May 2007

Dr CHAN Chin Pang Ian

Intensive Care Unit, United Christian Hospital

 

Introduction

Severe sepsis triggers a series of mediator release leading to multiple organ injuries. Management of sepsis is multifactorial comprising source control, adequate antimicrobial therapy, early resuscitation of perfusion abnormalities, tight glycemic control and minimization of iatrogenic ventilator-induced lung injury.  Yet the morbidity and mortality associated with severe sepsis remains substantial.  Mediator removal by extracorporeal blood purification has been recently introduced into clinical practice with promising preliminary results.

 

With the introduction of newer and more sophisticated haemofiltration system, higher ultrafiltration rate (UF) (4L-6L/hour) is feasible.  Regarding the dose of CRRT, Ronco and coworkers demonstrated survival benefits, particularly in the subgroup suffering from sepsis, with higher UF (i.e. 35ml/kg/hr or 45ml/kg/hour as compared to 20ml/kg/hr).  Role of high-volume haemofiltration (HVHF) (UF > 35ml/kg/hour) in severe sepsis attracted clinicians’ attention.  They further proposed “Pulse” high-volume haemofiltration (PHVHF): i.e. the application of HVHF for 6–8 hours per day, followed by conventional continuous venovenous haemofiltration (CVVH) for treatment of severe sepsis complicated with acute renal failure.

 

Method

This is a retrospective single-arm case review study conducted in United Christian Hospital, Hong Kong.  Patients with severe sepsis and associated acute renal failure who had undergone PHVHF were reviewed.  The effect on physiological responses, biochemical parameters, inotrope and vasopressor requirement, clinical outcomes and side effects were analyzed by studying the clinical records between 30th September, 2005 and 30th September, 2006 retrieved from the Clinical Management System (CMS) and Clinical Data and Reporting System (CDARS).

 

Result

Eighteen patients with severe sepsis and underwent daily PHVHF (12 males and 6 females; mean APACHE II score 28.3, mean SAPS II score 56.6) were identified.  Haemodynamics and respiratory rate were improved after PHVHF, i.e. heart rate (P<0.001), MAP (P=0.016), DBP (P=0.013) and RR (P=0.001).  Predicted mortality rates were 61.6% (based on APACHE II score) and 57% (based on SAPS II score) respectively, and the observed 28-day mortality rate was 27.8%. Hypokalaemia and mild hypothermia were the main side effects associated with PHVHF.

 

Conclusion

PHVHF is a potential adjuvant treatment modality for management of severe sepsis with acute renal failure.  Retrospective analysis showed improvement in blood pressure, respiratory rate and survival benefits when compared to predictions based on severity scoring systems. Hypokalaemia and mild hypothermia are the major side effects.  However, current evidence base of application of PHVHF in clinical practice is not adequate.  Further large-scale, properly design clinical trials to establish the benefits and side effects of PHVHF are required.

 

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