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Plasmapheresis in Sepsis

Bilgin CÖMERT, MD.

Dokuz Eylül University, School of Medicine

Department of Medical Intensive Care Unit

Terminology

• Therapeutic Plasma Exchangeseparates out plasma from other components of blood, the plasma is removed and replaced with a replacement solution such as colloid solution (e.g., albumin and/or plasma) or combination of crystalloid/colloid solution

• Plasmapheresisseparates out plasma from other components of blood and the plasma is removed (i.e. less than 15% of total plasma volume) without the use of replacement solution

Plasmapheresis/Plasma Exchange in Critical Illness

• Thrombotic Thrombocytopenic Purpura

• Atypical Hemolytic Uremic Syndrome

• Thrombotic Microangiopathy: Drug-Associated (ticlopidine and clopidogrel)

• Wilson’s disease in fulminant hepatic failure with hemolysis

• Guillain-Barre Syndrome

• Chronic Inflammatory Demyelinating Polyradiculoneuropathy

• Sydenham’s Chorea

• Multiple Sclerosis

• Myasthenia Gravis

• Goodpasture’s Syndrome

• Wegener’s Granulomatosis

Sepsis Treatment (Standart)

• Antimicrobial agents

• Control of the source of the infection

• Hemodynamic support• Fluids• Vasopressors

• Oxygenation and ventilatory support

• Avoidance of complications

Sepsis Treatment (innovative)

• Corticosteroids• Monoclonal antibodies to TNF• Antitrombin• Activated protein C• Extracorporeal Therapies• CRRT• Plasma Exchange• ECMO

Aims of the Extracorporeal Therapies• Provide immunohomeostasis of pro- and anti-inflammatory

cytokines and other sepsis mediators

• Decrease organ microthrombosis through removal of pro-coagulant factors

• Modulating the impaired septic coagulation response in sepsis

• Provide mechanical support of organ perfusion during the acute septic episode

Semin Pediatr Infect Dis 2006;17:72-9

Artif Organs 2003;27:792-801

Plasma Exchange

• Remove harmful and toxic mediators from circulation as non-selectively

• If fresh frozen plasma is used as the replacement solution, substance consumed during systemic inlammatory process would be replaced

Plsmapheresis

(n=54)

Control(n=52) P

AgeApache III

41±1556.4±18.8

48±1653.5±15.8

0.030.40

28-day survivalTotal study populationAbdominal groupOther groups

18 (33%)11/33 (33%)7/21 (33%)

28 (54%)11/16 (68%)17/36 (47%)

0.050.030.4

Intensive Care Med 2002;28:1434-9

22 Adults, 8 Children

• Filtration/PE group n=14

• Control group n=16

Continuous Plasmafiltration in sepsis syndrome

Crit Care Med 1999;27:2096-104

Crit Care Med 2008;36:2878-87

Survival (28-day)

Plasma Exchange (n=5) 5/5

Standard Therapy (n=5)1/5 Crit Care Med 2008;36:2878-87

*Semin Pediatr Infect Dis 2006;17:72-9

Survival 28-day 1-year

Plasma Exchange (n=60) 90%80%

Standard Therapy (n=16) 20%15%

(Unpublished data)*

Crit Care Med 2007;35:2375-82

p < 0.01 p < 0.001

P < 0.001

• Therapeutic Plasma Exchange in Sepsis with Multiorgan Failure

Recommendation : Grade 2B

J Clin Apheresis 2010;25:83-177

Surviving Sepsis Campaign-2012

Plasma therapies in children to correct sepsis-induced thrombotic purpura disorders• Progressive DIC• Secondary Thrombotic microangiopathy• TTP

• Recommendation: Grade 2C

• No recommendations for adultsCrit Care Med 2013;41:580-637