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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 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
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 
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
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
Crit Care Med 2008;36:2878-87
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
Crit Care Med 2007;35:2375-82 
P < 0.001 
p < 0.01 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 adults 
Crit Care Med 2013;41:580-637
Salon a 14 kasim 13.30 14.45 bi̇lgi̇n cömert

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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
  • 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

Editor's Notes

  1. Reeves ve ark tarafından yapılan çok merkezli, randomize, kontrollü bir çalışmada, çalışma grubuna 34 saat boyunca sürekli plazma filtrasyonu ile plazma değişimi uygulanmış.
  2. 2 veya daha fazla organ yetmezliği olan hastalar çalışmaya alınmış. TTP düşünülen ve onam alınmayan hastalar çalışma dışı. Trombositopeni ilişkili çoklu organ yetersizliği olan 28 çocuğun 25’inde ADAMTS 13 seviyesinde düşüklük saptanmış. Trombositopeni olmayan çoklu organ yetmezlikli 9 hastanın sadece 3’ünde ADAMTS 13 seviyesi düşük olarak tespit edilmiş.
  3. Çalışmanın 2nci bölümünde trombositopenisi olan ve 3 veya daha fazla organ yetmezliği olan hastalar Plazma değişimi ve satandart tedavi için randomize edilmiş. Ara incelemede 28 günlük sağkalım PD grubunda %100, standart tedavi grubunda %20 olması üzerine çalışma sonlandırılmış ve Pittsburg çocuk hastanesinde TAMOF’lu çocuklarda PD rutin olarak uygulanmaya başlanmış.
  4. Öneri düzeyi zayıf, çalışma kaliteleri düşük.