ABSTRACTS from 16th International COnference on ... - CRRT Online

D28
Extracorporeal Techniques for Sepsis 2
Patrick M. Honoré MD
8:00-9:30
Thursday, February 16
Educational Objectives:
1)Review briefly the rationale of Hybrid therapy in sepsis regarding experimental issues.Special focus on Hybrid
therapy regarding large bore membranes and highly adsoptive membranes.
2) Describe the New Possibilities given with the New Membranes for High permeability hemofiltration (HPHF)
that do offers to the clinician especially with the combined use of high volume hemofiltration (for Synergic
action ) a new tool in order to try to effectively combat septic shock with acute kidney injury (AKI).
Previous studies did show that HPHF especially with combined HVHF can removed much large quantities of
mediators.
3)Describe the new possibilities given with the New Membranes for Hybrid Therapies regarding High
Adsorptive Hemofiltration doing at the same time, Endotoxin Adsorption and Cytokine Adsorption.
4)Review all clinical data regarding this issue.
5)Try to see which clinical situation could fit the best with those new types of membranes.
Content Description:
Clinical use day by day for bedside intensivists need to be further established.Although some data can be show
about safety issues regarding the use of some membranes.
A step by step approach will be needed before routine implementation.Nevertheless, some clinical scenarios can
be outlined so far.
Briefly, we should describe new insides regarding the “New Active Transportation between two Asymmetric
Compartments” Hypothesis and New Insights into Rationale & Potential Mechanisms. Pro-mediators as well as
mediators are removed at interstitial and tissue levels, following removal <strong>from</strong> the blood compartment, until a socalled
threshold point is reached at which some pathways and cascades are stopped .At this level, the cascades
are interrupted and no further harm can be done to the tissues.Until recently, this mechanism was taught to be a
passive transportation pathway.As said in the introduction, effectiveness through only a passive transportation
mechanism remains elusive.Indeed as demonstrated before and knowing that the surface of the central blood
compartment (CEBC) is about 30 mÇ, which is much smaller than the surface of the capillary blood compartment
(CABC)which is about 300 mÇand therefore passive transport between these two asymmetric compartments
will not yield the same elimination rate on both sides.As a consequence, when a given technique is able to
remove 40 % of the mediators of the CEBC side, it will only represents 4 % of the removal into the CABC side
if the removal is only a passive mechanism.It is therefore easy to understand, that an other mechanism has to
take place and this should be this time, an active transportation mechanism. Previous studies did show that
HPHF especially with combined HVHF can removed much large quantities of mediators.A preliminary study
called the HICOSS study(High Cut-off in Septic Shock)was looking as pilot study in order to compare in 80
patients with Septic Shock plus AKI. 40 patients were assigned with conventional membrane and 40 patients
were assigned with an hyperpermeable membrane (septex).Those patients were in septic shock plus AKI but also
in multiple organ failure (MODS).The mode chosen was CVVD for 5 consecutive days.The principal aim was to
evaluate the safety regarding albumin losses (cut-off of 60 kDa) and a 50 % reduction in catecholamine requirements.Mortality
was a secondary end point.The results shows a excellent safety as the membrane was not loosing
albumin more than a classical membrane.Nevertheless, regarding vasopressors free days as well length of ICU
stay and mortality , no differences could be seen between the two groups.This may be due the fact that the mode
111