Salon a 14 kasim 13.30 14.45 bi̇lgi̇n cömert

1. Plasmapheresis in Sepsis
Bilgin CÖMERT, MD.
Dokuz Eylül University, School of Medicine
Department of Medical Intensive Care Unit

2. Terminology
• Therapeutic Plasma Exchange
separates 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
• Plasmapheresis
separates 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

3. 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

4. Sepsis Treatment (Standart)
• Antimicrobial agents
• Control of the source of the infection
• Hemodynamic support
• Fluids
• Vasopressors
• Oxygenation and ventilatory support
• Avoidance of complications

5. Sepsis Treatment (innovative)
• Corticosteroids
• Monoclonal antibodies to TNF
• Antitrombin
• Activated protein C
• Extracorporeal Therapies
• CRRT
• Plasma Exchange
• ECMO

6. 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

7. Artif Organs 2003;27:792-801

8. 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

9. Plsmapheresis
(n=54)
Control
(n=52) P
Age
Apache III
41±15
56.4±18.8
48±16
53.5±15.8
0.03
0.40
28-day survival
Total study population
Abdominal group
Other groups
18 (33%)
11/33 (33%)
7/21 (33%)
28 (54%)
11/16 (68%)
17/36 (47%)
0.05
0.03
0.4
Intensive Care Med 2002;28:1434-9

10. Continuous Plasmafiltration in sepsis syndrome
22 Adults, 8 Children
• Filtration/PE group n=14
• Control group n=16
Crit Care Med 1999;27:2096-104

11. Crit Care Med 2008;36:2878-87

12. Survival (28-day)
Plasma Exchange (n=5) 5/5
Standard Therapy (n=5) 1/5
Survival
28-day 1-year
Plasma Exchange (n=60) 90% 80%
Standard Therapy (n=16) 20% 15%
(Unpublished data)*
Crit Care Med 2008;36:2878-87
*Semin Pediatr Infect Dis 2006;17:72-9

13. Crit Care Med 2007;35:2375-82
P < 0.001
p < 0.01 p < 0.001

14. • Therapeutic Plasma Exchange in Sepsis with Multiorgan Failure
Recommendation : Grade 2B
J Clin Apheresis 2010;25:83-177

15. 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 adults
Crit Care Med 2013;41:580-637