Hemodynamic changes during hemofiltration in meningococcal septicemia

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Hemodynamic changes during hemofiltration in
meningococcal septicemia

• Dr Rajiv Chhabra
• Dr Prabhat Maheshwari
• Dr Claudine De Munter

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Meningococcal sepsis

• Incidence
• One of the most common infectious cause of death
  in children outside neonatal period

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Meningococcal sepsis (MS) at St Marys hospital

• Tertiary care center
• Research on meningococcal disease in
• Prof Michael Levins lab
• PICU 8 bedded unit
• Over 900 cases of MS since 1993

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Meningococcal sepsis (MS) patient population at
St Marys Hospital PICU

• endotracheally intubated 100
• fluid volume
• gt 100 ml/Kg first 24 hours 70
• gt 200 ml/Kg first 24 hours 20
• inotropes 90 adrenaline and/or noradrenaline
• haemofiltration since 1996
• for renal failure
• 5

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Retrospective StudyObjective

• BASIS Observation of rapid clinical improvements
  in hemodynamics after initiation of CRRT
• despite the rapid clinical deterioration
  prior to and leading to CRRT
• compared to the rate of improvement in the
  less sick non-haemofiltered cases.
• AIM To review the clinical improvements in
  hemodynamics after initiation of CRRT in MS

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Methods

• Retrospective review of notes
• Parameters inotropic requirement, base excess,
  fluid requirement, blood lactate
• Recorded
• - 12 hours before starting haemofiltration,
• - time of starting,
• - 6, 12, 24 48 hours after initiating CRRT
• statistics used ANOVA

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CRRT

• Hygeia (Kimal)
• Filters polysulfones
• Heparin infusion
• High flows Flows used 80-120 ml/kg/hour
• choice highest flows tolerated within
  this range

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Results

• 27 patients (5 of MS cases)
• Age 6 months to 16 years (median 5.5 years)
• 3 died, within 8 hours of admission excluded
• mean PRISM score among the 24 survivors 64.7(3.4
  96).

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Controls

• 21 severely ill controls chosen on the basis of
  their inotropic requirement
• adrenaline gt 0.1mcg/kg/min
• and noradrenaline gt 0.1mcg/Kg/min
• Age 8m-14 years (median 6 years)
• PRISM score 7.1-84.7 (median45.8)

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(No Transcript)
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Adrenaline infusion
CRRT controls
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Noradrenaline infusion
CRRT controls
CRRT
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Base excess
CRRT controls
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Lactate levels
CRRT controls

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Continuous veno-venous hemofiltration improves
hemodynamics in septic shock with acute renal
failure without modifying TNFalpha and IL6 plasma
concentrations.J Nephrol. 2002
Mar-Apr15(2)150-7.

• In patients with septic shock and ARF, CVVH
  improves mean arterial pressure and SVR.

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Early filtration and mortality in meningococcal
septic shock?Arch Dis Child. 2000
Dec83(6)508-9

• Following the introduction of a policy of early
  therapeutic filtration for presumed meningococcal
  septicaemic shock, the overall mortality has
  decreased.

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Pulse high-volume haemofiltration for treatment
of severe sepsis effects on hemodynamics and
survival Critical Care 2005, 9R294-R302  High-v
olume hemofiltration in septic shock.Crit Care.
2005 Aug9(4)329-30   

• high-volume haemofiltration (HVHF) has exhibited
  beneficial effects in severe sepsis, improving
  haemodynamics.

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Pulse High-Volume Hemofiltration in Critically
Ill Patients A New Approach for Patients with
Septic ShockSemin Dial. 2006 Jan-Feb19(1)69-74.

• PHVHF applied in patients with septic
  shock/severe sepsis beneficial effects on
  vasopressor requirements.
• PHVHF may represent a beneficial adjuvant
  treatment for severe sepsis/septic shock in terms
  of patient survival.

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Limitations and comments

• Observational study
• Small number of patients
• -but all patients have the same disease process
• Controls are not matched
• Data confirms results of existing studies

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Conclusion

• Hemodynamic status of patients with extremely
  severe meningococcal sepsis improved rapidly
  after initiation of CRRT. This allowed rapid
  reduction of dose of vasoconstrictors that were
  initially required and avoid potential
  deleterious effects.