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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
was only CVVD and perhaps the results would be very different if we were using CVVH at 35 ml/kg/h plus HPHF.Description will be done also regarding data for new adsorptive membranes. Attenuation of SIRS post-Bypass will be also evaluated in order to see whether therapy aiming at reducing it might improved related organ remoted damages. Experimental studies and clinical evaluation are still under way.Those studies will need mechanistic steps, small RCT’s and large RCT’s at some point. In conclusion, the hyperpermeable membrane (septex) is safe and could be a important therapeutic tool in the future when associated with HVHF.Potential effect of highly adsorptive membranes need to be evaluated. As said and although further evaluation need to be done, some specific clinical scenarios can be identified in order to delineate the current use in clinical conditions of these new hybrid therapies by the bedside clinician. Suggested Reading: Suggested Readings: 1- Honore PM, Joannes-Boyau O,Boer Willem, Collin V High Volume Haemofiltration for Sepsis & SIRS:Current Concepts & Future Prospects. In-Depth-Review. Blood Purif 2009;28;1-11. 2- Honore PM, Joannes-Boyau O, Boer W, Collin V,Jennes S. Continuous Haemofiltration in 2009 : What’s New for Clinicians regarding : Pathophysiology , Technique to be Privileged and Dose to be Recommended . In-Depth-Review.Blood Purif 2009;28-135-143. 3- Honoré PM, Joannes-Boyau O, Jacobs R,Solignac M .Blood Purification in Sepsis:Fiction or Fact for the Clinician. Reanimation 2010;19:7-12 4.- Honoré PM, Zydney AL, Matson JR. High volume and high permeability haemofiltration in sepsis. The evidences and the key issues. Care Crit ill 2003;3:69-76 5. Matson J R, Zydney AR, Honore,PM. Blood Filtration: New Opportunities and the Implications On System Biology.Critical Care and Resucitation 2004; 6:209-218. 6. Morgera S, Haase M, Kuss T, et al. Pilot study on the effects of high cutoff hemofiltration on the need for norepinephrine in septic patients with acute renal failure. Crit Care Med 2006;34:2099-104. 7. Cruz DN, Antonelli M, Fumagalli R, et al. Early use of polymyxin B hemoperfusion in abdominal septic shock: the EUPHAS randomized controlled trial. JAMA 2009;301:2445-52. 8. Honore PM, Joannes-Boyau O, Dobbeleir N.Blood Purification in Sepsis & Acute Kidney Injury in Critically Ill Patients:New Insights & Potential Mechanisms with an Update on Recent Trials.Chapter of the Yearly Book in Intensive Care Medicine 2011 (31 th ISICEM March 2011) 9. Honore PM et al. Continuous Hemofiltration or Intermittent Dialysis for Septic Shock Patients in ICU with AKI :A Pragmatic Approach for Bedside Intensivists Summarizing the More Recent Advances.Annals of Intensive Care 2011: 26 10.De Silva RJ, Armstrong J, Bottrill F, Goldsmith K, Colah S, Vuylsteke A. A lipopolysaccharide adsorber in adult cardiopulmonary bypass: a single centre randomised controlled pilot trial. Interact Cardiovasc Thorac Surg. 2010 ;11:86-92. 112
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CRRT 2012 SEVENTEENTH INTERNATIONAL
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FACULTY DISCLOSURES CRRT 2012 Facul
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CRRT 2012 ORGANIZING COMMITTEE USA
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CRRT 2012 FACULTY Patrick Honoré,
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ACKNOWLEDGEMENTS CRRT 2012 ACKNOWLE
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PLENARY SESSIONS CRRT 2012 PROGRAM/
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WORKSHOPS CRRT 2012 PROGRAM/INDEX T
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WORKSHOPS CRRT 2012 PROGRAM/INDEX W
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POSTER ABSTRACTS C
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POSTER ABSTRACTS C
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NURSING FORUM LUNCHEON Communicatio
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Nutritional Support in ICU Patients
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Educational Objectives: The Endothe
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SPECIAL LECTURE Engineering Critica
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Nishimura R, Ornato JP, Page RL, Ri
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Do Vasoactive Drugs and Fluids Impr
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Blood Transfusions are Important fo
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Thinking Outside of the Box: A Nove
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Nursing Forum 2 Luncheon Benchmarki
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4. Mori K, Lee HT, Rapoport D, Drex
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Differential Diagnosis of AKI: Can
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Myocardial Stunning and Brain Edema
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4. Udy A, Roberts JA, Lipman J. Wha
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CRRT and ECMO: Techniques and Outco
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Management of Severe Heart Failure:
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Avoiding Anticoagulation for CRRT:
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Improving Outcomes from</st
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The Changing Face of AKI: Snapshots
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