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Objective:To investigate the therapeutic potential of therapeutic plasma exchange (TPE) combined with continuous venovenous hemofiltration (CVVH) in the treatment of children with severe sepsis and multiple organ dysfunction syndrome (MODS).Methods:It was a prospective randomized controlled study (RCT) involving 70 children with severe sepsis and MODS admitted to Anyang Maternal and Child Health Hospital from February 2019 to February 2023.According to random number table method, they were randomly divided into combination group (35 cases) and CVVH group (35 cases). Patients in the CVVH group were treated with CVVH alone, and those in the combination group were treated with TPE combined with CVVH.The antibiotic use time of the two groups was recorded and compared by the t test.The prothrombin time (PT), thrombin time (TT), partial prothrombin time (APTT), fibrinogen (FIB), and serum levels of interleukin (IL)-1β, IL-6, tumor necrosis factor-α (TNF-α), high mobility group protein B1 (HMGB1), Toll-like receptor 4 (TLR4) and soluble receptor (sFLT) levels before treatment and 48 h and 72 h after treatment were compared by the repeated measurement ANOVA for the overall comparison at multiple time points, and LSD- t test for pair-wise comparison.The 28-day survival of the two groups was recorded and compared by the Chi- square test. Results:The PT, TT and APTT at 48 h and 72 h after treatment were significantly lower in the combination group than those of CVVH group (all P<0.05). The FIB at 48 h[(2.15±0.42) g/L vs.(1.84±0.31) g/L]and 72 h after treatment [(2.89±0.27) g/L vs.(2.49±0.20) g/L]were significantly higher in the combination group than those of CVVH group (all P<0.05). The duration of antibiotic use in the combination group was significantly shorter than that of CVVH group [(11.33±1.16) d vs.(13.54±1.92) d, t=5.828, P<0.05]. Serum levels of IL-1β, IL-6 and TNF-α at 48 h and 72 h were significantly lower in the combination group than those of CVVH group (all P<0.05). Serum levels of HMGB1, TLR4 and sFLT at 48 h and 72 h were significantly lower in the combination group than those of CVVH group (all P<0.05). The 28-day survival of the combination group was significantly higher than that of CVVH group (94.29% vs.77.14%, χ2=4.200, P=0.040). Conclusions:TPE combined with CVVH can improve the coagulation function and inflammatory factor levels in children with severe sepsis and MODS, which may achieve therapeutic objectives by regulating the levels of HMGB1, TLR4 and sFLT, and improve the short-term prognosis.
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Mortality rate in multisystem organ failure (MOF) is very high. Acute renal failure is an important part of MOF. In this special feature article I have aimed to streamline the achievements of different studies on continuous renal replacement therapy (CRRT) for a fruitful outcome. For this I have gone for retrospective evaluation of the studies reached through PubMed, internet alert system of different journals, proceedings of conferences on CRRT and personal communication with the experts in this field. I have evaluated the outcome of studies to explore the causes of failure to achieve a positive result and to identify the positive gains of studies. Finally, I have compiled the positive gains to outline a new strategy for future study and greater achievement. The findings of evaluation led to the conclusion that while planning for initiation of CRRT, multiple strategies should be targeted. The strategy should involve early initiation of CRRT guided by new markers of acute kidney injury (AKI), continuous venovenous hemofiltration (CVVH) modality, optimum intensity (intensity should be adequate enough to improve hemodynamics within a targeted period), selection of an effective filter membrane. Elderly patients should be studied in a different group. Cardiac patients with AKI should not be studied in the same group along with the patients with sepsis.
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Objective To evaluate the effect of single CVVH and HDF on endothelial system. Methods Group CVVH:20 patients with multiple organ dysfunction syndrome ( MODS) underwent CVVH for 12h.Vascular access was through two-lumen catheter in femoral vein;Group HDF:Twenty patients with end stage renal disease (ESRD) on maintenance hemodialysis underwent HDF for 4h.Vascular access was through internal arteriovenous fistula.Group control:Healthy people were examined at our hospital.The se-rum levels of sVCAM-1, sICAM-1, vWF and MMP-9 were measured by enzyme-linked immunosorbent assay ( ELISA) after centrifugation in treatment group before and after treatment.Four cytokines were also meas-ured in fasting healthy subjects in the morning.Results The levels of serum sVCAM-1, sICAM-1, vWF, MMP-9 were significantly higher in Group CVVH and HDF than control group before and after treatment( P<0.05).Group CVVH:The serum levels of sICAM-1 and sVCAM-1 were significantly lower in post-treat-ment than pre-treatment, But the serum levels of vWF and MMP-9 showed no obvious changes after CVVH;Group HDF:the levels of four cytokines showed no obvious changes after single HDF.Conclusions Endo-thelium becomes impaired in MODS and ESRD patients, Endothelium may be protected by CVVH through the partial removal of cytokines harmful to endothelium in MODS patients.Single HDF therapy does not pro-tect endothelial function obviously in MHD patients.
