.
A retrospective analysis.
A PICU in an academic children's hospital.
Fourteen consecutive children with sepsis and multiple organ dysfunction syndrome who received therapeutic plasma exchange while on extracorporeal life support from 2005 to 2013.
Median of three cycles of therapeutic plasma exchange with median of 1.0 times the estimated plasma volume per exchange.
Organ Failure Index and Vasoactive-Inotropic Score were measured before and after therapeutic plasma exchange use. PICU survival in our cohort was 71.4%. Organ Failure Index decreased in patients following therapeutic plasma exchange (mean ± SD: pre, 4.1 ± 0.7 vs post, 2.9 ± 0.9; p = 0.0004). Patients showed improved Vasoactive-Inotropic Score following therapeutic plasma exchange (median [25th-75th]: pre, 24.5 [13.0-69.8] vs post, 5.0 [1.5-7.0]; p = 0.0002). Among all patients, the change in Organ Failure Index was greater for early therapeutic plasma exchange use than late use (early, -1.7 ± 1.2 vs late, -0.9 ± 0.6; p = 0.14), similar to the change in Vasoactive-Inotropic Score (early, -67.5 [28.0-171.2] vs late, -12.0 [7.2-18.5]; p = 0.02). Among survivors, the change in Organ Failure Index was greater among early therapeutic plasma exchange use than late use (early, -2.3 ± 1.0 vs late, -0.8 ± 0.8; p = 0.03), as was the change in Vasoactive-Inotropic Score (early, -42.0 [16.0-76.3] vs late, -12.0 [5.3-29.0]; p = 0.17). The mean duration of extracorporeal life support after therapeutic plasma exchange according to timing of therapeutic plasma exchange was not statistically different among all patients or among survivors.
The use of therapeutic plasma exchange in children on extracorporeal life support with sepsis-induced multiple organ dysfunction syndrome is associated with organ failure recovery and improved hemodynamic status. Initiating therapeutic plasma exchange early in the hospital course was associated with greater improvement in organ dysfunction and decreased requirement for vasoactive and/or inotropic agents.
确定治疗性血浆置换对因脓毒症导致多器官功能障碍综合征且需要体外生命支持的儿童的血流动力学、器官功能衰竭及生存率的影响。
回顾性分析。
一所学术儿童医院的儿科重症监护病房。
2005年至2013年期间，14例在接受体外生命支持时接受治疗性血浆置换的脓毒症及多器官功能障碍综合征患儿。
进行三个周期的治疗性血浆置换，每个周期置换量中位数为估计血浆量的1.0倍。
在使用治疗性血浆置换前后测量器官功能衰竭指数和血管活性药物-正性肌力药物评分。本队列患儿在儿科重症监护病房的生存率为71.4%。接受治疗性血浆置换后，患者的器官功能衰竭指数下降（均值±标准差：治疗前，4.1±0.7；治疗后，2.9±0.9；p = 0.0004）。接受治疗性血浆置换后，患者的血管活性药物-正性肌力药物评分有所改善（中位数[第25-75百分位数]：治疗前，24.5[13.0-69.8]；治疗后，5.0[1.5-7.0]；p = 0.0002）。在所有患者中，早期使用治疗性血浆置换时器官功能衰竭指数的变化大于晚期使用（早期，-1.7±1.2；晚期，-0.9±0.6；p = 0.14），血管活性药物-正性肌力药物评分的变化情况类似（早期，-67.5[28.0-171.2]；晚期，-12.0[7.2-18.5]；p = 0.02）。在幸存者中，早期使用治疗性血浆置换时器官功能衰竭指数的变化大于晚期使用（早期，-2.3±1.0；晚期，-0.8±0.8；p = 0.03），血管活性药物-正性肌力药物评分的变化情况也是如此（早期，-42.0[16.0-76.3]；晚期，-12.0[5.3-29.0]；p = 0.17）。根据治疗性血浆置换的时机，治疗性血浆置换后体外生命支持的平均持续时间在所有患者或幸存者中无统计学差异。
对于因脓毒症诱导的多器官功能障碍综合征而接受体外生命支持的儿童，使用治疗性血浆置换与器官功能衰竭恢复及血流动力学状态改善相关。在病程早期开始治疗性血浆置换与器官功能障碍的更大改善及血管活性和/或正性肌力药物需求减少相关。
