Selective LPS Adsorption Using Polymyxin B-Immobilized Fiber Cartridges in Sepsis Patients Following Cardiac Surgery.

Sepsis remains the leading cause of morbidity and mortality in intensive care units. The extracorporeal therapy in the complex treatment of sepsis seems to be the most promising direction. The aim of this study was to assess the safety and effectiveness of selective endotoxin adsorption on the basis of the analysis of our own experience with the intensive therapy for sepsis in adult cardiac surgical patients. Our single-center study included 143 patients with sepsis. One hundred and three adult patients received lipopolysaccharide adsorption procedures using Toraymyxin-PMX-20R columns. The historical control group included 30 adult patients received only conservative therapy, and 10 children (6.2-14 kg) received hemoperfusion with Toraymyxin-PMX-0.5R. After the lipopolysaccharide-adsorption course, we noted improving of the hemodynamic and respiratory parameters. A favorable effect of hemoperfusion was a decrease procalcitonin and endotoxin activity assay, expressed by changes of leukocytosis, a normalization of body temperature. The 28-day survival was 53% in the study group and 30% in the control group (P = 0.037). The 28-day survival of children who received selective hemoperfusion was 90%. Our own experience with the use of selective hemoperfusion in a fairly large group of cardiovascular patients with sepsis showed the safety and efficacy of these procedures.

The Level of Oxidative Neutrophil Response When Determining Endotoxin Activity Assay: A New Biomarker for Defining the Indications and Effectiveness of Intensive Care in Patients with Sepsis.

Background. To analyse the clinical informativity of the neutrophil oxidative response level ("Response") during an Endotoxin Activity Assay (EAA) as a new biomarker defining the indications and effectiveness of intensive care in cardiac surgical patients with septic complications. Methods. Blood samples were taken from 198 adult patients who were admitted to the ICU after cardiac surgery (SIRS: 34, MODS: 36, and sepsis: 128). The composite of laboratory studies included CRP, PCT, EAA with "Response" level, and presepsin. Results. 83% of patients had a "normal" neutrophil response, 12% of patients had a low neutrophil response, and 5% of patients had a critically low neutrophil response. Patients with critically low responses had the lowest values of the EAA and the highest concentrations of PSP and D-dimer (p < 0.05). Conclusions. EAA results should be interpreted with the level of neutrophil response. "Response" > 0.5 has a negative predictive value; the EAA < 0.6 at "Response" < 0.5 may indicate a high level of endotoxaemia.

Prometheus therapy for the treatment of acute liver failure in patients after cardiac surgery.

INTRODUCTION: Acute liver failure usually develops in multiple organ dysfunction syndrome and significantly increases the mortality risk in patients after cardiac surgery. AIM: To assess the safety and efficacy of extracorporeal liver support in patients with acute liver failure after cardiac surgery. MATERIAL AND METHODS: We studied 39 adult patients with multiple organ dysfunction syndrome and acute liver failure as postoperative complication, treated with Prometheus therapy. Inclusion criteria comprised clinical and laboratory signs of acute liver failure. Criteria to start Prometheus therapies were: serum bilirubin above 180 µmol/l (reference values: 3-17 µmol/l), hepatocyte cytolysis syndrome (at least 2-fold increase in aspartate aminotranspherase and alanine aminotranspherase concentrations; reference values 10-40 U/l) and decrease in plasma cholinesterase (reference values 4490-13 320 U/l). RESULTS: Extracorporeal therapy provided stabilization of hemodynamics, decrease in serum total bilirubin and unconjugated bilirubin levels, decrease in cytolysis syndrome severity and positive effect on the synthetic function of the liver. The 28-day survival rate in the group treated with Prometheus therapy was 23%. CONCLUSIONS: Prometheus procedures could be recommended as a part of combined intensive care in patients with acute liver failure after cardiac and major vessel surgery. The efficiency of this method could be improved by a multi-factor evaluation of patient condition in order to determine indications for its use.

Prognostic value of sCD14-ST (presepsin) in cardiac surgery.

INTRODUCTION: Prediction of complications and mortality after cardiac surgery is an important aspect of timely correction of these conditions. One possibility in this case is the use of biomarkers and some prognostic scores. AIM OF THE STUDY: To study the prognostic value of presepsin (PSP) as a predictor of postoperative complications development in cardiosurgical patients. MATERIAL AND METHODS: Patients operated for acquired heart diseases with cardiopulmonary bypass (CPB) were included in the study (n = 51, age: 58 ± 11 years). Besides routine clinical and laboratory data, PSP and procalcitonin (PCT) levels were monitored perioperatively (before surgery, and on the 1(st), 2(nd), 3(rd) and 6(th) day after surgery). RESULTS: There were no clinical signs of infection before surgery in any of the studied patients. We found supranormal PSP levels in 6 patients (11.8%) before operations (543 [519-602] pg/ml, max 1597 pg/ml; normal value: 365 pg/ml). Infectious complications developed in 19 patients (37%). Statistically significant differences in PSP levels, APACHE II (Acute Physiology and Chronic Health Evaluation II) and SOFA (Sequential Organ Failure Assessment) scores in groups of patients with and without infection were documented from the 1(st) and in PCT from the 2(nd) day after the operation. The cut-off values were 702 pg/ml, 8.5 points, 7.5 points and 3.3 ng/ml, respectively. Hospital mortality was 13.7% (7 patients); all cases of death were in the group of patients with infectious complications. Statistically significant differences in PCT levels, APACHE II and SOFA scores between the groups with favorable and lethal outcomes were observed from the first postoperative day. The same for PSP levels was documented only on the 3(rd) postoperative day. The cut-off values were 7.42 ng/ml, 11 points, 8.5 points and 683 pg/ml, respectively. CONCLUSION: The use of modern biomarkers alongside integral severity-of-disease scores allows prediction of the risk of infectious complications and mortality in cardiosurgical patients.