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ObjectiveTo evaluate the influence of continuous venovenous hemofiltration (CVVH) on measurement of transpulmonary thermodilution parameters.MethodsA prospective observational study was conducted. Fifty-six patients who received CVVH and hemodynamic monitoring at the same time admitted to the Department of Critical Care Medicine of Tianjin Third Central Hospital from July 2012 to July 2014 were enrolled. In all the patients, the dialysis catheter was inserted through the femoral vein, and transpulmonary thermodilution measurements were performed by pulse indicator continuous cardiac output (PiCCO) monitoring technology at the same time. Mean arterial pressure (MAP), central blood temperature, cardiac index (CI), global end-diastolic volume index (GEDVI), intrathoracic blood volume index (ITBVI) and extravascular lung water index (EVLWI) were measured before CVVH, immediately after CVVH, and 30 minutes after CVVH, respectively.Results In the 56 patients, there were 36 males and 20 females, (66±16) years of old, height of (172±6) cm, body weight of (68±10) kg. The acute physiology and chronic health evaluationⅡ (APACHEⅡ) scores was 26±6. After CVVH,the central blood temperature was gradually decreased, and blood temperature at 30 minutes after CVVH was significantly lower than that before CVVH (℃: 37.17±1.06 vs. 37.57±1.26,P 0.05]. CI, GEDVI, ITBVI at 30 minutes after CVVH were significantly decreased [CI (mL·s-1·m-2): 57.84±20.50 vs. 63.85±21.84, GEDVI (mL/m2):681±106 vs. 727±100, ITBVI (mL/m2): 851±133 vs. 908±125, allP< 0.05]. CVVH was associated with a decline of 6.01 mL·s-1·m-2 at 30 minutes after CVVH [95% confidence interval (95%CI) = -10.67 to -1.50,P = 0.011]. The declines of GEDVI and ITBVI were observed with 46 mL/m2 (95%CI = -81 to - 11,P = 0.014), 57 mL/m2 (95%CI =-101 to - 13,P = 0.014 ) respectively 30 minutes after CVVH.Conclusions CVVH had no significant effect on the transpulmonary thermodilution measurements of CI, GEDVI, ITBVI and EVLWI. Thirty minutes after the start of CVVH, CI, GEDVI and ITBVI was decreased significantly, but had no effect on EVLWI.
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We report the experiences of pump-driven continuous venovenous hemofiltration therapy in three children with acute renal failure. The all three patients required mechanical ventilation and needed the support of vasopressors. Renal replacement therapy was needed to meet the metabolic and fluid balance, but intermittent hemodialysis and peritoneal dialysis were not feasible because of hemodynamic instability and concurrent infection. We instituted pump-driven continuous venovenous hemofiltration(CVVH), and immediate improvement of pulmonary edema and successful removal of retained fluid were observed. Urea clearance also was satisfactory. During the filter running time, significant thromboembolic event or rapid drop of systemic blood pressure were absent. We concluded that the CVVH is an effective and safe method of renal support for critically ill pediatric patient.
Subject(s)
Child , Humans , Acute Kidney Injury , Blood Pressure , Critical Illness , Hemodynamics , Hemofiltration , Peritoneal Dialysis , Pulmonary Edema , Renal Dialysis , Renal Replacement Therapy , Respiration, Artificial , Running , Urea , Water-Electrolyte BalanceABSTRACT
PURPOSE: Continuous renal replacement therapy (CRRT) has been developed and it has advantages, although the patients receiving CRRT still have a high mortality. This study was designed to compare the clinical characteristics of patients treated with CRRT between survivors and non-survivors. METHODS: From May 1992 to February 2000, continuous venovenous hemofiltration(CVVH) treatment was applied to 51 patients. Underlying disease, duration of CVVH treatment, blood pressure before and after the treatment were reviewed and APACHE III score, number of organ failures, blood pressure at the begining were compared between two groups. RESULTS: The average age was 56.3+/-5.6 years and the mortality was 86.3%(44 patients). The comorbid conditions were sepsis(66.7% of total patients), hepatic failure(33.3%), congestive heart failure(17.6%) and adult respiratory distress syndrome(9.8%). Mean arterial pressure(MAP) at the begining was 66.9+/-9.7 mmHg and MAP 2 hours after the treatment was 59.3+/-1.5 mmHg(p=0.076). APACHE III score was 59.5+/-3.5 in non-survivors and 56.0+/-0.9 in survivors and mean number of organ failures was 2.63+/-.98 in non-survivors and 1.68+/-.34 in survivors, but there was no difference between two groups(p=0.072). MAP at begining was significantly higher in survivors than that of non-survivors(87.86+/-3.15 vs. 63.49+/-7.04)(p=0.002). CONCLUSION: Most of the patients receiving CVVH have more than two organ failures. There were no significant difference in the number of organ failures and APACHE III score between survivor group and non-survivor group. It may be due to underlying disease of patients that MAP at the begining was lower in non-survivors than survivors. APACHE III score would not be a good prognostic predictor.