A pilot study of selective lipopolysaccharide adsorption and coupled plasma filtration and adsorption in adult patients with severe sepsis.

AIM: To evaluate the safety and effectiveness of combined extracorporeal therapy in patients with severe sepsis after cardiac surgery. MATERIALS AND METHODS: Twenty patients received combined extracorporeal therapy (LPS-adsorption with Toraymyxin columns + CPFA). The inclusion criteria were clinical signs of severe sepsis, EAA = 0.6, and PCT >2 ng/ml. 20 comparable patients in the control group received only standard therapy. RESULTS: Each patient in the study group received 2 daily treatments of combined extracorporeal therapy. In contrast to controls, we noted an increase in the values of MAP from 73 to 82 mm Hg, (p < 0.001) and the mean oxygenation index (from 180 to 246, p < 0.001), decrease of EAA from 0.77 to 0.55, p < 0.001, and PCT (from 6.23 to 2.83 ng/ml, p < 0.001). The 28-day survival rate was 65 and 35% in the study and control groups respectively, p = 0.11. CONCLUSION: The combined use of LPS-adsorption and CPFA in a single circuit with standard therapy is a safe and possibly effective adjunctive method for treating severe sepsis.

Endotoxin adsorption using polymyxin B immobilized fiber cartridges in severe sepsis patients following cardiac surgery.

INTRODUCTION: Sepsis still represents an obstacle in modern medicine. The purpose of this study was to evaluate the safety and effectiveness of selective lipopolysaccharide (LPS)-adsorption therapy using polymyxin B immobilized fiber cartridges in adult patients complicated with severe sepsis after cardiac surgery. METHODS: 65 patients received extracorporeal LPS-adsorption procedures using Toraymyxin columns (PMX; Toray, Tokyo, Japan) in addition to the standard treatment according to the Surviving Sepsis Campaign guidelines. The inclusion criteria were clinical signs of severe sepsis, endotoxin activity assay (EAA)≥0.6, and blood plasma procalcitonin (PCT)>2 ng/ml. For the control group, we selected 40 patients who were comparable with the study group but who received only the standard therapy. RESULTS: Each patient received 2 standard LPS-adsorption procedures (lasting for 120 min each). After the LPS-adsorption course, we noted any indices of hemodynamic improvements, including an increase in mean arterial pressure from 73 to 89 mmHg (p<0.001), mean oxygenation index (213-265, p<0.001. We observed a decrease in LPS concentrations by the EAA (0.71-0.55, p<0.001) and by the LAL test (1.44-0.36 EU/ml, p<0.001). In the control group, there were no significant changes in any of the studied parameters. Moreover, the 28-day mortality was 42% in the study group and 65% in the control group (p=0.032). The endotoxin adsorption procedures were not associated with any adverse reactions, and specifically, no extracorporeal circuit thrombosis cases were noted. CONCLUSIONS: Selective LPS-adsorption is a safe and possibly effective adjunctive treatment method for severe sepsis patients.

Prognostic value of endotoxin activity assay in patients with severe sepsis after cardiac surgery.

BACKGROUND: To evaluate the prognostic value of endotoxin activity assay (EAA) in adult patients with suspected or proven severe sepsis after cardiac surgery METHODS: Blood samples taken from 81 patients immediately after the diagnosis of severe sepsis were tested with the EAA. Patients were divided into 3 groups: low (<0.4, n = 20), moderate (0.4-0.59, n = 35) and high (≥0.6, n = 26) EAA levels. RESULTS: Gram-negative bacteraemia was found in 19/55 (35%) of cases with ЕАА <0.6 and in 11/26 (42%) of cases with higher ЕАА, p = 0.67. Mortality at 28 days in Groups 1, 2 and 3 was 20%, 43% and 54%, respectively. Patients with an EAA higher than 0.65 had a higher 28-day mortality than those with lower EAA values (18/26 - 69% vs. 19/55 - 34.5%; p = 0.0072). ROC analysis for the prediction of 28-day mortality revealed an AUC for APACHE II scores, EAA and PCT of 0.81, 0.73 and 0.66, respectively. CONCLUSIONS: EАА might be useful for recognising patients who have an increased risk of mortality due to severe sepsis.